The Conflict Between Public Health Goals and the Temperance Mentality - Talking to People about Drinking

Written by Stanton Peele

Talking to People about Drinking

The fear of discussing benefits from drinking extends far beyond nervous secondary school educators.

1. Most prominent medical and public health authorities damn alcohol at every turn. According to Klatsky, "consideration of the harmful effects [of alcohol] almost completely dominates discussions in scientific and medical meetings, even when ... consider[ing] light to moderate drinking."³⁰ A 1990 government pamphlet, Dietary Guidelines for Americans, declared "Drinking them (alcoholic beverages) has no net health benefit, is linked with many health problems, is the cause of many accidents, and can lead to addiction. Their consumption is not recommended.³¹
2. Even researchers who find benefits from alcohol seem reluctant to describe them. A Wall Street Journal article³² about Rimm et al.²¹ noted: "Some researchers have played down alcohol's beneficial effects for fear of encouraging inappropriate drinking
   — 'We have to be very cautious in presenting this type of information,' says Eric B. Rimm." This report of the study's results — "men who consume from one-half to two drinks a day reduce their risk of heart disease by 26% compared with men who abstain" — failed to mention the 43% reduction in risk from more than two and up to four drinks a day and the 60% reduction from more than four drinks daily.
3. No American medical body will recommend drinking as healthful. The benefits of alcohol in reducing coronary artery disease are similar to those of the low-fat diets recommended by nearly all health and medical organizations, but no medical organization will recommend drinking. Typically, a conference of prominent researchers and clinicians convened in January 1990 declared, "Until we know more about metabolic and behavioral effects of alcohol and about its linkage to atherosclerosis, we have no basis for recommending either that patients increase their alcohol intake or that they start to drink if they do not already."³³ Perhaps additional research published since then would convince such a group to make this recommendation, but it is highly unlikely.
4. This attitude is, paradoxically, related to American clinicians' refusal to tell excessive drinkers to drink less. The United States has systematically eliminated efforts to help people reduce alcohol consumption in favor of instructing all problem drinkers to abstain.³⁴ We are not deterred by the finding that the abstinence prescription fails for a sizable majority of such drinkers, or that 80% of problem drinkers are not clinically dependent on alcohol.¹² Even other temperance cultures accept drinking reduction programs. In Britain, significant reductions in consumption have resulted from programs in which primary care physicians conduct drinking assessments and advise excessive, but nondependent, drinkers to lower their alcohol intake.³⁵
5. According to the data, alcohol has a role as a therapy for coronary artery disease, a role that scares American clinicians. Alcohol could be recommended as a therapy for coronary artery disease, just as patients with coronary artery disease are instructed to follow cholesterol-reducing diets. Cardiomyopathy and concurrent medications, among other things, would need to be considered in consultations with individual patients. One would think that findings that alcohol reduces coronary artery disease deaths for those at risk for coronary artery disease could not be ignored, but they are. Suh et al.,²¹ who reported such a relationship, nonetheless concluded, "alcohol consumption cannot be recommended because of the known adverse effects of excess alcohol use."
6. Americans would not drink more even if we told them to. Health professionals seem to live in fear that, on hearing it is good to drink, people will rush out and become alcoholics. They may be reassured to know that according to the Gallup poll,⁶ "fifty-eight percent of Americans are aware of recent research linking moderate drinking to lower rates of heart disease," but "only 5% of all respondents say the studies are more likely to make them drink moderately." Meanwhile, although only 2% of respondents said they averaged three or more drinks daily, more than a quarter of all drinkers planned to cut back or quit drinking altogether in the coming year.
7. Those we tell not to drink also do not listen to us. Young people, who are the primary targets of the abstinence message, blithely ignore it. Almost 90% of high school senior boys and girls have drunk alcohol (usually illegally obtained), and 30% (40% of boys) have drunk five or more drinks at one sitting in the 2 prior weeks, as have 43% of college students (over half of college men).¹¹
8. Advice about healthy drinking should not differ for children of alcoholics. The American medical preoccupation with alcoholism has led to the view that some children may be genetically destined to be alcoholics. Although positive evidence has been presented (along with negative) about the heritability of alcoholism, the model that people inherit loss of control — that is, alcoholism per se — has been soundly refuted.³⁶ Whatever people may inherit that heightens susceptibility to alcoholism operates over years as a part of the long-term development of alcohol dependence. Moreover, a large majority of children of alcoholics do not become alcoholic, and the majority of alcoholics do not have alcoholic parents.³⁷

Telling children they are born to be alcoholic on the basis of the available evidence is a double-edged sword. The broadest assertion yet made about the association of a genetic marker and alcoholism was Blum et al.'s³⁸ for the A1 allele of the dopamine D₂ receptor. Accepting at face value Blum et al.'s result (although it has been disputed by many and never fully matched by any other than the original research team³⁹), fewer than a fifth of those with the A1 allele would be alcoholic. This means that more than 80% of those with the gene variant would be misinformed if they were told they would become alcoholics. Because children readily ignore advice not to drink, we would be left with the self-fulfilling impact of our efforts to convince children with a putative genetic marker that drinking will lead them inevitably to alcoholism. Telling them this would only make it less likely that they would be able to control the drinking most will eventually initiate.

The goal of eliminating drinking for all Americans was abandoned in the United States in 1933. The failure of Prohibition implies that our public policy should be to encourage healthy drinking. Many people drink to relax and to enhance meals and social occasions. Indeed, human beings have discovered many health-related uses for alcohol over the centuries. Alcohol is used as a medicine to alleviate tension and stress, to promote sleep, to relieve pain in teething babies, and to assist in lactation. Perhaps public health policy should build on the healthy uses to which most people put alcohol. Short of this, perhaps we can simply tell the truth about alcohol.

Acknowledgements

The author thanks the following people for information and assistance they provided: Robin Room, Harry Levine, Archie Brodsky, Mary Arnold, Dana Peele, Arthur Klatsky, and Ernie Harburg.

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