Epidemiology, as a field, is concerned with the distribution and determinants of health and diseases, morbidity, injuries, disability and mortality in populations (Friis & Sellers, 1999). In the alcohol field, epidemiology is defined as the study of:
patterns of alcohol use, abuse, and dependence;
the developmental course of alcohol problems within a community or population; and,
factors that are associated with an increased risk or susceptibility in a population for developing alcohol-related problems, alcohol abuse, or dependence.
This unit presents basic knowledge concerning the definition and description of alcohol use and alcohol-related problems, as well as demographic characteristics and recent historical trends in alcohol use, abuse and dependence. The importance to social work practice of a relationship between level of alcohol consumption and health effects are addressed.
Epidemiological knowledge can (1) lead to the development of early intervention and prevention practices, (2) evaluate the impact of interventions at the community and population levels, (3) identify populations at-risk for alcohol problems, and (4) contribute to changes in social policy. Ultimately, epidemiological research illustrates the global context of social work practice by providing a foundation for comparisons within and between nations. The social work values conveyed in this unit include emphasis on the importance of using data that can inform social work practice; recognition of diversity in patterns of alcohol use, abuse, and dependence as contributing to culturally competent practice; and respecting the relationship between alcohol problems and other client system concerns faced in social work practice.
Learning ObjectivesBy the end of this module, learners should be able to:
A. Define and describe the demographic characteristics and recent historical trends of alcohol use, alcohol abuse/dependence and other alcohol-related problems.
B. Identify the relationship between level of alcohol use and health effects including poor pregnancy outcomes, interpersonal violence, homicide, and accidental death.
C. Recognize the implications of using epidemiological data for the early intervention and prevention of alcohol problems, and for evaluating intervention impact.
Defining Alcohol UseThroughout history, alcoholic beverages have played a major role in people's lives. Alcohol in our society has been consumed with meals, served for medicinal or religious purposes, used to celebrate special occasions, and served as a social facilitator. While most individuals who drink alcoholic beverages do not develop problems with, or dependence on, alcohol, many social workers encounter high rates of alcohol problems among the clients they serve. An epidemiological approach fits the social work frame of reference because epidemiologists use an ecological approach in their search for causality. This assumes that multiple risk, vulnerability, and resilience factors interact between a person and environmental contexts. Epidemiological studies provide social workers with science-based information for use in clinical practice, service delivery, prevention program planning, policy planning, and program and policy evaluation. Epidemiologists who study alcohol use address: (1) the distribution of alcohol consumption, (2) drinking patterns, (3) alcohol abuse and dependence, and (4) alcohol-related problems.
- The basic measure of the frequency of alcohol use or alcohol-related problems in a community or a population is a rate.
The rate is a measure of disease frequency in relation to a unit of population, during a specific period of time. The numerator is the amount of disease in a population and the denominator is the reference population at a given period in time. For instance, the rate of alcohol dependence in the U.S. general population can be represented by a fraction whose numerator is the number of individuals in the U.S. with alcohol dependence during a certain period of time (for example, a particular 12 month period like the year 2004) and whose denominator is the U.S. population segment of interest (for example, those 18 years of age and older) during that same time period, and multiplied by 100.
- The most widely used rates are 'incidence' and 'prevalence' rates.
The incidence of a disease is the rate at which new cases occur in a population during a specified period of time. Incidence provides an estimate of the risk of developing the disease during a specified time period. The numerator is the number of new cases of a specific disease and the denominator is the population at risk during the same period of time (the population who has not been diagnosed as a case in the past). For example, it might be the number of individuals in a specific geographical region (county, state, or nation) who are first identified as alcohol dependent between January and December of the last full calendar year compared to the at-risk population within that area, during that time.
The prevalence of a disease is the proportion of cases that exist in a population at a given point in time. Prevalence provides an estimate of the probability that an individual will have the disease at a point in time. The numerator is the number of existing cases of a disease and the denominator is the total population, at a specific point in time. In cases where disease manifestations are sporadic, a 'point' prevalence based on a single examination at one point in time will underestimate the disease's total frequency. If multiple assessments of the same individuals are possible, a better measure would be the 'period' prevalence. This is defined as the proportion of a population that represents cases at any time within a stated period (e.g., last month, last year, last decade).Measures of alcohol use vary across studies, depending on the methodology and definitions used. For example, a survey study of alcohol use disorders might define a new case by the age or year of first use or first intoxication. On the other hand, defining the age of onset for the clinical disorder of alcohol dependence relies on the age when an individual first experienced any of the symptoms for diagnosis of alcohol dependence. Recently, a more conservative approach has been taken by defining the age of onset of an alcohol use disorder as the age of occurrence of the third dependence symptom or the age when symptoms first clustered (i.e., two or more symptoms occurred within a single calendar year).
- Another aspect used in the calculation of epidemiological rates is the measurement of the amount of alcohol consumed. Commercially available beverage alcohol is sold in various sizes and concentrations. Beer, wine, and distilled spirits contain different concentrations of absolute ethanol and are available in different size containers. Consequently, the investigation of patterns of alcohol use requires a common definition of a 'unit' of beverage alcohol. If different studies use definitions of a 'standard drink' that are unique to each study, it will be difficult to compare findings across studies. Without some standardization of drinking units, varying levels of alcohol consumption cannot be obtained across subjects, even when subjects report consuming the same number of 'drinks' (Turner, 1990; DuFour, 1999).
Note: People buy many of these drinks in containers that hold multiple standard drinks. For example, malt liquor is often sold in 16-, 22- or 40 oz. containers that hold between two and five standard drinks, and table wine is typically sold in 25 oz (750ml.) bottles that hold five standard drinks.
Currently, there is no universally accepted definition of a standard drink. However, the National Institute on Alcohol Abuse and Alcoholism (NIAAA, NIH) has published this definition (Dawson, 2003). According to this guideline, a standard drink contains 0.5 fl oz of absolute ethanol and corresponds to 12 fl oz of regular beer, 5 fl oz of wine, or 1.5 fl oz of 80 proof distilled spirits.
