The Antidote to Alcohol Abuse: Sensible Drinking Messages

Stanton and Archie Brodsky, of Harvard Medical School, detail the remarkable differences in amount, style, and outcomes from drinking in Temperance and non-Temperance cultures (there is a strong negative correlation between volume of alcohol consumed in a country and AA membership in that country!). They derive from these stark data and similar information healthy and unhealthy group and cultural dimensions to the drinking experience and how these should be communicated in public health messages.

In Wine in Context: Nutrition, Physiology, Policy, Davis, CA: American Society for Enology and Viticulture, 1996, pp. 66-70

Morristown, NJ

Archie Brodsky
Program in Psychiatry and the Law
Harvard Medical School
Boston, MA

Cross-cultural research (medical as well as behavioral) shows that a no-misuse message about alcohol has sustained advantages over a no-use (abstinence) message. Cultures that accept responsible social drinking as a normal part of life have less alcohol abuse than cultures that fear and condemn alcohol. Moreover, moderate-drinking cultures benefit more from the well-documented cardioprotective effects of alcohol. Positive socialization of children begins with parental models of responsible drinking, but such modeling is often undermined by prohibitionist messages in school. Indeed, alcohol phobia in the US is so extreme that physicians are afraid to advise patients about safe levels of drinking.

The beneficial effect of alcohol, and especially of wine, in reducing the risk of coronary artery disease has been characterized in the American Journal of Public Health as "close to irrefutable" (30) and "robustly supported by the data" (20)—conclusions supported by editorials in this country's two leading medical journals (9,27). This thoroughly documented benefit of moderate wine consumption should now be made known to Americans as part of an accurate and balanced presentation of information about the effects of alcohol.

Some in the public-health and alcoholism fields worry that replacing the current "no-use" (abstinence-oriented) message with a "no-misuse" (moderation-oriented) message would lead to increased alcohol abuse. Yet worldwide experience shows that the adoption of the "sensible drinking" outlook would reduce alcohol abuse and its damaging effects on our health and well-being. To understand why, we need only compare the drinking patterns found in countries that fear and condemn alcohol with those of countries that accept moderate, responsible drinking as a normal part of life. This comparison makes clear that, if we really want to improve public health and reduce the damage resulting from alcohol abuse, we should convey constructive attitudes toward alcohol, especially in the physician's office and at home.

Temperance vs. Nontemperance Cultures

National comparisons: Table 1 is based on an analysis by Stanton Peele (30) that makes use of historian Harry Gene Levine's distinction between "temperance cultures" and "nontemperance cultures" (24). The temperance cultures listed in the table are nine predominantly Protestant countries, either English-speaking or Scandinavian/Nordic, that had widespread, sustained temperance movements in the 19th or 20th centuries, plus Ireland, which has had similar attitudes toward alcohol. The eleven nontemperance countries cover much of the rest of Europe.

Table 1 reveals the following findings, which probably would surprise most Americans:

1. Temperance countries drink less per capita than non-temperance countries. It is not a high overall level of consumption that creates anti-alcohol movements.
2. Temperance countries drink more distilled spirits; nontemperance countries drink more wine. Wine lends itself to mild, regular consumption with meals, whereas "hard liquor" is often consumed more intensively, drunk on weekends and in bars.
3. Temperance countries have six to seven times as many Alcoholics Anonymous (A.A.) groups per capita as nontemperance countries. Temperance countries, despite having much lower overall alcohol consumption, have more people who feel they have lost control of their drinking. There are often phenomenal differences in A.A. membership which are exactly opposed to the amount of drinking in a country: the highest ratio of A.A. groups in 1991 was in Iceland (784 groups/million people), which has among the lowest levels of alcohol consumption in Europe, while the lowest A.A. group ratio in 1991 was in Portugal (.6 groups/million people), which has among the highest levels of consumption.
4. Temperance countries have a higher death rate from atherosclerotic heart disease among men in a high-risk age group. Cross-cultural comparisons of health outcomes must be interpreted with caution because of the many variables, environmental and genetic, that may influence any health measure. Nonetheless, the lower death rate from heart disease in nontemperance countries seems to be related to the "Mediterranean" diet and lifestyle, including wine consumed regularly and moderately (21).

