Search

Objectives: The purpose of this study was to conduct a comprehensive analysis of alcohol-treatment service utilization trends in the general population during the 1980s., Methods: Three national surveys of the US household population (1979, 1984, and 1990) were used for trend analysis of treatment utilization. Trends in demographic characteristics of persons with lifetime treatment rates and particular types of treatment were examined by means of logistic regression analysis, controlling for alcohol problem severity and other variables., Results: Substantial increases in the numbers reporting treatment were found. In all surveys, Alcoholics Anonymous was the treatment used most frequently and its use increased most, especially for women. Men were more likely than women (odds ratio [OR] = 2.01, 95% confidence interval [CI] = 1.20, 5.39) and unmarried persons were twice as likely as married persons to have been treated [corrected]. Social consequences carried more predictive power than dependence symptoms., Conclusions: From a general population perspective, while overall treatment capacity has increased, the structural changes in the public/private balance of services have not positively affected the representation of women or other characteristics of the treatment population.

Trends in public opinion about 11 possible alcohol policy initiatives are analysed in probability surveys of adults in the United States and in Ontario in 1989, 1990 and 1991. In both sites, public opinion is fairly conservative on alcohol policies, with majorities favoring either the status quo or decreased availability on such dimensions as tax levels, opening hours, sale of alcoholic beverages in corner stores and the minimum legal drinking age. Between 1989 and 1991, the most substantial net change in attitudes was in favor of warning labels in Ontario, although it was in the United States and not in Canada that warning labels were introduced after the 1989 surveys. For some other alcohol policies, public support for restrictions tended to decline in Ontario but not in the United States. In logistic regressions predicting attitudes on each policy with gender, age, education, drinking pattern, study site and year of study, the strong and consistent secular trend for support for warning labels held up; the only other significant and consistent secular trend was against increased efforts to prevent drunken customers being served. Since public support for alcohol controls is crucial to their effectiveness and long-term viability, regular tracking of public opinion on them is needed, along with efforts to increase their public understanding and support.

The criteria for alcohol dependence in both the ICD-10 and DSM-III-R nosologies were measured in a national general population survey, using 24 stem items and follow-ups. For current (12-month) dependence (at the criterion of 3+ components), the rate was 3.2% according to DSM-III-R criteria, and 5.4% according to ICD-10. The Kappa coefficient of agreement between the two systems for classification of individuals as currently dependent was 0.62, and for lifetime diagnosis the Kappa coefficient was 0.68. Prevalence for the individual components of each diagnosis and for the underlying items are given, and the contribution of each component to the overall dependence score is examined. Implications of the results for future epidemiological work with the two classifications are discussed.

Based on the 1990 US National Alcohol Survey, this note provides the first available comprehensive findings on self-reported utilization of a variety of sources of personal support and counselling for alcohol and other problems. Respondents were queried about lifetime attendance and number of times they went to identified sources of help in the prior year. Twelve-step groups included Alcoholics Anonymous, Al-Anon, Adult Children of Alcoholics, and other non-alcohol-oriented groups like Gamblers Anonymous, Narcotics Anonymous, and Overeaters Anonymous; additional questions inquired about support or therapy groups and individual counselling for non-alcohol problems. Of the US adult population, 9% have been to an AA meeting at some time, 3.6% in the prior year, only about one-third of these for problems of their own. About half these percentages, mostly women, have attended Al-Anon. Of the same population, 13.3% indicate ever attending a 12-step meeting (including non-alcohol-oriented groups), 5.3% in the last year. During the prior year a further 2.1% used other support/therapy groups and 5.5% sought individual counselling/therapy for personal problems other than alcohol. In contrast to this high reported utilization, only 4.9% (ever) and 2.3% (12-months) reported going to anyone including AA for a problem (of their own) related to drinking.

In popular conceptions, loss of control over drinking involves a double loss of control, over one's life as well as over one's drinking. A measure of "control worries," concerning the experience of difficulties in controlling one's life, was developed. The relationships between measures of control worries, loss of control over drinking and heavy-drinking behavior were examined in samples both of alcohol treatment clients and of the general population in a California county. Alcohol treatment clients reported greater control worries and loss of control over drinking than members of the general population. Although control worries were only slightly correlated with drinking loss of control, this relationship tended to be conditional in the general population. The findings suggest that concerns about personal control in general may be a useful construct to consider in conjunction with the drinking loss of control concept.