Describing Alcohol Use and Abuse
Alcohol problems refer to any situation caused by drinking which directly harms the drinker, places the drinker at risk, or places others at risk. Alcohol use problems exist on a continuum of severity from occasional binge drinking to alcohol abuse or dependence. Alcohol abuse is described as continued drinking despite adverse effects on: health; family, work, or personal relationships; interpersonal problems; or alcohol-related legal problems (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2001a). The most severe type of alcohol problem is alcohol dependence or alcoholism. Alcohol dependence is a chronic disease characterized by physical withdrawal symptoms in the absence of alcohol consumption or the need to drink substantially large amounts despite continued alcohol-related problems and cognitive, behavioral, and physiologic symptoms (NIAAA, 2000). It is important to note that the risk for developing alcohol dependence varies due to individual factors such as genetics, personality, behavior, and environment.
Epidemiologists are concerned with several different alcohol consumption measures. One is volume of drinking. This is the number of standard drinks, grams of ethanol, or gallons of absolute alcohol consumed in a given time frame. The second is drinking patterns. This relies on an index that classifies drinkers based on both the frequency and quantity of their drinking (e.g., abstainer, infrequent, less frequent, frequent, frequent heavy). The third is high risk drinking. This refers to patterns of drinking which have been associated with an increased risk of problem development (e.g., drinking that brings blood alcohol concentrations to 0.08 gm% or above).
One of the ways in which epidemiologists study alcohol consumption in the U.S. is by tracking per capita alcohol consumption based on sales statistics. This information enables epidemiologists to approximate the amount of alcohol consumed by each individual in the nation who could be drinking alcoholic beverages. Prior to 1970, the U.S. per capita consumption rate was computed by dividing the total alcohol beverage sales by the total number of residents aged 15 years or older. Since 1970, the denominator used in this formula has been changed to include the total number of residents aged 14 years and older (Nephew, Williams, Stinson, Nguyen, & DuFour, 1999). In 1997, per capita alcohol consumption in the U.S. was 2.18 gallons of ethanol per year.
Twenty-five percent of adults in the U.S. report either currently having alcohol-related problems or drinking patterns that put them at risk for developing problems. The definition of at-risk drinking behavior differs for individuals based on their age, gender, and alcohol consumption (NIAAA, 1995). It also differs in terms of how the information is to be used-research surveys define the behavior somewhat differently than clinical diagnosis.
Drinking patterns are often defined according to quantity and frequency of alcohol consumption. For instance, using a modified version of Cahalan, Roizen, and Room's (1976) Quantity-Frequency Index (QF), the number of drinks per occasion and the frequency of drinking occasions throughout the past year can be combined into the following drinking categories:
Never drinks, or
Drinks less than once a year
Less Frequent Drinks 1 to 3 times a month, and
May or may not drink 5 or more drinks, at least once a year
Drinks at least once a week, and
May or may not drink 5 or more drinks at a sitting less than once a week but at least once a year
Frequent Heavy Drinker
Drinks at least once a week, and
Has 5 or more drinks at one sitting at least once per week
In February, 2004 the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Advisory Council Task Force issued recommendations regarding the definition of "binge drinking." This definition is not dependent on the number of drinks consumed, nor is it related to the time frame of drinking session. It is based on drinking behaviors that raise an individual's blood alcohol concentration (BAC) up to or above the level of 0.08 gm%. This is typically reached for men with 5 or more drinks in about 2 hours, and for women with 4 or more drinks. For some individuals (e.g., older people; those taking other drugs or certain medications), the number of drinks needed to reach a binge-level BAC is lower than for the "typical adult."
- In the above definition, a "drink" refers to half an ounce of alcohol (e.g., one 12 oz. beer, one 5 oz. glass of wine, one 1 ½ oz. shot of distilled spirits).
- Binge drinking is distinct is distinct from "risky" drinking (reaching a peak BAC between .05 gm% and .08 gm%) and a "bender" (2 or more days of sustained heavy drinking).
- People with risk factors for the development of alcoholism have increased risk with any alcohol consumption, even that below a "risky" level.
- For pregnant women, any drinking presents risk to the fetus.
- Drinking by persons under the age of 21 is illegal.
"Binge drinking is clearly dangerous for the drinker and for society."
Historical Trends in Alcohol ConsumptionThe long-term trends of per capita alcohol consumption provide a historical perspective on the amount of alcoholic beverage consumption in a community or a nation. Current information concerning per capita ethanol consumption is published in an annual surveillance report produced by the National Institute on Alcohol Abuse and Alcoholism (Nephew et al., 1999). In this report, the data were derived using the actual sales and/or tax receipt reports collected from all states as the formula numerator. Corresponding census data were used as the computational denominator. The amount of any beverage type consumed (beer, wine, spirits) was converted to units of absolute ethanol.
Historical Trends: 1850-1997
The influence of historical events and policy trends, as well as changes in cultural factors, attitudes about alcohol use, and life styles are reflected in per capita ethanol consumption in the U.S. from 1850 to 1997 (Alcohol Epidemiology Program, 2000). While a direct comparison of apparent per capita consumption is difficult before and after 1970 when the computation method for calculating ethanol concentration was modified, it is possible to identify overall changes in per capita consumption over the past 150 years.
Per capita ethanol consumption consistently increased from the mid 1880's until 1915, and decreased just prior to enactment of Prohibition in 1919. After Prohibition ended in 1934, consumption of all types of alcohol continued to ncrease until the 1950's. The overall per capita level of alcohol consumption peaked in 1975, and began to decline during the 1980's. The decline has continued with consumption dropping 43% since 1975.