Levine's work on temperance and nontemperance cultures, while offering a rich field for research, has been limited to the Euro/English-speaking world. Anthropologist Dwight Heath has extended its application by finding similar divergences in drinking-related attitudes and behavior worldwide (14), including Native American cultures (15).

Ethnic groups in the U.S. The same divergent drinking patterns found in Europe—the countries in which people collectively drink more have fewer people who drink uncontrollably—also appear for different ethnic groups in this country (11). Berkeley's Alcohol Research Group has thoroughly explored the demographics of alcohol problems in the U.S. (6,7). One unique finding was that in conservative Protestant regions and dry regions of the country, which have high abstinence rates and low overall alcohol consumption, binge drinking and related problems are common. Likewise, research at the Rand Corporation (1) found that the regions of the country with the lowest alcohol consumption and highest abstinence rates, namely the South and Midwest, had the highest incidence of treatment for alcoholism.

Meanwhile, ethnic groups such as Jewish and Italian-Americans have very low abstinence rates (under 10 percent compared with a third of Americans at large) and also little serious problem drinking (6,11). Psychiatrist George Vaillant found that Irish-American men in an urban Boston population had a rate of alcohol dependency over their lifetimes 7 times as great as those from Mediterranean backgrounds (Greek, Italian, Jewish) living cheek by jowl in the same neighborhoods (33). How little alcoholism some groups may have was established by two sociologists who intended to show that the Jewish alcoholism rate was increasing. Instead, they calculated an alcoholism rate of one-tenth of one percent in an upstate New York Jewish community (10).

These findings are readily understandable in terms of different patterns of drinking and attitudes towards alcohol in different ethnic groups. According to Vaillant (33), for example, "It is consistent with Irish culture to see the use of alcohol in terms of black or white, good or evil, drunkenness or complete abstinence." In groups that demonize alcohol, any exposure to alcohol carries a high risk of excess. Thus drunkenness and misbehavior become common, almost accepted, outcomes of drinking. On the other side of the coin, the cultures that view alcohol as a normal and pleasurable part of meals, celebrations, and religious ceremonies are least tolerant of alcohol abuse. These cultures, which do not believe alcohol has the power to overcome individual resistance, disapprove of overindulgence and do not tolerate destructive drinking. This ethos is captured by the following observation of Chinese-American drinking practices (4):

Chinese children drink, and soon learn a set of attitudes that attend the practice. While drinking was socially sanctioned, becoming drunk was not. The individual who lost control of himself under the influence was ridiculed and, if he persisted in his defection, ostracized. His continued lack of moderation was regarded not only as a personal shortcoming, but as a deficiency of the family as a whole.

The attitudes and beliefs of cultures that successfully inculcate responsible drinking contrast with those that do not:

Moderate-Drinking (Nontemperance) Cultures

1. Alcohol consumption is accepted and is governed by social custom, so that people learn constructive norms for drinking behavior.
2. The existence of good and bad styles of drinking, and the differences between them, are explicitly taught.
3. Alcohol is not seen as obviating personal control; skills for consuming alcohol responsibly are taught, and drunken misbehavior is disapproved and sanctioned.

Immoderate-Drinking (Temperance) Cultures

1. Drinking is not governed by agreed-upon social standards, so that drinkers are on their own or must rely on the peer group for norms.
2. Drinking is disapproved and abstinence encouraged, leaving those who do drink without a model of social drinking to imitate; they thus have a proclivity to drink excessively.
3. Alcohol is seen as overpowering the individual's capacity for self-management, so that drinking is in itself an excuse for excess.

Those cultures and ethnic groups that are less successful at managing their drinking (and, indeed, our nation as a whole) would benefit greatly by learning from those that are more successful.

Transmitting drinking practices across generations: In cultures that have high rates of both abstinence and alcohol abuse, individuals often show considerable instability in their drinking patterns. Thus, many heavy drinkers will "get religion" and then just as frequently "fall off the wagon." Remember Pap, in Mark Twain's Huckleberry Finn, who swore off drinking and offered his hand to his new temperance friends:

There's a hand that was the hand of a hog; but it ain't so no more; it's the hand of a man that's started on a new life, and'll die before he'll go back.

Later that night, however, Pap

got powerful thirsty and clumb out onto the porch roof and slid down a stanchion and traded his new coat for a jug of forty-rod.

