ALCOHOL

INTRODUCTION

The sociological study of alcohol in society is concerned with two broad areas. (1) The first area is the study of alcohol behavior, which includes: (a) social and other factors in alcohol behavior, (b) the prevalence of drinking in society, and (c) the group and individual variations in drinking and alcoholism. (2) The second major area of study has to do with social control of alcohol, which includes: (a) the social and legal acceptance or disapproval of alcohol (social norms), (b) the social and legal regulations and control of alcohol in society, and (c) efforts to change or limit deviant drinking behavior (informal sanctions, law enforcement, treatment, and prevention). Only issues related to the first area of study, sociology of alcohol behavior, will be reviewed here.

PHYSICAL EFFECTS OF ALCOHOL

There are three major forms of beverages containing alcohol (ethanol) that are regularly consumed. Wine is made from fermentation of fruits and usually contains up to 14 percent of ethanol by volume. Beer is brewed from grains and hops and contains 3 to 6 percent ethanol. Liquor (whisky, gin, vodka, and other distilled spirits) is usually 40 percent (80 proof) to 50 percent (100 proof) ethanol. A bottle of beer (12 ounces), a glass of wine (4 ounces), and a cocktail or mixed drink with a shot of whiskey in it, therefore, each have about the same absolute alcohol content, one-half to three-fourths of an ounce of ethanol.

Alcohol is a central nervous system depressant, and its physiological effects are a direct function of the percentage of alcohol concentrated in the body’s total blood volume (which is determined mainly by the person’s body weight). This concentration is usually referred to as the BAC (blood alcohol content) or BAL (blood alcohol level). A 150-pound man can consume one alcoholic drink (about three-fourths of an ounce) every hour essentially without physiological effect. The BAC increases with each additional drink during that same time, and the intoxicating effects of alcohol will become noticeable. If he has four drinks in an hour, he will have an alcohol blood content of .10 percent, enough for recognizable motor-skills impairment. In almost all states, operating a motor vehicle with a BAC between .08 percent and .10 percent (determined by breathalyzer or blood test) is a crime and is subject to arrest on a charge of DWI (driving while intoxicated). At .25 percent BAC (about ten drinks in an hour) the person is extremely drunk, and at .40 percent BAC the person loses consciousness. Excessive drinking of alcohol over time is associated with numerous health problems. Cirrhosis of the liver, hepatitis, heart disease, high blood pressure, brain dysfunction, neurological disorders, sexual and reproductive dysfunction, low blood sugar, and cancer, are among the illnesses attributed to alcohol abuse (National Institute on Alcohol Abuse and Alcoholism 1981, 1987; Royce 1990; Ray and Ksir 1999).

SOCIAL FACTORS IN ALCOHOL BEHAVIOR

Alcohol has direct effects on the brain, affecting motor skills, perception, and eventually consciousness. The way people actually behave while drinking, however, is only partly a function of the direct physical effects of ethanol. Overt behavior while under the influence of alcohol depends also on how they have learned to behave while drinking in the setting and with whom they are drinking with at the time. Variations in individual experience, group drinking customs, and the social setting produce variations in observable behavior while drinking. Actions reflecting impairment of coordination and perception are direct physical effects of alcohol on the body. These physical factors, however, do not account for ”drunken comportment”— the behavior of those who are ”drunk” with alcohol before reaching the stage of impaired muscular coordination (MacAndrew and Edgerton 1969). Social, cultural, and psychological factors are more important in overt drinking behavior. Cross-cultural studies (MacAndrew and Edgerton 1969), surveys in the United States (Kantor and Straus 1987), and social psychological experiments (Marlatt and Rohsenow 1981), have shown that both conforming and deviant behavior while ”under the influence” are more a function of sociocultu-ral and individual expectations and attitudes than the physiological and behavioral effects of alcohol. (For an overview of sociocultural perspectives on alcohol use, see Pittman and White 1991)

Sociological explanations of alcohol behavior emphasize these social, cultural, and social psychological variables not only in understanding the way people act when they are under, or think they are under, the influence of alcohol but also in understanding differences in drinking patterns at both the group and individual level. Sociologists see all drinking behavior as socially patterned, from abstinence, to moderate drinking, to alcoholism. Within a society persons are subject to different group and cultural influences, depending on the communities in which they reside, their group memberships, and their location in the social structure as defined by their age, sex, class, religion, ethnic, and other statuses in society. Whatever other biological or personality factors and mechanisms may be involved, both conforming and deviant alcohol behavior are explained sociologically as products of the general culture and the more immediate groups and social situations with which individuals are confronted. Differences in rates of drinking and alcoholism across groups in the same society and cross-nationally reflect the varied cultural traditions regarding the functions alcohol serves and the extent to which it is integrated into eating, ceremonial, leisure, and other social contexts. The more immediate groups within this sociocultural milieu provide social learning environments and social control systems in which the positive and negative sanctions applied to behavior sustain or discourage certain drinking according to group norms. The most significant groups through which the general cultural, religious, and community orientations toward drinking have an impact on the individual are family, peer, and friendship groups, but secondary groups and the media also have an impact. (For a social learning theory of drinking and alcoholism that specifically incorporates these factors in the social and cultural context see Akers 1985, 1998; Akers and La Greca 1991. For a review of sociological, psychological, and biological theories of alcohol and drug behavior see Goode 1993.)