The greatest quantity of alcohol consumed by Americans during the past 50 years is in the form of beer, followed by spirits and wine. During the 1980's beer consumption declined, yet at a slower rate than the decline seen in spirits and wine. More recently, a study examining the National Alcohol Surveys found that between 1984 and 1995, on a per capita basis, beer and wine consumption levels are essentially unchanged, while consumption of spirits continues to decrease (Greenfield, Midanik, & Rogers, 2000).
While per capita consumption trends illustrate historical trends over the past 150 years, they show nothing about changes in drinking patterns. A 10-year trend analysis of the U.S. National Alcohol Survey data comparing 1984, 1990, and 1995 shows that rates of current drinking dropped sharply between 1984 and 1990, but did not change from 1990 to 1995 (Greenfield et al., 2000).
Prevalence of Lifetime Alcohol Use by Age and Gender
Many epidemiological surveys of alcohol use have been conducted in the U.S. Most Americans, according to data from the National Household Survey (Substance Abuse and Mental Health Services Administration [SAMHSA], 1999a), have had at least one drink of alcohol by late adolescence. Among men, 70% to 83% reported consuming alcohol on at least one occasion during their lifetime, as compared to 39% to 66% of women. The prevalence rate of lifetime alcohol use among men is highest among those aged 25 to 55 and lowest among the 18 to 24 and 55 or older age groups.
Similar trends were found for women, although women reported lower rates of lifetime alcohol use than men across all age groups. The rate of lifetime alcohol use was the lowest among women ages 55 or older. The largest gender difference was noted among the 55 years or older age group, with males drinking more. The smallest gender difference in the rate of alcohol use was found among young adults 18 to 24 years old.
National Trends in Alcohol Consumption
Per capita alcohol consumption in the United States is by no means the highest in the world. France has the highest level, followed by Germany, Australia, and the United Kingdom. All are above the per capita consumption levels in the U.S. (NIAAA, 1997a).
A number of factors may contribute to errors in per capita estimates of alcohol consumption. The estimate of per capita consumption of beverage alcohol tends to underestimate actual individual consumption levels. Abstainers and occasional consumers are included along with heavy users in the base figures. These figures also may be offset by spoilage, breakage and other losses in production or distribution. Further, unregistered and illegally produced alcoholic beverages (including home production), and duty-free purchases are not included in the estimates.
Trends by Age
Most research involving eation and age indicate a sharp increase from the early teens to the mid-twenties with a steady decline thereafter (NIAAA, 2000). According to the Monitoring the Future Survey, conducted by the University of Michigan (Johnston, O'Malley, & Bachman, 1998), age is positively correlated with both rates of lifetime use and of intoxication among high school students.
The Monitoring the Future Survey asks students across the US about lifetime use, past year use, past month use, and daily use of alcohol, other drugs, cigarettes, and smokeless tobacco.
Age Trends: Alcohol Use
A large majority of 12th graders (80%), more than two-thirds of 10th graders, and more than half of 8th graders reported that they have used alcohol sometime in their lives (Johnston et al, 1998).
Age Trends: Intoxication
Similarly, the highest rate of lifetime intoxication was reported by 12th graders, followed by 10th graders. Rates were the lowest among the 8th graders. One of four 10th graders reported being intoxicated at least once in their lifetime (Johnston et al, 1998).
Age Trends: Heavy Use in Pase 30 days
The rate of current heavy drinking was also relatively high among high school students. One of every three 12th graders, one in four 10th graders and one in seven 8th graders reported heavy alcohol use in the 30 days prior to the survey (Johnston et al, 1998).
Prevalence of Lifetime Alcohol Dependence (DSM-IV)
The most recent National Household Survey on Drug Abuse (SAMHSA, 2000a) found that self-reports of alcohol dependence were much higher among young adults under the age of 26. Among men, the rate of alcohol dependence was inversely correlated with the individuals' ages. A similar trend was found for women, except for a slightly higher rate of abuse among the 25-34 year olds compared to the younger age group.
The age of drinkers appears to be inversely related to the risk for becoming dependent, and this relationship is consistent with age trends for heavy drinking.
Prevalence of Alcohol Use (Men) and Depencence by Age
Approximately one-third of men drinkers in the 18-24 age group met DSM-IV criteria for alcohol dependence. The rates of dependence declined with the progression of age.
Prevalence of Alcohol Use (Women) and Dependence by Age
Women reported a similar relationship, even though the rates of alcohol dependence in all groups of women were much lower than for men.
Alcohol problems are observed among elderly individuals, as well. This becomes an increasingly important issue as the nation's demographics shift to include large numbers of aging "baby boomers." The number of older adults is expected to increase from 33 million in 1994 to 80 million by the year 2030.
Epidemiological studies of the general population find that people over 65 years of age generally consume less alcohol and have fewer alcohol-related problems than do younger people. A recent National Household Survey on Drug Abuse found that, during the past 30 days, 32.7% of adults aged 65 or older used alcohol, 5.6% binge drank, and 1.6% reported heavy (5 or more days of binge) drinking (SAMHSA, 2000a). However, high rates of alcohol abuse symptoms have been found among clinical samples of elderly who are admitted to hospitals, psychiatric facilities, and emergency rooms (NIAAA, 1998a).
Alcohol use among the elderly is associated with increased risks for hip fracture, alcohol-related traffic accidents, adverse interactions with medications, and risk for co-morbid depression (NIAAA, 1998a). Because of their reluctance to seek help, and the tendency of health care professionals to mistakenly assume senility rather than suspect alcohol-related consequences, it may be difficult to assess the extent of problem drinking among older people (SAMSHA, 1998). Further, memory loss and the effects of prescription medications may affect clinical interviews with the elderly. Obtaining collateral information from family members or friends may be necessary to compensate for memory difficulties when assessing some clients.
Age Interactions with Other FactorsData from the 1999 National Household Survey on Drug Abuse (SAMHSA, 1999a) show that rates of alcohol use, binge drinking (5 or more drinks per occasion), and heavy drinking were higher among men than women, and higher among young adults than older adults. Furthermore, younger men tend to be binge drinkers and heavy drinkers when they drink.
