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Alcohol Proseminar


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Title: Alcohol Proseminar

Alcohol Proseminar
  • Fall, 2002

Address to the legislature by a Mississippi state
senator in 1958.
  • You have asked me how I feel about whisky. All
    right, here is just how I stand on this question
  • If, when you say whisky, you mean the devil's
    brew, the poison scourge, the bloody monster that
    defiles innocence, yea, literally takes the bread
    from the mouths of little children
  • if you mean the evil drink that topples the
    Christian man and woman from the pinnacles of
    righteous, gracious living into the bottomless
    pit of degradation and despair, shame and
    helplessness, then certainly I am against it with
    all my power.

  • But, if you when you say whisky, you mean
    the oil of conversation, the philosophic wine,
    the stuff that is consumed when good fellows get
    together, that puts a song in their hearts and
    laughter on their lips and the warm glow of
    contentment in their eyes
  • if you mean Christmas cheer,
  • if you mean the stimulating drink that puts the
    spring in the old gentleman's step on a frosty
  • if you mean the drink that enables a man to
    magnify his joy, and his happiness, and to
    forget, if only for a little while, life's great
    tragedies and heartbreaks and sorrows,

  • if you mean that drink, the sale of which pours
    into our treasuries untold millions of dollars,
    which are used to provide tender care for our
    little crippled children, our blind, our deaf,
    our dumb, our pitiful aged and infirm, to build
    highways, hospitals, and schools, then certainly
    I am in favor of it.
  • This is my stand, I will not retreat from it I
    will not compromise.

Prohibition Legislative Summary
  • Period
  • Up to 1906
  • 19071913
  • 19141918
  • 1917
  • January 1918
  • January 1919
  • Status
  • 3 Prohibition States
  • 23 Prohibition States
  • (17 by referenda)
  • 48 Prohibition States
  • (25 new referenda 16
  • 18th Amendment introduced
  • Ratified by Congress
  • U.S. Prohibition Effective

Source Moore Gerstein, 1981
Repeal Alcohol Control
  • 1932 Roosevelt campaigns for repeal of 18th
  • December 1933 21st Amendment (Repeal) ratified
    by 35 states
  • Alcohol Control becomes a pivotal idea in
    post-Repeal era
  • Federal
  • regulate production of spirits, wine beer (curb
    illegal production)
  • manage product purity and labeling impose excise
  • Authority with Department of Justice (ATF since
  • State
  • Devolved Powers including dry option, retail
    monopolies, taxation
  • Alcoholic Beverage Control (ABC Laws)

Sources Levine 1980 Moore Gerstein, 1981
Alcohol Warning Label (PL100-690, 1988)
  • Federal law required health warning on container
  • Government warning from credible source Surgeon
  • Pregnant women should not drink risk of birth
  • Impairs ability to drive a car or operate
    machinery and may cause health problems
  • Major Results
  • By 1994, 60 drinkers reported exposure to
    labelcurve flattening
  • Messages reach many but not all target groups,
    heavier drinkers e.g., 50 males 18-20 (drunk
    driving) 65 drinkers 18-29 (pregnancy) may
    miss less educated and ethnic groups
  • Modest associations with precautionary behavior,

Sources Greenfield Kaskutas, 1998 Greenfield
et al, 1999 Hankin et al, 1993
U.S. Support for Stronger Alcohol Policies

Room et al, 1995 Giesbrecht Greenfield, 1999
Domains of Alcohol Involvement
  • Abstention vs. Drinking
  • Frequency of Consumption
  • Quantity of Consumption
  • Quantity-Frequency (Volume)
  • Volume Variability
  • Frequency of heavy consumption or drunkenness
  • Risky drinking

Domains of Alcohol Involvement(continued)
  • Alcohol-related problems (consequences,
  • Alcohol dependence syndrome
  • Alcohol use disorders
  • Alcohol abuse
  • Alcohol dependence