SOCIAL CHARACTERISTICS AND TRENDS IN DRINKING BEHAVIOR

Age. Table 1 shows that by time of high school graduation, the percentages of current teenage drinkers (still under the legal age) is quite high, rivaling that of adults. The peak years for drinking are the young adult years (eighteen to thirty-four), but these are nearly equaled by students who are in the last year of high school (seventeen to eighteen years of age). For both men and women, the probability that one will drink at all stays relatively high from that time up to age thirty-five; about eight out of ten are drinkers, two-thirds are current drinkers, and one in twenty are daily drinkers. The many young men and women who are in college are even more likely to drink (Berkowitz and Perkins 1986; Wechsler et al. 1994). Heavy and frequent drinking peaks out in later years, somewhat sooner for men than women. After that the probability for both drinking and heavy drinking declines noticeably, particularly among the elderly. After the age of sixty, both the proportion of drinkers and of frequent or heavy drinkers decrease. Studies in the general population have consistently found that the elderly are less likely than younger persons to be drinkers, heavy drinkers, and problem drinkers.

Sex. The difference is not as great as it once was, but more men than women drink and have higher rates of problem drinking in all age, religious, racial, social class, and ethnic groups and in all regions and communities. Teenage boys are more likely to drink and to drink more frequently than girls, but the difference between male and female percentages of current drinkers at this age is less than it is in any older age group. Among adults, men are three to four times more likely than women (among the elderly as much as ten times more likely) to be heavy drinkers and two to three times more likely to report negative personal and social consequences of drinking (National Institute on Alcohol Abuse and Alcoholism 1987).

Table 1: Percentages Reporting Drinking by Age Group (1997)

Social Class. The proportion of men and women who drink is higher in the middle class and upper class than in the lower class. The more highly educated and the fully employed are more likely to be current drinkers than the less educated and unemployed. Drinking by elderly adults increases as education increases, but there are either mixed or inconsistent findings regarding the variations in drinking by occupational status, employment status, and income.

Community and Location. Rates of drinking are higher in urban and suburban areas than in small towns and rural areas. As the whole country has become more urbanized the regional differences have leveled out so that, while the South continues to have the lowest proportion of drinkers, there is no difference among the other regions for both teenagers and adults. Although there are fewer of them in the South, those who do drink tend to drink more per person than drinkers in other regions (National Institute on Alcohol Abuse and Alcoholism 1998a).

Race, Ethnicity, and Religion. The percent of drinking is higher among both white males and females than among African-American men and women. Drinking among non-Hispanic whites is also higher than among Hispanic whites. The proportion of problem or heavy drinkers is about the same for African Americans and white Americans (Fishburne et al. 1980; National Institute on Drug Abuse, 1988; National Institute on Alcohol Abuse and Alcoholism 1998a). There may be a tendency for blacks to fall into the two extreme categories, heavy drinkers or abstainers (Brown and Tooley 1989), and black males suffer the highest rate of mortality from cirrhosis of the liver (National Institute on Alcohol Abuse and Alcoholism 1998b). American Indians and Alaskan Natives have rates of alcohol abuse and problems several times the rates in the general population (National Institute on Alcohol Abuse and Alcoholism 1987).

Catholics, Lutherans, and Episcopalians have relatively high rates of drinking. Relatively few fundamentalist Protestants, Baptists, and Mormons drink. Jews have low rates of problem drinking, and Catholics have relatively high rates of alcoholism. Irish Americans have high rates of both drinking and alcoholism. Italian Americans drink frequently and heavily but apparently do not have high rates of alcoholism (see Cahalan et al. 1967; Mulford 1964). Strong religious beliefs and commitment, regardless of denominational affiliation, inhibit both drinking and heavy drinking among teenagers and college students (Cochran and Akers 1989; Berkowitz and Perkins 1986).

Trends in Prevalence of Drinking. There has been a century-long decline in the amount of absolute alcohol consumed by the average drinker in the United States. There was a period in the 1970s when the per capita consumption increased, and the proportion of drinkers in the population was generally higher by the end of the 1970s than at the beginning of the decade, although there were yearly fluctuations up and down. The level of drinking among men was already high, and the increases came mainly among youth and women. But in the 1980s the general downward trend resumed (Keller 1958; National Institute on Alcohol Abuse and Alcoholism 1981, 1987, 1998). Until the 1980s, this per capita trend was caused mainly by the increased use of lower-content beer and wine and the declining popularity of distilled spirits rather than a decreasing proportion of the population who are drinkers.