During an outbreak of hepatitis A that occurred in Gloucester, UK between September 1989 and January 1991, 162 clinical cases were identified through notifications and laboratory reports, a monthly attack rate of 1.05 per 10,000 residents. The highest attack rate was seen in 5-14-year-olds. There were significant correlations between hepatitis A attack rates in the electoral wards of Gloucester and with the Jarman UPA 8 scores for the wards and with overcrowding, unemployment, under 5-year-olds and ethnic minority. The use of human normal immune globulin prophylaxis (HNIG) for household contacts was unsuccessful in ending the outbreak, partly because only one third of cases reported a household contact with recent hepatitis A. Our experience does not support the use of HNIG in stopping community-wide outbreaks of hepatitis A. Two public health campaigns were mounted during the outbreak; both were followed by a fall in the number of cases. Greater priority should be given to the implementation and evaluation of public health campaigns in future community-wide outbreaks of hepatitis A.

During a community-wide outbreak of hepatitis A in Gloucester, UK there was a high attack rate in children attending two city primary schools and a pre-school centre sharing the same site. In September 1990, saliva specimens were collected from 478 (85%) of the 562 children. The prevalence of antibody to hepatitis A virus (anti-HAV), as determined by saliva testing, was 29.6%; highest prevalences were seen in 5-6-year-olds and in children from that area of the city at the centre of the community-wide outbreak. The proportion of immune children with a history of clinical hepatitis varied with age from 1 in 42.7 of under-5-year-olds to 1 in 4.7 of 8-10-year-olds. Six children who received prophylaxis with human normal immune globulin (HNIG) because they were household contacts of cases subsequently became infected. Since there was evidence of transmission outside the school environment it is unlikely that a policy of universal prophylaxis within the schools would have stopped the outbreak. Mass prophylaxis in school outbreaks is only likely to be effective if most transmission is occurring at school and if the target population can be clearly defined. Salivary antibody testing is a simple, practical and acceptable procedure in young children. Salivary antibody surveys in conjunction with vaccination against hepatitis A should provide a cost-effective method for control of future outbreaks.

Two main prescriptions are offered for reducing rates of alcohol problems in English-speaking and Nordic cultures: a "dry" solution of reducing the physical and cultural availability of alcohol, and a "wet" solution of reducing problems of intoxication by better integrating drinking into the culture. Empirical evaluations of change in particular cultures have tended to support the dry, and not the wet, solution. But such studies focus on relatively short-term effects, and there is evidence that long-run effects may be weaker or may even be reversed from shortterm effects. Some particular societies that have been put forward as examples of the long-term success of wet strategies are considered. The most likely success from this perspective is the Netherlands, which is also an exceptional society in terms of the wetness of its drug policies. In the light of these cases, consideration is given to some issues concerning the criteria for evaluating the success of one or the other solution. It is argued that alcohol policy discussions need to recognize that intoxication has a particular social position in our societies, in terms of characteristics of the drinker and of the occasion, in terms of intoxication's cultural significance, and in terms of its entrenchment in social worlds of heavy drinking. Some implications for policy are noted.

The use of psychoactive drugs is regarded by many as a basic human drive, but it is one that induces a variety of societal responses to curb it. The present review examines two aspects of government policy on drugs: first, the influence of social movements on drug policy; and secondly, the choices for constraining drug use as an alternative to total prohibition. Addiction is essentially a repeated behaviour which is viewed as excessive or harmful. As such, it has many similarities with a wide range of human behaviours. With the concept of addiction becoming progressively banalized, there is the possibility of a more natural debate about decriminalization and legalization of drugs in terms of a balance between harm and benefits. The current public debate may create a climate for serious political consideration of the strategies.

Alcohol problems have long been especially associated with city life, although this perception is not always supported empirically in comparisons of urban and rural rates. Potential explanations of higher urban rates include: more complete reporting of problems in the city; that problems may occur in the city, but involve non-inhabitants; that migrants to the city may be especially attracted by or vulnerable to heavy drinking; and characteristics of city lifestyles that are conducive to heavy drinking, and to heavy drinking being defined as problematic. On the other hand, there are also potential explanations of higher rural rates, such as the ready availability associated with home production. Collective efforts to reduce rates of alcohol problems have often focused on the city or its neighborhoods; these local communities bear many of the costs of the problems, while alcohol tax revenues tend to go to national governments. Three forms of urban alcohol problems prevention are briefly discussed: local alcohol control through municipal public-houses or sales license controls; community action movements to reduce rates of alcohol-related problems; and AA and other mutual-help movements, which are particularly attuned to counteracting characteristically urban problems.

As the agenda of alcohol problems prevention has broadened, new traditions of research have emerged: of experimental studies at the community or the societal level, of "natural experiment" studies of the effects of sudden changes such as strikes or new legislation, and of sophisticated time-series analyses of the effects of sudden and of long-term changes. While it has been shown that control measures can influence alcohol problems rates, substantial change seems to require changes in the political status quo, often also involving popular movements. Except for taxes, raising the drinking age and drinking-driving countermeasures, the political will to restrict availability has been lacking in market-oriented industrial societies in the modern era, so that the modern experience of the effects of other control measures is based on centrally-planned or non-industrial economies.