Total per capita ethanol consumption, United
States, 1997
Relative Price of Alcoholic Beverages, 1970-1997
Relative Price, 1970
Sources Mosher, 1997 Mosher Cowan, 1985
Bureau of Labor Statistics, 1996
Abstention by Age, Sex and Race
From NLAES, 1992
Concentration of U.S. Alcohol Consumption
Greenfield TK Rogers JD. J Stud Alcohol 6078
Hazardous U.S. Alcohol Consumption
Rogers Greenfield, 1999
Total Per Capita Consumption of Ethanol by State,
United States, 1997
Total Per Capita Consumption of Ethanol among
Current Drinkers by State, United States, 1997
  • Frequency Drinking days/year.
  • How often did you have a drink containing
    alcohol, that is beer, wine or liquor?
  • Quantity Drinks per Drinking Day
  • About how many drinks would you have on average
    on a typical day when you drank?
  • Volume (Drinking days/year X Drinks per drinking
    day)/days in a year Drinks per day

Graduated QF
  • Think of all kinds of alcoholic beverages
    combined, that is, any combination of cans of
    beer, glasses of wine, or drinks containing
    liquor of any kind.
  • During the past 12 months, Start with largest
    amount drunkwhat is the largest number ask
    frequency of consumingof drinks on a single
    day? successively lower amounts per day.
  • Was it 24 or more drinks on  Daily or
    nearly every day a single day?  3 or
    4 times a week 12 to 23 drinks on a single
    day?  Once or twice a week  8-11?  2
    or 3 times a month  5-7?   Once a month
     3-4?  11-3 times in the past year  1-2?
     Twice in the past year  No drinks
     Once in the past year  Never

Drinking Pattern Questionnaire--DPQ
  • 1. On Fridays during a typical month, how often
    did you drink - every Friday, three Fridays, two
    Fridays, one Friday, or hardly ever on Fridays?
  • 2. How many drinks would you usually have on a
  • 3. Repeat for Saturday, Sunday, and weekdays.
  • 4. Were there days when you had more than your
    usual in the past 12 months?
  • 5. If yes, what did you typically drink and how
  • 6. Proportion of time you drank with a meal,
    while snacking, or without eating anything.
  • 7. Did you ever drink enough to get drunk or
    very high, that is, your speech was slurred or
    you were unsteady on your feet?
  • 8. If yes, how often did you drink enough to get
    drunk or very high?

Heavy Drinking by Age, Sex, and Race
From NLAES, 1992, 1 oz. ethanol per day
Drinking Volume Partitioned by 6 Contexts
1984 1995 National Alcohol Surveys Clark,
1988 Greenfield et al, 2000
Hispanics, Abstention and Heavy Drinking by
Gender and Country of Origin, United States, 1984.
Abstention Heavy Drinking
Drinks at least once a week and has five or more
at a sitting at least once a year.
Asian-Americans Abstention and Heavy Drinking by
Gender and Country of Origin, Los Angeles, 1980s.
Abstention Heavy Drinking
Drinks at least once a week and has five or more
at a sitting at least once a year.
Drinking Patterns of Japanese in Japan,
Japanese-Americans in Hawaii, and
Japanese-Americans in Santa Clara, California,
Abstention Heavy Drinking
DSM-IV Alcohol Abuse
  • A person's maladaptive alcohol use causes
    clinically important distress or impairment, as
    shown in a single 12-month period by one or more
    of the following
  • failure to carry out major obligations at work,
    home, or school because of repeated alcohol use,
  • repeated use of alcohol even when it is
    physically dangerous to do so,
  • repeated experience of legal problems, or
  • continued use of alcohol despite knowing that it
    has caused or worsened social or interpersonal

DSM-IV Alcohol Dependence
  • A person's maladaptive pattern of alcohol use
    leads to clinically important distress or
    impairment, as shown in a single 12-month period
    by three or more of the following
  • tolerance
  • withdrawal
  • amount or duration of use often greater than
  • repeatedly trying without success to control or
    reduce alcohol use
  • spending much time using alcohol, recovering from
    its effects, or trying to obtain it
  • reducing or abandoning important work, social, or
    leisure activities because of alcohol use or
  • continuing to use alcohol, despite knowing that
    it has probably caused ongoing physical or
    psychological problems.