Alcohol-use rates were quite high in the United States throughout the 1970s and into the 1980s (see table 2). Since then, there have been substantial declines in use rates in all demographic categories and age groups. In 1979 more than two-thirds of American adolescents (twelve to seventeen years of age) had some experience with alcohol and nearly four out of ten were current drinkers (drank within the past month). In 1988, these proportions had dropped to one-half and one-fourth respectively. In 1997, adolescent rates had dropped even lower to four out of ten having ever used alcohol and only two out of ten reporting use in the past month. Current use in the general U.S. population (aged twelve and older) declined from 60 percent in 1985 to 51 percent in 1997. Among the adult population eighteen years of age and older, current use declined from 71 percent in 1985 to 55 percent in 1997. Lifetime use rates have also declined from 88.5 percent in 1979 to 81.9 percent in 1997 (aged twelve and older). Generally, there have been declines in both annual (past year) prevalence of drinking (decreases of 3 to 5 percent) and current (past month) prevalence of drinking (decreases of 7 to 10 percent) among high school seniors, young adults, and older adults. Although lifetime prevalence is not a sensitive measure of short-term change in the adult population (since the lifetime prevalence is already fixed for the cohort of adults already sampled in previous surveys), it does reflect an overall decline in alcohol use. It should be remembered, however, that most of this is light to moderate consumption; the modal pattern of drinking for all age groups in the United States has long been and continues to be nondeviant, light to moderate social drinking.

The relative size of the reductions in drinking prevalence over the last two decades have been rather substantial; however, the proportions of drinkers remains high. By the time of high school graduation, one-half of adolescents are current drinkers and the proportion of drinkers in the population remains at this level throughout the young adult years. Three-fourths of high school seniors and young adults and two-thirds of adults over the age of thirty-five have consumed alcohol in the past year (see table 1).

Although lifetime use and current use rates appear to be continuing a slight decline in all categories, there have been some slight increases in rates of frequent (daily) drinking among high school seniors and young adults. While these increases do not approach the rates observed in the 1980s they may indicate that the overall rates are stabilizing and hint of possible increases in alcohol use rates in the future.

Estimates of Prevalence of Alcoholism. In spite of these trends in lower levels of drinking, alcoholism remains one of the most serious problems in American society. Alcohol abuse and all of the problems related to it cause enormous personal, social, health, and financial costs in American society. Cahalan et al. (1969) in a 1965 national survey characterized 6 percent of the general adult population and 9 percent of the drinkers as ”heavy-escape” drinkers, the same figures reported for a 1967 survey (Cahalan 1970). These do not seem to have changed very much in the years since. They are similar to findings in national surveys from 1979 to 1988 (National Institute on Alcohol Abuse and Alcoholism 1981, 1987, 1988, 1989; Clark and Midanik 1982), which support an estimate that 6 percent of the general population are problem drinkers and that about 9 percent of those who are drinkers will abuse or fail to control their intake of alcohol. Royce (1989) and Vaillant (1983) both estimate that 4 percent of the general population in the United States are ”true” alcoholics. This estimate would mean that there are perhaps 10.5 million alcoholics in American society (see also Liska 1997). How many alcoholics or how much alcohol abuse there is in our society is not easily determined because the very concept of alcoholism (and therefore what gets counted in the surveys and estimates) has long been and remains controversial.

Percentages Reporting Lifetime, Past Year, and Past Month Use of Alcohol in the U.S. Population Aged 12 and Older (1979-1997)

THE CONCEPT OF ALCOHOLISM

The idea of alcoholism as a sickness traces back at least 200 years (Conrad and Schneider 1980). There is no single, unified, disease concept, but the prevailing concepts of alcoholism today revolve around the one developed by E. M. Jellinek (1960) from 1940 to 1960. Jellinek defined alcoholism as a disease entity that is diagnosed by the ”loss of control” over one’s drinking and that progresses through a series of clear-cut ”phases.”

The final phase of alcoholism means that the person is rendered powerless by the disease to drink in a controlled, moderate, nonproblematic way.

The disease of alcoholism is viewed as a disorder or illness for which the individual is not personally responsible for having contracted. It is viewed as incurable in the sense that alcoholics can never truly control their drinking. That is, sobriety can be achieved by total abstention, but if even one drink is taken, the alcoholic cannot control how much more he or she will consume. It is a ”primary” self-contained disease that produces the problems, abuse, and ”loss of control” over drinking by those suffering from this disease. It can be controlled through proper treatment to the point where the alcoholic can be helped to stop drinking so that he or she is in ”remission” or ”recovering.” ”Once an alcoholic, always an alcoholic” is a central tenet of the disease concept. Thus, one can be a sober alcoholic, still suffering from the disease even though one is consuming no alcohol at all. Although the person is not responsible for becoming sick, he or she is viewed as responsible for aiding in the cure by cooperating with the treatment regimen or participation in groups such as Alcoholics Anonymous.