Age and Gender Interactions
Past Month Alcohol Use by Ethnicity: Ages 18-25
Past Month Alcohol Use by Ethnicity: Ages 26 or Older
Alcohol and Other Drugs
According to the 1999 National Household Survey on Drug Abuse (SAMHSA, 1999a), alcohol is, by far, the most widely consumed substance in the U.S. and the prevalence of dependence was much higher than for any other drug. In 2000, an estimated 4.6% of the population was dependent on or abused alcohol, while 1.0% of the population was found to be dependent on or abused both alcohol and drugs (SAMHSA, 2000a).
Use of Alcohol and Other Drugs, 1999 Ages 18-25
The rates of alcohol use by persons 14 years or older were higher than rates for tobacco, illicit drugs, and non-medical use of prescription drugs. Among young adults 18 to 25 years old, the rates of lifetime use, past year use, and current use of alcohol and tobacco were much higher than for other drugs. The rate of alcohol use was slightly higher than tobacco use in this age group. Once alcohol and tobacco use was initiated, young adults tended to continue their use, while only a small proportion of lifetime drug users reported current use of substances other than alcohol and tobacco (SAMHSA, 2000a).
Use of Alcohol and Other Drugs, 1999 Ages 26 and Older
Drugs other than alcohol and tobacco tended to be used more by younger adults. For example, reported marijuana consumption in the month prior to interview was reported by 15% of younger adults, but rarely (3%) by adults 26 or older (SAMHSA, 2000a).
Reported Past Year Subtance Dependence by Age, 1999
One-year prevalence of alcohol dependence was highest among young adults, followed by youth 12-17 years old. The 18-25 year old group was more than three times as likely to be dependent on alcohol than the adolescents, and was five times more likely to be dependent on both alcohol and drugs (SAMHSA, 2000a).
Risk and Protective Factors for Adolescents
Risk factors that have been associated with adolescent alcohol use include: negative interaction with mother, negative interaction with father, parental alcohol dependence, parent dislike of friends, heavy drinking friends, daily cigarette smoking, childhood & adolescence conduct problems (Kuperman et al, 2001; NIAAA, 1997b).
Several protective factors found to be associated with reduced levels of drinking among adolescents include attendance at religious services, parental trusting, and seeking advice from parents (Califano & Booth, 1998).
Alcohol-Associated Health and Psychological Problems
Problem Reported by Alcohol Users (past year)
Alcohol and Violence
Research findings consistently document an association between alcohol and violence (Collins & Schlenger, 1988; Roizen, 1993). Alcohol use not only promotes aggressive behavior, but victimization may also lead to excessive alcohol use (NIAAA, 1997c). The National Crime Victimization Survey (NCVS) found that alcohol-related violence was far more common than violence associated with other drug use (NIAAA, 2000). Similarly, Parker and Auerhahn (1998), in their review of studies on alcohol, drugs and violence, suggested that alcohol was the most frequently implicated substance used in violent crimes, and found little evidence that illicit drugs are uniquely associated with violent crime. A review of studies on violent offenders found that offenders were drinking at the time of committing the offense in as high as 86% of homicides, 37% of assaults, 60% of sexual offenses, 57% of men and 27% of women involved in marital violence, and 13% of child abuse cases (Roizen, 1997).
It is important to note that rates of alcohol involvement vary across studies depending on the methodology and definition of alcohol involvement. This makes the comparison of specific rates difficult. Moreover, despite a consistent association between alcohol use and the occurrence of violent crime, it is difficult to establish a causal association without considering additional factors that may interact or modify the hypothesized causality.
Roizen (1993) reviewed empirical studies of police reports concerning rape offenders and their victims between 1940 and 1978 in the U.S. and Canada. She found alcohol use at the time of the offense was associated with 13% to 50% of offenders and 6% to 36% of victims. Miczek, Weerts, and DeBold's (1993) review of epidemiological studies on alcohol and violence found 6 studies where alcohol was involved in 35% to 65% of rapes, 2 studies indicating alcohol involvement in 50% of incest cases, and 3 studies reporting alcohol involvement in 20% to 83 % of family violence cases. In addition, two studies indicated alcohol involvement in 10% to 83% of murders and homicides. Nearly one fourth of offenders who commit violent crimes were thought to be drinking before committing the offense, while one of three homicide offenders reported being intoxicated at the time of the offense (Spunt, Brownstein, Goldstein, Fendrich, & Liberty, 1995). Research on alcohol and severity of violence and injuries also shows a consistent positive association between drinking by the perpetrator and the frequency of domestic violence (Leonard & Quigley, 1999) and the severity of injuries inflicted on the victims (Martin & Backman, 1997).
Shepherd and Brickley (1996) found similar amounts and frequency of drinking for young men (ages 18 to 35) who visited the emergency room as the result of being injured in an assault compared with patients who were not involved in an assault. However, the young men who visited the emergency room after being injured in an assault tended to drink more on weekends and had a tendency for binge drinking.
Alcohol use is more often associated with intimate partner violence (i.e., husband, ex-husband, boyfriend, ex-boyfriend) than in violence between strangers (Greenfield & Henneberg, 2001). It has been estimated that in 45% of the cases of domestic violence men were drinking, and that in 20% of the cases women were drinking (Roizen, 1993). Independent of whether male- or female-perpetrated, couples with alcohol-related problems were more likely to report intimate partner violence (Caetano, Schafer, & Cunradi, 2001).
Prevalence of Alcohol Abuse in the Criminal Justice System
Alcohol, Drug, and Violent Events Related to Arrest
Alcohol and drug use are associated with arrest. In California, about half of arrestees, male and female, reported that the reason for their arrest was tied to alcohol. The rate of drug-related events which led to arrest was higher among women than men, while rates of violent events were higher for men (Nunes-Dinis & Weisner, 1997). Approximately two-thirds of men and one-half of women who were arrested were frequent alcohol users, and more than 40% of men and women arrested were regular drug users (Nunes-Dinis & Weisner, 1997). The rate of frequent alcohol use was higher for men, but the rate of regular drug use was similar for both men and women in this population.