NLAES Data on Alcohol Abuse and Dependence by
Age, Race, Sex
1992 National Longitudinal Alcohol Epidemiology
Survey (NLAES)
  • Only 10 of the U.S. adult population currently
    abusing or dependent on alcohol had received any
    treatment in the 12 months prior to interview.
  • Only 28 of individuals with a past diagnosis of
    alcohol dependence reported ever having any kind
    of alcohol treatment.
  • 75 of the people who recovered from a previous
    alcohol disorder did so without having received
    any treatment, often termed natural recovery.

Costs of Alcohol Abuse to the Nation - 1990
  • Other Alcohol-related Costs 15.8 Billion
  • Crime (36)
  • Victims of crime (3)
  • Incarceration (30)
  • Motor vehicle crashes (24)
  • Fire destruction (4)
  • Social welfare administration (1)
  • Fetal Alcohol Syndrome 2.1 Billion
  • Total 98.6 Billion
  • Core Medical Expenditures 10.5 Billion
  • Specialty organizations (33)
  • Short-stay hospitals (44)
  • Nursing homes (10)
  • Support Other (13)
  • Indirect 70.3 Billion
  • Morbidity (52)
  • Mortality (48)

Rice, 1993 NIAAA, Alcohol Health, 1997
Percent distribution of principal (first-listed)
diagnoses among discharges with any (all-listed)
mention of an alcohol-related diagnosis, 1997
Trends in percent of discharges with principal
(first-listed) or any (all-listed) mention of an
alcohol-related diagnosis among all discharges,
The influence of alcohol on morbidity and
mortality Alcohol-Attributable Fractions (AAF)
  • AAF Age
  • Causes of death directly attributable
  • to alcohol 1.0 15
  • Diseases indirectly attributable to
    alcoholCancer of the esophagus 0.75 35Acute
    pancreatitis 0.42 35
  • Injuries and adverse effects indirectly
    attributable to alcoholMotor vehicle traffic and
  • non-traffic deaths 0.42 0Suicide and
    self-inflicted injury 0.28 15Homicide and
    injury purposefully
  • inflicted by others 0.46 15

Source Stinson, F.S., and DeBakey, S.F.,
Alcohol-related mortality in the United States,
1979-1988, Brit. J. Addict. 87777-783, 1992.
Death Rates and Premature Mortality by Years of
Potential Life Lost (YPLL), 1980.

  • Percent of Percent of

  • YPLL Deaths
  • Accidents, adverse effects 26.8
  • Suicides, homicides 14.0
  • Chronic liver disease, cirrhosis 3.0
  • Malignant neoplasms (CA) 18.0
  • Diseases of heart (CHD) 16.4
  • Cerebrovascular disease (CVD) 2.8 8.3

Age-adjusted death rates of liver cirrhosis by
sex (death registration States, 1910-32, and
United States, 1933-96)
Reductions in Problems During Prohibition
Source Moore Gerstein, 1981
Total and alcohol-related traffic fatality rates
per 100 million vehicle miles traveled (VMT),
United States, 1977-97
What Well Be Doing This Semester
  • Learning about various aspects of alcohol use,
    consequences, and dependence
  • Epidemiology
  • Assessment
  • Neurobiology
  • Genetics
  • Comorbidity
  • Personality and Motivation
  • Treatment
  • Prevention

What Well Be Doing This Semester (contd)
  • Getting training in various aspects of alcohol
  • Learning about other forms of substance use,
    abuse, and dependence
  • Have a chance to hear from a variety of
    scientists and clinicians with various
    perspectives on alcohol research