Over one-half of famous American authors with reputations for drunkenness were born between 1888 and 1900. Although college students of their generation seem to have been "drier" than earlier or later cohorts, many of the writers were already drinking heavily in college. Several reasons are suggested. After World War I, many fledgling authors spent time in Paris, becoming known as the "lost generation" and adding French and other drinking styles to their existing drinking patterns. Bohemian Americans during Prohibition found a resonance with the residual political symbolism of drinking in France as a statement of autonomy against the state. The community of expatriate writers provided a supportive environment for heavy drinking. In turn, the lost generation became a transmitter of new values concerning drinking to American culture in general. Their writings inadvertently promoted mass middle-class tourism to Paris in the late 1920s. Their lives and works strengthened the association between writing and drinking as a model for later literary generations. Both in written form and as films, their works conveyed an attractive image of drinking and often of drunkenness to the wider public. The decisive shift in drinking patterns among middle-class youth in the late 1920s ushered in a lasting change in the cultural position of drinking, as it became a cosmopolitan, progressive and eventually respectable behavior. At a minimum, the writers of the lost generation served as harbingers, carriers and catalysts of this change.

Quantitative information on alcohol consumption patterns derives from four possible sources: indirect measures, observational studies, aggregate consumption statistics, and sample surveys of general populations. The potentials and problems of each method are briefly discussed, with primary attention to the various traditions of survey questioning and data analysis. While medically oriented epidemiologists have often used only an overall drinking volume measure, social scientists have pointed to the importance also of variability in characterizing drinking, particularly in relation to social and casualty as opposed to chronic health problems with drinking. The dimensions of drinking patterns which might be relevant to hypothesized linkages of alcohol and cancer are discussed. It is suggested that measurement will need to extend beyond volume of drinking and may indeed involve studies of new kinds of dimensions in the patterning of drinking.

At least 34 Hollywood films were made between The Lost Weekend (1945) and Days of Wine and Roses (1962) with an alcoholic as a major character; six depicted an Alcoholics Anonymous-like self-help organization. Presentations of alcoholism's origin as mysterious competed with psychodynamic interpretations and situational explanations, often in the same film and sometimes concerning the same character. Will-power and mutual help were each frequently shown as paths to recovery, whereas neither professional treatment nor AA's spiritual side were often shown. For the women alcoholics (17 of 39 depicted), drinking went with sexuality, but for men it replaced it. "Creative" occupations were hugely overrepresented among screen alcoholics, in part reflecting the personal struggles with drinking of the movies' creators. These writers, actors and directors were drawn from the "wet generations" of middle-class youth, who had adopted heavy drinking in their college years as a generational revolt against "Victorian morality." Alcoholics Anonymous was founded and peopled by members of these same cohorts as a generational solution to their eventual life-problems. The flurry of alcoholism films represented a parallel and overlapping generational response.

This chapter recounts what is known about the international development of treatment institutions for inebriates in the century before 1940. It begins with the origins of treatment in the self-help temperance movement of the 1830s and 1840s and the founding of the first inebriate homes, tracing in the United States the transformation of these small, private, spiritually inclined programs into the medically dominated, quasipublic inebriate asylums of the late 19th century. A similar institutional development occurred in other English-speaking countries. Both in the United States and Britain, these institutions almost disappeared by the end of the First World War. In Germany and Switzerland, a three-tier system of community advice bureaus, inpatient sanatoria, and work camps developed at the turn of the century; an analogous system, with temperance boards at the community level, developed in Nordic countries between 1912 and 1940. The societal emphasis on the problem of impoverished inebriates often turned inebriate treatment efforts in the direction of coercive and custodial handling.

Respondents in a 1984 national adult sample report on the experiences of treatment for alcohol problems, of talking to someone about an alcohol problem of their own, and of others' suggestion that the respondent cut down. Most who have been treated (3.4% on a lifetime basis, 1.3% within the last year) have also encountered informal pressures. A majority of respondents have pressured others to cut down their drinking; such efforts do not appear to be clustered in a few 'control specialists', and heavier drinkers are about as likely as lighter drinkers to pressure others. Within the family, the flow of pressure is from older to younger generations, and from women to men, but a heavy-drinking woman is as likely to be pressured as a heavy-drinking man. Somewhat more men than women report applying pressure on friends.

Alcohol consumption and many alcohol-related problems have increased in most industrialized countries in the postwar period. The main societal responses have been increases in the treatment response to alcohol problems and in public and school education efforts. In the present era of fiscal crisis, there is also a trend toward punitive controls of the individual drinker. Potential policy alternatives should be broadened to include environmental protections for and from drunkenness, and a reconsideration of alcohol control strategies. Recent studies have shown that in some circumstances such laws have strong effects.