Alcohol and Drug Use: 12 Months of Arrests in Northern California
There is a high prevalence rate of past alcohol use among individuals on probation. As stated earlier, alcohol was more frequently involved in the commission of crimes than were other drugs. The Bureau of Justice Statistics (Mumola & Bonczar, 1998) reported that 40% of all probationers were under the influence of alcohol, and 14% were high on other drugs at the time their offenses were committed. Similarly 40% of violent crimes were committed under the influence of alcohol as compared to 11% for drugs, and 75% of public order crimes were committed while under the influence of alcohol as compared to 6% on other drugs.
Scores of three or more positive responses on the CAGE screening instrument (Ewing, 1984) served as the criterion defined by the Bureau of Justice Statistics. One out of three probationers with public order offenses reported 3 or more positive CAGE responses. Twenty-two percent of probationers with violent offenses, 18% with property offenses, and 16% with drug offenses met the criteria for alcohol abuse (Mumola & Bonczar, 1998).
CAGE: In the past year
1. have you ever felt that you should cut down on your drinking?
2. have people annoyed you by criticizing your drinking?
3. have you ever felt bad or guilty about your drinking?
4. have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
A 1999 NIAAA surveillance report on alcohol-related morbidity showed that approximately 421,000 hospital discharge episodes of persons age 15 and older had a first-listed (primary) alcohol-related diagnosis. Alcohol misuse was mentioned in 1.3 million discharge episodes, with 20.2 first-listed and 64.5 misuse per 10,000 population (Whitmore, Stinson, & DuFour, 1999). The data came from the National Hospital Discharge Survey, a national sample of hospital discharge episodes compiled by the National Center for Health Statistics (1999).
Disorders Percent Alcohol-related morbidity is defined as directly associated with the alcohol dependence syndrome (acute intoxication, withdrawal, and chronic alcohol dependence symptoms), nondependent abuse of alcohol, or chronic liver disease and cirrhosis. Half of the first-listed alcohol-related discharges were for the alcohol dependence syndrome (49%), followed by alcoholic psychoses (22%), cirrhosis of the liver (20%), and alcohol abuse (9%). Persons in the 45 to 64 year old age group generally had the highest proportion of alcohol-related morbidity rates, while persons in the 25 to 44 year old age group had higher rates of alcohol abuse. The proportion of first-listed alcohol-related diagnoses accounted for 61% of all alcohol-related morbidity in 1979, but decreased to slightly less than one-third of all alcohol-related morbidity in 1997. The high rate of all listed alcohol-related diagnoses reported among discharge summaries, while not the first-listed diagnosis, implies a high rate of health problems caused by alcohol abuse among hospital patients.
Alcohol dependence syndrome
Cirrhosis of the liver
Alcohol abuse, nondependent
Rates of Alcohol-Related Liver Cirrhosis
Age-Adjusted Liver Cirrhosis Mortality U.S. 1910-1996
According to an NIAAA Surveillance Report on liver cirrhosis mortality in the U.S. (Saadatmand, Stinson, Grant & DuFour, 1999), the mortality rate for all types of liver cirrhosis was high between 1910 and Prohibition. Prohibition period rates were not estimated, but the rate of cirrhosis gradually increased after 1931 (post- Prohibition), and peaked during the 1970s. The mortality rate slowly declined through the 1980s and became steady in the 1990s. The reported rate is consistently higher for men (Saadatmand et al., 1999).
Alcohol-Related Cirrhosis by Race and Gender
The level of susceptibility to liver disease and the severity of alcohol-related liver disease vary considerably, even among drinkers with similar drinking patterns and drinking histories. The risk factors for alcohol-related liver disease include genetic factors (structural and functional variability of liver cell types and biochemical substances); dietary factors (high fat, low carbohydrate, and poly-unsaturated fat intake); gender (increased susceptibility in women at lower doses/levels of alcohol consumption and shorter duration, higher mortality rate); and presence of Hepatitis C (increased susceptibility and severity and reduced effects of antiviral medication, e.g., interferon) (NIAAA, 1998b; Roizen, Kerr, & Fillmore, 1999).
The age-adjusted death rates for alcohol-related cirrhosis are higher among Hispanic men than any other ethnic group, followed by non-Hispanic Blacks and lastly, non-Hispanic whites. This trend also applies for females, with Hispanic females having the highest risk followed by black non-Hispanic females and white non-Hispanic females (NIAAA, 2001b). Different drinking patterns among ethnic groups may explain increased risk for liver cirrhosis. It has been noted that some Hispanic groups are more likely to engage in drinking styles marked by periodic consumption of large amounts of alcohol (NIAAA, 2001b).
Alcohol and Pregnancy
Maternal alcohol consumption during pregnancy can result in the development of Fetal Alcohol Syndrome (FAS), a condition characterized by certain facial features; postnatal growth deficiency; and central nervous system, cognitive, and behavioral deficits. Fetal Alcohol Syndrome is a life-long condition, and the affected child can experience varying degrees of mental retardation, learning difficulties, and behavioral problems (CDC, 1999a).
Alcohol Consumption Among U.S.
Pregnant & Child-bearing Aged Women
sources: SAMSHA, 1999a; CDC, 1997
The Surgeon General's official advisory warnings against the use of alcohol by pregnant women and women considering pregnancy were released in 1981, 1990 and 1995. In spite of repeated warnings, including federally-mandated warning labels introduced in 1989 (Greenfield, Graves, & Kaskutas, 1999), the CDC's Behavioral Risk Factor Surveillance System (BRFSS) data showed increased rates of alcohol use, binge drinking, and frequent use for 1991 and 1995 among pregnant women, despite stable rates of alcohol use among women of child-bearing age (18-44) (CDC, 1997).