Alcohol Policies Levels, Types, Issues
  • Jurisdictional Level
  • Federal, state, county, municipal (or local
  • Type
  • Taxation/pricing, access, advertising,
    transportation, etc.
  • Legally based policies, enforcement, and justice
  • Institutional policies (e.g., schools, workplace,
  • Health services and public health measures
  • Science priorities and research policies
  • Issues
  • Studies of policy making, policy analysis
  • Evidentiary basis of policies and the role of

Prevention Policies
  • They are all policies that operate in a non-
    personalized way to alter the set of
    contingencies affecting individuals as they drink
    or engage in activities that (when combined with
    intoxication) are considered risky.

Moore Gerstein (1981), p 53 Beyond the Shadow
of Prohibition
Controversy in Optimal Policy Approaches
  • Single Distribution Theory (Ledermann Theory)
  • Posits that a substantial decrease in a
    populations mean (or per capita) consumption
    will be accompanied by a decrease in the
    prevalence of heavy drinkers
  • Harm Reduction Abates hazardous drinking
  • Attention is less on trying to modify everyones
    drinking, be it light or heavy, and more on
    policy measures targeting heavy quantity per
    occasion drinking patterns

Sources Skog, 1985 Edwards et al, 1994 Rehm et
al, 1996 Stockwell et al, 1997
Concentration of U.S. Alcohol Consumption
Greenfield Rogers, 1999
Economic costs of alcohol abuse by type, 1990
U.S. Data
(e.g., medical)
(e.g., crime, crashes)
Rice, 1993 NIAAA, Alcohol Health, 1997
Jurisdictional Levels Example Policies
  • Federal
  • Excise taxes
  • Transportation (e.g., Minimum Drinking Age,
  • Commercial regulation, labeling, advertising
  • Federal agencies NIAAA, SAMHSA, CDC, USDA, FTC,
    ATF, etc.
  • State
  • State alcohol taxes
  • Access alcohol distribution systems, State ABCs,
    retail monopolies, local options, regulating
    outlets, labeling, etc.
  • Server licensing, training, dram shop or server
  • Drinking driver laws mandatory license actions,

Price and Taxation Policies
  • Studies at both federal and state levels show
  • generally significant price effect on consumption
  • heavier drinkers are as or more affected than
    light ones
  • some studies have found affects on
    population-level problem indicators cirrhosis
    mortality, vehicular crashes
  • not particularly regressive tax measure compared
    to other commodity taxesthere is a lower burden
    on the poor
  • supported by public health experts, anathema to

Sources Coate Grossman, 1988 Babor et al,
1978 Cook Tauchen, 1982 Edwards et al, 1994
Drinking Driving Legislative Policies
  • Minimum Drinking Age (MDA)
  • Federal law required 21 year old MDA for states
    to receive national highway funds created
  • By mid 1980s all states adopted uniform MDA of
  • Changes before and after federal law provide
    natural experiments most studies found
    reductions in indicators
  • 1987 GAO Review
  • Reviewed 32 studies 14 deemed methodologically
  • Found reductions of from 5 to 28 in drivers
    under 21
  • Conclusion Sound scientific evidence for
    effectiveness of MDA policy

Sources Moore Gerstein, 1981 Edwards et al,
U.S. Adults Seeing Warning Label, 1993
Weighted percentages of subgroup. Source
Greenfield, 1994 Greenfield, 1997
Alcohol Access Regulation
  • Access primarily regulated at state and local
  • Responsibility of State Alcoholic Beverage
    Control agency
  • Monopoly States
  • By 2 years after Repeal, 15 states enacted retail
  • 1980s saw increasing deregulatory pressure with
    privatization of wine sales in Idaho, Maine,
    Virginia, and Washington (3 of 4 showed increased
    wine consumption) also Iowa, W. Virginia
  • Iowa and West Virginia case studied separately
    significant increase in wine consumption and net
    increase in ETOH