The disease concept is the predominant one in public opinion and discourse on alcohol (according to a 1987 Gallup Poll, 87 percent of the public believe that alcoholism is a disease). It is the principal concept used by the vast majority of the treatment professionals and personnel offering programs for alcohol problems. It receives widespread support among alcohol experts and continues to be vigorously defended by many alcohol researchers (Keller 1976; Vaillant 1983; Royce 1989). Alcoholics Anonymous, the largest single program for alcoholics in the world, defines alcoholism as a disease (Rudy 1986). The concept of alcoholism as a disease is the officially stated position of the federal agency most responsible for alcohol research and treatment, the National Institute of Alcoholism and Alcohol Abuse (National Institute on Alcohol Abuse and Alcoholism 1987).

Nonetheless, many sociologists and behavioral scientists remain highly skeptical and critical of the disease concept of alcoholism (Trice 1966; Cahalan and Room 1974; Conrad and Schneider 1980; Rudy 1986; Fingarette 1988, 1991; Peele 1989). The concept may do more harm than good by discouraging many heavy drinkers who are having problems with alcohol, but who do not identify themselves as alcoholics or do not want others to view them as sick alcoholics, from seeking help. The disease concept is a tautological (and therefore untestable) explanation for the behavior of people diagnosed as alcoholic. That is, the diagnosis of the disease is made on the basis of excessive, problematic alcohol behavior that seems to be out of control, and then this diagnosed disease entity is, in turn, used to explain the excessive, problematic, out-of-control behavior.

In so far as claims about alcoholism as a disease can be tested, ”Almost everything that the American public believes to be the scientific truth about alcoholism is false” (Fingarette 1988, p.1; see also Peele 1989; Conrad and Schneider 1980; Fingarette 1991; Akers 1992). The concept preferred by these authors and by other sociologists is one that refers only to observable behavior and drinking problems. The term alcoholism then is nothing more than a label attached to a pattern of drinking that is characterized by personal and social dsyfunctions (Mulford and Miller 1960; Conrad and Schneider 1980; Rudy 1986: Goode 1993). That is, the drinking is so frequent, heavy, and abusive that it produces or exacerbates problems for the drinker and those around him or her including financial, family, occupational, physical, and interpersonal problems. The heavy drinking behavior and its attendant problems are themselves the focus of explanation and treatment. They are not seen as merely symptoms of some underlying disease pathology. When drinking stops or moderate drinking is resumed and drinking does not cause social and personal problems, one is no longer alcoholic. Behavior we label as alcoholic is problem drinking that lies at one extreme end of a continuum of drinking behavior with abstinence at the other end and various other drinking patterns in between (Cahalan et al. 1969). From this point of view, alcoholism is a disease only because it has been socially defined as a disease (Conrad and Schneider 1980; Goode 1993).

Genetic Factors in Alcoholism. Contrary to what is regularly asserted, evidence that there may be genetic, biological factors in alcohol abuse is evidence neither in favor of nor against the disease concept, any more than evidence that there may be genetic variables in criminal behavior demonstrates that crime is a disease. Few serious researchers claim to have found evidence that a specific disease entity is inherited or that there is a genetically programmed and unalterable craving or desire for alcohol. It is genetic susceptibility to alcoholism that interacts with the social environment and the person’s drinking experiences, rather than genetic determinism, that is the predominant perspective.

The major evidence for the existence of hereditary factors in alcoholism comes from studies that have found greater ”concordance” between the alcoholism of identical twins than between siblings and from studies of adoptees in which offspring of alcoholic fathers were found to have an increased risk of alcoholism even though raised by nonalcoholic adoptive parents (Goodwin 1976; National Institute on Alcohol Abuse and Alcoholism 1982; U.S. Department of Health and Human Services 1987; for a review and critique of physiological and genetic theories of alcoholism see Rivers 1994). Some have pointed to serious methodological problems in these studies that limit their support for inherited alcoholism (Lester 1987). Even the studies finding evidence for an inherited alcoholism report that only a small minority of those judged to have the inherited traits become alcoholic and an even smaller portion of all alcoholics have indications of hereditary tendencies. Whatever genetic variables there are in alcoholism apparently come into play in a small portion of cases. Depending upon the definition of alcoholism used, the research shows that biological inheritance either makes no difference at all or makes a difference for only about one out of ten alcoholics. Social and social psychological factors are the principal variables in alcohol behavior, including that which is socially labeled and diagnosed as alcoholism (Fingarette 1988; Peele 1989).