Binge Drinking Among U.S.
Pregnant & Child-bearing Aged Women
sources: SAMSHA, 1999a; CDC, 1997
Frequent Drinking Among U.S.
Pregnant & Child-bearing Aged Women
source: CDC, 1997
Between 1979 and 1993, the National Birth Defects Monitoring Program (BDMP) developed by the Centers for Disease Control and Prevention showed an approximately fourfold increase in the rate of FAS from 1/10,000 births to 3.7/10,000 births. The rates jumped to 6.7/10,000 births in 1993 (CDC, 1995). While epidemiological studies show that drinking during pregnancy provides an increased risk for FAS or other effects from fetal exposure, it is difficult to determine an exact dose effect relationship between the level of exposure and the incidence of FAS.
Reported Rates of Fetal Alcohol Syndrome, U.S. 1979-1993
Sampson, et al., (1997) found that, among heavy drinkers, the incidence of FAS ranged from 2.8 to 4.6 per 1,000 live births. The incidence of infants who do not exhibit full diagnostic criteria of FAS but show some FAS signs was estimated at 9.1 per 1,000 live births.
Even though FAS is one of the most preventable birth defects, knowledge about FAS is low among women, particularly among those without a college education (CDC, 1994a; 1999b). Many pregnant women first contact an obstetrician or gynecologist regarding prenatal care, but these physicians often fail to inquire adequately about the expectant mother's drinking practices. In a recent survey of obstetricians and gynecologists, almost all physicians surveyed reported assessing patients' alcohol use at the initial visit. However, these assessments were completed by non-physician staff or by self-administered patient questionnaires. Only one-half of the physicians surveyed reported asking patients directly about their alcohol use.
Advice and education about the consequences of drinking during pregnancy were given out by 50% of the physicians.One-third gave advice and education to only those patients with identified risk factors (Diekman et al., 2000).
Only 50% of surveyed obstetricians and gynecologists asked their patients directly about alcohol use.
Among the most common risk factors for FAS are maternal health characteristics. Multiple studies have identified health-related risk factors, such as co-use of tobacco and other drugs, and alcohol (NIAAA, 2000). Alcohol consumption during pregnancy is often associated with smoking, which is also found to be associated with increased risk during pregnancy. A recent study of Alaskan Native women found that those who smoked were more likely to report heavy drinking than were nonsmokers (CDC, 1994b). Ebrahim, Ducoufle, and Palakathodi (2000) reported that one of seven women between the ages of 18 and 44 used tobacco and alcohol. While most pregnant women quit using both alcohol and tobacco when they realized they were pregnant, those who continued to use both substances faced an increased risk to the developing fetus. In short, fetal exposure to alcohol is associated with a host of developmental risks and other problems of concern to social workers.
Alcohol and Mortality
Alcohol Death Rates by Ethnicity (Age-Adjusted), 1979-1997)
According to the most recent National Vital Statistics Report (Hoyert, Kochanek, & Murphy, 1999), age-adjusted death rates from alcohol misuse declined from 1979 to 1997. While a dramatic decline was observed among non-white males over the past 20 years, their rate of alcohol-related death was still highest, followed by white males. Death rates for nonwhite females have also declined over the past 20 years. The death rates for white men and women were unchanged, and remained lower than for nonwhites.
Age-Adjusted Death Rates for 10 Leading Causes, U.S. (1997)
The Centers for Disease Control and Prevention (CDC) publishes major causes of death annually in the U.S. National Vital Statistics Report. The primary indicator of alcohol-related cause of death, liver disease, was the 11th highest cause of death in 1997 (Hoyert et al., 1999). Alcohol use is also involved with other causes of death including car accidents, other accidents, suicide, and homicide. If added together, these alcohol-related causes of death would be the third highest cause of death in the U.S. across all age groups.
Drug Abuse Deaths 1995-1998
Emergency department data from the Drug Abuse Warning Network (DAWN) (SAMHSA, 2000b), a survey of hospital emergency departments conducted every year by the Substance Abuse and Mental Health Services Administration, show that the number of drug- and alcohol-related deaths is increasing among both men and women in the U.S. From 1995 to 1998, the number of fatalities among men was more than twice the rate for women, however, the rate of increase among women was much higher than that of men.
Drug-Related Deaths by Age (1996)
The number of drug-related deaths was the highest among people 35 years or older, followed by the 26 to 34 year old age group and the 18 to 25 year old age group. Although the number is very small, 124 cases of drug-related deaths occurred among children and youths ages 6 to 17 during 1996 (SAMHSA, 1997). While it is difficult to separate alcohol-specific causes of death from the DAWN data, the majority of drug-related deaths involved a combination of alcohol and other drug use.
Traffic Alcohol-Related Fatalities, 1997-1999
Alcohol is also associated with fatalities from injury, homicide, suicide, and motor vehicle accidents. Nearly half of the deaths resulting from traffic accidents were associated with alcohol use (Abel & Zeidenberg, 1985). The NIAAA Surveillance Report on alcohol-related fatal crashes (Yi, Stinson, Williams, & Bertolucci, 2001) reported that 30.1% of traffic crash fatalities in 1999 were alcohol-related. While the proportion of alcohol-related traffic crash fatalities declined from 17,414 in 1977 to 12,547 in 1999, the 1999 rate included nearly 4,000 people under the age of 25 (Yi et al., 2001).
The decline in the number of crash fatalities could be due to increased safety regulations and features adopted by car manufacturers, reductions in legal blood alcohol driving limits imposed in many states, or to national policies linking federal highway funds to state adoption of a uniform 21 year old minimum legal drinking age. Hingson, Heeren, and Winter's (2000) study clearly showed that lowering legal blood alcohol limits from 0.10% to 0.08% blood alcohol concentration resulted in a 6% decrease in the proportion of drivers involved in fatal crashes while under the influence of alcohol. This is one area where epidemiological findings have clearly played a role in changing alcohol policies.