Sources Wagenaar Holder, 1991 Edwards et al,
1994 Holder Wagenaar, 1990.
Case Study Stiffening Regulatory Powers
  • 1994 California law gave ABC the right to
    rescind licenses
  • Outlet license revocation process began following
    3 cited infractions of sales to a minor within a
    3 year period (Three Strikes Bill)
  • California Supreme Court rules police can use
    minors as decoys
  • In 1997-98 law enforcement conducted 291 minor
    decoy operations, finding a 20.6 violation rate,
    down from 29.4 in 1993-94
  • ABC developed Grant Assistance to local Law
    Enforcement (GALE)
  • 1998 SB1696 introducedweakens decoy
  • Provided fourth strike notification on decoys,
    GALE funds redirected
  • Supported by retail groups, grocers, and beverage
  • Sponsor forced to compromise after intensive
    media advocacy

Sources Ryan Mosher, 2000 Grube, 1997
Server Intervention, RBS Programs
  • Steps servers take to reduce chance of
  • One third to one half alcohol-impaired drivers
    drank last at public placesbars or restaurants
  • 1980s Server intervention training demonstrated
  • Newer studies focus on factors enhancing
    effectiveness management incentives, enforcement
    of laws banning service to intoxicated patrons
    community involvement
  • State mandated training program for
  • Time-series analyses estimate 23 reduction in
  • State-wide mandated programs may assure critical
    mass of trained servers, with greater adoption
    of RBS practices

Sources Saltz, 1997 Holder Wagenaar, 1994
Workplace Policies
  • Workplace management style
  • Study contrasted U.S. traditional and Japanese
    management styles in 2 firms, same industry, same
  • Plant alcohol policies (and how genuine their
    enforcement) predicted drinking norms and alcohol
    availability on job
  • Social control and enabling mechanisms mediated
  • New studies investigate drinking off the job
  • Hangovers found to relate to job problems and
    sleep on job
  • Variation in experiences thwarts the formulation
    of simple worktime-hangover policies

Sources Ames et al, 2000 Ames et al, 1997
Moore, 1998
Summary and Conclusions
  • A wide range of legislative policies at various
    jurisdictional levels is currently regulating
    public alcohol commerce and use in the U.S. over
    time these evolve
  • In the last 20 years, policy analysis and
    evaluation has matured, demonstrating efficacy of
    model programs implementation and effectiveness
    studies are now underway and are accelerating
  • We need both policies that affect all drinkers
    and targeted harm reduction measures aimed at
    heavy drinkers and settings in which drinking
    large quantities is promoted
  • Policy development studies reveal opportunities
    and may improve strategies for enacting
    evidence-based policies

  • Health Services Research studies the
    organization, financing, utilization, costs,
    effectiveness, and outcomes of service delivery.
  • Service delivery includes alcoholism and other
    substance use treatment, mental health, general
    medical, emergency room, self-help, and any other
    service sectors.

Framework for Alcohol Health Services Research
Treatment Prevention
Source NIAAA, 1997.
One-Year Help-Seeking
  • Individuals with alcohol disorders or problem
  • ECA 11 specialty mental health/addictive
  • services 8 voluntary support network
  • NLAES 10
  • RAS 7-10

ECAEpidemiologic Catchment Area Studies,
NLAESNational Longitudinal Alcohol
Epidemiologic Survey, RASRural Alcohol Study
Regier et al., 1993 Grant, 1996 Booth et al.,
Distribution of Problem Drinkers in Health
Community Agencies
(One California County)
Source Weisner, 1995.
Interactions Between Clients Services
  • Client Characteristics
  • Demographics
  • Clinical
  • Access
  • Belief systems
  • System Characteristics
  • Organization
  • Financing

Client Characteristics
  • Demographics GENDER
  • Gender Disparities In Help-Seeking
  • Women less likely to enter alcoholism specialty
    treatment (not found in NLAES).
  • Women more likely to seek care in mental health
    or primary car/general medical settings.