Pap got "drunk as a fiddler," fell and broke his arm, and "was froze most to death when somebody found him after sun-up."

Likewise, there is often considerable change within families which do not have stable norms about drinking. In a study of a middle-American community—the Tecumseh, Michigan study (12,13)—the drinking habits of one generation in 1960 were compared with their offspring's drinking in 1977. The results showed that moderate drinking practices are maintained more stably from one generation to the next than either abstinence or heavy drinking. In other words, children of moderate drinkers are more likely to adopt their parents' drinking habits than children of abstainers or of heavy drinkers.

Although parents who are heavy drinkers inspire a higher-than-average incidence of heavy drinking in their children, this transmission is far from inevitable. Most children do not imitate an alcoholic parent. Instead, they learn as a result of their parents' excesses to limit their alcohol intake. What about the children of abstainers? Children raised in an abstemious religious community may well continue to abstain as long as they remain safely within that community. But children in such groups often move and leave behind the moral influence of the family or community from which they came. In this way, abstinence is often challenged in a mobile society like our own, one in which most people do drink. And young people with no training in responsible drinking can more readily be tempted to indulge in unrestrained binges if that is what is going on around them. We often see this, for example, among young people who join a college fraternity or who enter the military.

Reeducating Our Culture

We in the United States have ample positive models of drinking to emulate, both in our own country and around the world. We have all the more reason to do so now that the federal government has revised its Dietary Guidelines for Americans (32) to reflect the finding that alcohol has substantial health benefits. Beyond such official pronouncements, there are at least two crucial contact points to reach people with accurate and useful instruction about drinking.

Positive socialization of the young: We can best prepare young people to live in a world (and a nation) where most people do drink by teaching them the difference between responsible and irresponsible drinking. The most reliable mechanism for doing this is the positive parental model. Indeed, the single most crucial source of constructive alcohol education is the family that puts drinking in perspective, using it to enhance social gatherings in which people of all ages and both genders participate. (Picture the difference between drinking with your family and drinking with "the boys.") Alcohol does not drive the parents' behavior: it doesn't keep them from being productive, and it doesn't make them aggressive and violent. By this example, children learn that alcohol need not disrupt their lives or serve as an excuse for violating normal social standards.

Ideally, this positive modeling at home would be reinforced by sensible-drinking messages in school. Unfortunately, in today's neotemperance times, alcohol education in school is dominated by a prohibitionist hysteria that cannot acknowledge positive drinking habits. As with illicit drugs, all alcohol use is classified as misuse. A child who comes from a family in which alcohol is drunk in a convivial and sensible manner is thus bombarded by exclusively negative information about alcohol. Although children may parrot this message in school, such an unrealistic alcohol education is drowned out in high-school and college peer groups, where destructive binge-drinking has become the norm (34).

To illustrate this process with one ludicrous example, a high-school newsletter for entering freshmen told its youthful readers that a person who begins to drink at age 13 has an 80 percent chance of becoming an alcoholic! It added that the average age at which children begin to drink is 12 (26). Does that mean that nearly half of today's children will grow up to be alcoholic? Is it any wonder that high-school and college students cynically dismiss these warnings? It seems as though schools want to tell children as many negative things as possible about alcohol, whether or not they stand any chance of being believed.

Recent research has found that antidrug programs like DARE are not effective (8). Dennis Gorman, the Director of Prevention Research at the Rutgers Center of Alcohol Studies, believes this is due to the failure of such programs to address the community milieu where alcohol and drug use occurs (18). It is especially self-defeating to have the school program and family and community values in conflict. Think of the confusion when a child returns from school to a moderate-drinking home to call a parent who is drinking a glass of wine a "drug abuser." Often the child is relaying messages from AA members who lecture school children about the dangers of alcohol. In this case, the blind (uncontrolled drinkers) are leading the sighted (moderate drinkers). This is wrong, scientifically and morally, and counterproductive for individuals, families, and society.