Alcohol Involvement in Accidental Death, Homicide, and Suicide
Alcohol consumption may increase the risk for many types of accidental death. Smith, Branas, and Miller (1999) abstracted the cause of death from medical examiners' reports of non-traffic fatalities. They conducted a meta-analysis of aggregated data from 65 studies published between 1975 and 1995. The cause of death was classified according to the International Classification of Diseases, 9th revision (ICD-9-CM). Alcohol involvement in decedents was defined as any blood alcohol content (BAC) level greater than zero. Intoxication was defined as a BAC > 100 mg/dL. The investigators found that a high rate of alcohol involvement was associated with a variety of deaths due to accidental injuries, homicide, suicide, and motor vehicle accidents.
The aggregate percentage of intoxication was the highest for homicide (31.5%) and unintentional injury death (31%). Alcohol involvement (where BAC >0) in unintentional injuries ranged from 27% for poisonings to 90% for cold or hypothermia. Rates of intoxication (where BAC >100) for unintentional injury ranged from 20.5% for gunshot to 42% for burn or fire. About two-thirds (63%) of victims from fatal falls tested positive for alcohol use and almost one-third (32%) tested at the intoxicated level. Nearly one-half of drowning, gunshot, and homicide victims were found to be positive for alcohol use. Victims of burns and hypothermia had the highest intoxication levels, followed by drowning, falls, motor vehicle accidents, homicides, and suicides. While the levels of alcohol involvement vary by cause of death, this study demonstrates that stopping or reducing the victims' alcohol consumption may have prevented many fatal injuries.
Alcohol use is also associated with traumatic injury. Macdonald, Wells, Giesbrecht, and Cherpitel (1999) compared violent and accidental injuries among emergency room patients. They found that violent injuries were likely to occur in a bar or restaurant, and to involve alcohol use by one or more of the participants. More than one-third of trauma injury from falls or stabbing, one-third of car or motorcycle accidents, and one-third of pedestrian accidents are associated with alcohol use on the part of the injured person (NIAAA, 1997a).
Alcohol and Trauma, by Age
The highest prevalence of trauma involving both intoxication and non-intoxication occurs among the 25-34 year old age group, followed by the 18-25 year old group, and the 35-44 year old group. The prevalence of traumatic injury declines after age 45, but begins to increase again after age 55. As people age, the association between intoxication and traumatic injury tends to decline. Traumatic injury among the 55 and older age cohort is rarely related to alcohol use (NIAAA, 1997a).
Relative Risk Over 21 years, Alcohol Consumption & Mortality (Scottish Men)
More recent examinations of historical trends and empirical data have provided a broader view of alcohol consumption and mortality from all causes. For example, Hart, Smith, Hole, and Hawthorne (1999) followed a cohort of Scottish men for 21 years and found that those who ranker 15 units of alcohol per week were at greater risk of mortality from all causes than non-drinkers. The strongest correlation was between weekly alcohol use and death from stroke, with those men drinking 35 units a week 2 times at greater risk of death from stroke than non-drinkers.
Beneficial Effects of Moderate Alcohol Consumption: Empirical evidence indicates that heavy alcohol use is associated with increased health risks (NIAAA, 1997a; 1999). However, studies also suggest an association between moderate drinking and certain health benefits. 'Moderation' is defined as no more than one drink per day for women and persons over age 65, and no more than two drinks per day for men under the age of 65 (DuFour, 1999). The relationship between the amount of alcohol consumed per occasion and health risks is described as a J- or U-shaped curve, showing higher mortality rates among lifetime abstainers and heavy drinkers than among moderate drinkers. Mortality rates also increase with the frequency of heavy drinking. However, it is difficult to determine a 'safe level' of alcohol consumption or to determine a consumption level that increases risks for mortality and morbidity.
Alcohol and Mortality: 11- Year Follow-up, Adults Age 50+
(16,304 Danish Men & Women)
Gronbaek et al. (1998) prospectively studied 16,304 Danish men and women 50 years or older over an 11-year period and found a U-shaped rate between alcohol use and mortality. Those reporting lower levels of alcohol intake seemed to have a reduced mortality risk when compared to abstainers, while large amounts of alcohol intake increased mortality risk. In the U.S., Thun et al. (1997) followed 490,000 men and women ages 30 to 104 for nine years and examined cause-specific death rates. Moderate alcohol consumption was associated with slightly reduced overall mortality. Mortality from alcoholism, cirrhosis, and alcohol-related cancers was positively associated with the baseline level of alcohol consumption among daily drinkers.
For women, alcohol use was associated with an increase in breast cancer deaths. Mortality from cardiovascular disease was lower for drinkers than abstainers among both men and women. Thun et al. (1997) concluded that, while a low level of alcohol consumption may improve mortality risk, the overall benefit was small and alcohol consumption increased the risk for an alcohol-related death. Any beneficial effect of alcohol consumption was far outweighed by the large increase in mortality risk from the tobacco use that often accompanies drinking behavior.
A low level of alcohol consumption may improve mortality risk, but the overall benefit is small and alcohol consumption increases the risk for an alcohol-related death.
The beneficial effects of moderate drinking on coronary heart disease (CHD) risk were documented in the 16-year follow-up of the National Health and Nutrition Examination Survey I (Gartside, Wang & Glueck, 1998). Significant independent factors negatively associated with coronary heart disease were race (non-whites), female gender, alcohol intake, exercise or physical activities, and intake of fish, cheese, and dessert. However, the level of alcohol use was found to interact with cholesterol level and age. The lowest rate of cardiac events was seen in subjects with lower cholesterol (<250) and alcohol intake 1-6 times per week. The highest CHD was among those with high cholesterol (>250) and who drank every day. Alcohol intake was also associated with a high rate of CHD among 70-74 year olds, while the incidence of CHD was lower among people 50 years of age or younger. Using the same data set, Rehm, et al. (1997) also found an increased risk for CHD events among women who consumed more than 4 drinks per day. However, they also found an association between smoking and high levels of alcohol consumption that may have contributed to an increased risk for CHD among female heavy drinkers.