Source Weisner et al., 1992 Grant, 1996
Kaskutas et al., 1997 Booth et al.,
2000. NLAESNational Longitudinal Alcohol
Epidemiologic Survey.
Client Characteristics
  • Alcohol use severity
  • Psychiatric comorbidity
  • Previous treatment
  • Alcohol consequences
  • symptoms DSM-IV alcohol use disorder (NLAES)
  • Diagnosis of alcohol disorder (NAS, NHIS)
  • Social consequences of drinking (NAS 1984 F/U,

Source Grant, 1997 Kaskutas et al, 1997 Booth
et al., 2000, Hasin Grant, 1995.
NLAESNational Longitudinal Alcohol
Epidemiologic Survey, RASRural Alcohol Study,
NASNational Alcohol Survey, NHISNational Health
Interview Survey
Client Characteristics
  • Availability availability in the geographic area
  • ? tremendous variation across U.S.
  • Accessibility travel time, driver's license, car
  • ? longer travel times reduce outpatient use
  • Affordability income, health plan, cost of care
  • ? NLAES employment
  • ? HIP better insurance coverage
  • Acceptability stigma
  • Accommodation convenience

Source Penchansky Thomas, 1981 Fortney et
al., 1995 Manning et al., 1996 Grant, 1997
Booth et al., 2000 Fortney Booth, in press.
RASRural Alcohol Study NLAESNational
Longitudinal Alcohol Epidemiologic Survey
HIPRAND Health Insurance Experiment
Rural/Urban Differences in Access
p Source Booth et al., 2000.
Independent Predictors of Help-Seeking
Booth et al., 2000. ORodds ratio, listed only
when p 65
Organization Financing of Care
  • Organization
  • Multiple Systems of Care
  • Match of Needs with Services
  • Financing
  • Employer-based Insurance
  • Publicly Financed Programs
  • Growth of Managed Care

Key Roles in the Alcohol Services System
Policy Makers Regulators
  • Payers
  • Employers
  • State Local Governments
  • Federal Government
  • Patients
  • Intermediaries
  • Managed Behavioral Health Care Organizations
  • Integrated Health Maintenance Organizations
  • Managed Indemnity Insurers

Patients or Clients
Population at Risk
Source Improving the Delivery of Alcohol
Treatment and Prevention Services, NIAAA, 1997.
Locations Providers of CareHelping With
The Rural Alcohol Study 40 service users
Source Booth et al., 2000.
Match of Client Needs with Services
  • Alcohol and Drug Use
  • Medical
  • Psychiatric
  • Social

Growth in Managed Care Enrollment, 1988-1996
Conventional 71
Conventional 26
Source Gabel and Hunt, 1996.
Impact of Managed Care
  • Public Sector
  • Massachusetts Medicaid carve-out
  • Overall expenditures reduced by 22
  • Substance abuse costs reduced by 48
  • Inpatient SA costs reduced 67
  • Outpatient SA costs increase 8
  • Access evidence mixed

Source Callahan et al., 1995 Frank McGuire,
Impact of Managed Care
  • Private Sector
  • 1995 Behavioral carve-out
  • 79 inpatient detox followed by care within 30
  • Higher copayments decreased follow-up
  • Per user costs higher for SA compared to MH
  • SA accounted for only 13 of behavioral health
    care costs/member
  • 1998 Health Care for Communities
  • Unmet need defined by no care LOWER in MC
  • Less care or delayed care GREATER in MC

Source Sturm Sherbourne, 2000 Schoenbaum et
al., 1998 Stein et al., 2000.
  • We need to understand
  • How to improve help-seeking and treatment
  • Changes in organization and financing of alcohol
    and other services.
  • Community perspective for policy and program