Physician interventions: Along with bringing up our children in an atmosphere that encourages moderate drinking, it would be useful to have a nonintrusive way to help adults monitor their consumption patterns, i.e., to provide a periodic check on a habit that, for some, can get out of hand. Such a corrective mechanism is available in the form of brief interventions by physicians. Brief interventions can substitute for, and have been found superior to, specialized alcohol-abuse treatments (25). In the course of a physical examination or other clinical visit, the physician (or other health professional) asks about the patient's drinking and, if necessary, advises the patient to change the behavior in question so as to reduce the health risks involved (16).

Medical research worldwide shows that brief intervention is as effective and cost-effective a treatment as we have for alcohol abuse (2). Yet so extreme is the ideological bias against any alcohol consumption in the U.S. that physicians are afraid to advise patients about safe levels of drinking. While European physicians routinely dispense such advice, physicians in this country hesitate even to suggest that patients reduce their consumption, for fear of implying that some level of drinking can be positively recommended. In an article in a prominent U.S. medical journal, Dr. Katharine Bradley and her colleagues urge physicians to adopt this technique (5). They write: "There is no evidence from studies of heavy drinkers in Britain, Sweden, and Norway that alcohol consumption increases when heavy drinkers are advised to drink less; in fact it decreases."

So much for the fear that people cannot be trusted to hear balanced, medically sound information about the effects of alcohol.

Can We Turn a Temperance Culture Into a Culture of Moderation?

In the uneasy mix of ethnic drinking cultures that we call the United States of America, we see the bifurcation characteristic of a temperance culture, with a large number of abstainers (30%) and small but still troubling minorities of alcohol-dependent drinkers (5%) and nondependent problem drinkers (15%) among the adult population (19). Even so, we have a large culture of moderation, with the largest category (50%) of adult Americans being social, nonproblem drinkers. Most Americans who drink do so in a responsible manner. The typical wine drinker generally consumes 2 or fewer glasses on any given occasion, usually at mealtimes and in the company of family or friends.

And yet, still driven by the demons of the Temperance movement, we are doing our best to destroy that positive culture by ignoring or denying its existence. Writing in American Psychologist (28), Stanton Peele noted with concern that "the attitudes that characterize both ethnic groups and individuals with the greatest drinking problems are being propagated as a national outlook." He went on to explain that "a range of cultural forces in our society has endangered the attitudes that underlie the norm and the practice of moderate drinking. The widespread propagation of the image of the irresistible dangers of alcohol has contributed to this undermining."

Selden Bacon, a founder and long-time director of what became the Rutgers Center of Alcohol Studies, has graphically described the perverse negativism of alcohol "education" in the U.S. (3):

Current organized knowledge about alcohol use can be likened to...knowledge about automobiles and their use if the latter were limited to facts and theories about accidents and crashes.... [What is missing are] the positive functions and positive attitudes about alcohol uses in our as well as in other societies.... If educating youth about drinking starts from the assumed basis that such drinking is bad [and]...full of risk for life and property, at best considered as an escape, clearly useless per se, and/or frequently the precursor of disease, and the subject matter is taught by nondrinkers and antidrinkers, this is a particular indoctrination. Further, if 75-80% of the surrounding peers and elders are or are going to become drinkers, there [is]...an inconsistency between the message and the reality.

What is the result of this negative indoctrination? During the past few decades per capita alcohol consumption in the U.S. has declined, yet the number of problem drinkers (according to clinical and self-identification) continues to rise, especially in younger age groups (17,31). This frustrating trend contradicts the notion that reducing the overall consumption of alcohol—by restricting availability or raising prices—will result in fewer alcohol problems, even though this panacea is widely promoted in the public-health field (29). Doing something meaningful about alcohol abuse requires a more profound intervention than "sin taxes" and restricted hours of operation; it requires cultural and attitudinal changes.

We can do better than we are; after all, we once did do better. In eighteenth-century America, when drinking took place more in a communal context than it does now, per capita consumption was 2-3 times current levels, but drinking problems were rare and loss of control was absent from contemporary descriptions of drunkenness (22,23). Let's see if we can recover the poise, balance, and good sense our founding fathers and mothers showed in dealing with alcohol.

It is long past time to tell the American people the truth about alcohol, instead of a destructive fantasy that too often becomes a self-fulfilling prophecy. Revising the Dietary Guidelines for Americans is a necessary, but not sufficient condition for transforming a culture of abstinence warring with excess into a culture of moderate, responsible, healthy drinking.

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