More recently, Rehm, Greenfield, and Rogers (2001) investigated alcohol consumption and all-cause mortality data from the National Alcohol Survey. Using the adjusted relative risk for lifetime abstention as a standard, men were found to be at increased risk when consuming more than 6 drinks per day. For women, the relative risk for mortality from all causes was lower among those consuming 1-2 drinks per day, but increased when consumption was over four drinks per day on average.
Dietary Guidelines for Americans (DHHS & USDA): The U.S. Department of Health and Human Services (DHHS) and the U.S. Department of Agriculture (USDA) publish a document, "Nutrition and Your Health: Dietary Guidelines," which is updated every five years to advise the American public on the promotion of health. The most recent version provides recommendations in relation to daily alcohol consumption. The guideline recommends moderate consumption for most adult Americans who consume beverage alcohol. It is important to understand that the guidelines apply only to drinkers; they are not for the purpose of encouraging everyone to drink.
The DHHS and USDA guidelines also recommend abstinence for several classes of people. Total abstention from consuming alcohol is suggested for all children and adolescents, for people who are unable to limit their amount of drinking, for women who are pregnant or trying to conceive, for people who will be operating a motor vehicle or are planning to do activities that require attention or skill, for people who have family members with alcohol problems, and for people using prescription and over-the-counter medications (DuFour, 1999). In addition, persons with a variety of health conditions should be advised to drink less than the guidelines or not to drink at all.
One Day Census of Clients in Substance Treatment by Age
Individuals participating in substance abuse treatment within the U.S. very often abuse both alcohol and other drugs. On any given day in 1995, nearly one-half of the approximately 940,000 clients in substance abuse treatment abused both alcohol and drugs (43%). Almost one in three abused alcohol only (28%) or other drugs only (29%). The number of clients in treatment has increased from 520,000 during 1987 to nearly one million in 1995. The average age of clients in treatment during 1987, compared to 1996, shows an aging trend over the years. The proportion of clients over age 45 has been increasing, while the proportion of clients 25 or younger has been decreasing.
It should be noted, however, that the Uniform Facility Data Set (UFDS) (SAMHSA, 1999b) upon which these observations are based does not represent the total population of individuals with drug and alcohol problems. Not everyone with a substance abuse problem seeks treatment. While the increase in numbers of individuals who reported treatment for alcohol problems was consistent between 1979 and 1990 (National Household Survey, employing direct interview method), these increases were not reflected in the UFDS. The "National Household Survey on Drug Abuse" reported that Alcoholics Anonymous was the most frequently used treatment modality among those responding to the survey (Weisner, Greenfield, & Room, 1995). The "Epidemiological Catchment Area" study found that less than half of those who met DSM-III diagnostic criteria for alcohol dependence had ever used a treatment facility for substance abuse or mental health care (Narrow, Regier, Rae, Manderscheid, & Locke, 1993).
RECOMMENDED CLASSROOM ACTIVITIES
Hands On/ Experiential
1. Link to Research.
It is helpful to understand how epidemiological data are collected and analyzed. In small working groups, identify an epidemiological question related to alcohol use, abuse, and/or dependence (e.g., How have the rates of problematic alcohol use changed among men and women in your state since the historical turning point of September 11, 2001? How do these rates compare to rates in other regions of the nation? Or, What are the rates of alcohol dependence in a specific population not previously discussed-perhaps gay, lesbian, bisexual and transgender individuals nationally; dormitory vs. non-dormitory residing undergraduate students at your campus; BSW vs. MSW social workers nationally?).
Next, brainstorm ways of locating or collecting the information needed to answer your group's question. Discuss the limitations and research decisions that relate to the strategies you explored. Discuss the significant implications for social work practice of the various possible results.
2. Link to Research.
Have students take a sample of epidemiological data (either from this module, from a published article, or from one of the government research web sites-NIAAA, CDC, NIJ, NIA, NIDA, etc.) and learn to present it in graphic form using statistical software (e.g., SPSS, Excel, graphing in PowerPoint). Can they interpret the output? (Note: you may be able to acquire Epi Info software-Epidemiology on Microcomputers-from the U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention. The programs are in the public domain and available on the Internet at http://ftp.cdc.gov ).
3. Link to Prevention Practice.
Have students brainstorm prevention and/or early intervention strategies that might apply to a particular epidemiological finding (e.g., the trends in lifetime intoxication among high school students at 8th, 10th, and 12th grades; cohort of current baby boomers as they enter into the category of older adults). How will future epidemiological data help you to evaluate the impact of your intervention efforts? Note: The strategies should be grounded by the epidemiological data!
- Discuss the biological, social, and political implications of the age and gender distinctions in the dietary guidelines for alcohol consumption limits. What about the recommendations for pregnant women?
- Discuss the meaning of "risky situations" in the definitions for low-risk and at-risk use of alcohol. How does this apply to different populations (age, gender, ethnicity, race, social class, disability, family structure, national origin, religion, sexual orientation)?
- Discuss the social work practice implications of the epidemiological report described as the one-day census of clients in treatment (by age group).
- Discuss the social work practice and policy implications of the epidemiological reports concerning the links between alcohol and violence; alcohol and accidents; alcohol and health problems/mortality).
- Discuss the data concerning pregnant women and alcohol and the data concerning FAS. What are some possible interventions at the community and social policy levels that might affect these data? What are the feasibility, ethical, and political implications of these strategies?
- Discuss the ways that the epidemiological data presented in this module apply to at least one situation that you have encountered in your field or social work practice experiences.
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Updated: March 2005