Janet Fish, Smirnoff's Vodka and Don Q Rum, 1973

Even more remarkable is the way such attitudes have altered in America over the years. In colonial America, drinking was a family affair and took place in the community tavern. With small children, husbands, wives, and grandparents gathered together, liquor was consumed in a manner resembling moderate ethnic drinking styles today. The eighteenth-century American, according to a recent history, Drinking in America, by Mark Lender and James Martin, regarded alcohol as "God's good creature." But between 1790 and 1830, expanding frontiers and the accompanying social dislocations wreaked havoc with these healthy customs. Taverns became male preserves in which the only women likely to be present were prostitutes. In this atmosphere, drinking came to symbolize masculinity and male independence, and alcoholism rates rose dramatically. As abuse grew rampant, the Anti-Saloon League flourished, along with self-help groups organized to support the reformed alcoholic. These earnest fellowships followed the pattern of Protestant revival meetings, with their stylized public confessions, protestations of repentance, and exhortations for sinners to take and maintain the vow of sobriety. "God's good creature" disappeared, replaced by an evil genie in a bottle.

"Wets" and "drys" battled, often ferociously, until, in 1919, the temperance movement prevailed in passing the Eighteenth Amendment to the Constitution: national prohibition. Prohibition lasted just thirteen turbulent years, and with its failure and collapse, in 1933, the striving for national abstinence was over. This goal was gradually succeeded by the idea, first propounded in the eighteenth century by the Philadelphia physician Benjamin Rush, that some people have a specific disease, the nature and causes of which are mysterious, that makes it impossible for them to drink moderately. The disease theory of alcoholism has the merit of bringing troubled people into the care of hospitals and doctors, an advantage appreciated particularly by physicians themselves, who tend to see human problems in terms of the medical model: disease, treatment, cure. Yet it posits an inborn organic cause, a bodily deficiency, where there may be none, and for this reason the theory is troubling. Alcoholism may at its roots be a social and cultural problem, not a medical one.

Despite this drawback, the disease theory of alcoholism—that uncontrolled drinking is inbred and irreversible—became the banner of Alcoholics Anonymous, itself a continuation of the self-help alcoholism movements of the previous century. By the latter half of the twentieth century, with both AA and the American medical establishment embracing it, the disease theory became orthodoxy in this country. And because AA preserves much of the religious fervor of the nineteenth-century temperance movement, the concept became virtually a spiritual tenet. The disease theory maintains the same extreme view toward alcohol that prevailed in temperance days: whether alcoholism is seen as a deadly sin or a deadly disease, the only recourse is abstinence. "I am an alcoholic," the AA member is taught to declare; "I cannot drink."

By 1960, this view had gained such force that most health professionals had come to believe the goal of moderation to be entirely inappropriate for alcoholics. In effect, the fervor of Prohibition had moved off the streets and into the hospitals. If abstinence was not possible for the nation as a whole, it was crucial for the small but growing group considered to have the disease of alcoholism. Within the confines of hospitals and clinics, then, abstinence became once again a powerful political and emotional issue.

The first study that drew attack on these ideological grounds was published in 1962 by an Englishman, David L. Davies, who followed up on patients treated for alcoholism at Maudsley Hospital, in London. Of ninety-three patients, roughly a decade after treatment, seven had returned to normal drinking habits. Davies's report disconcerted those who believed such moderate reform to be a medical impossibility.

A louder outcry followed the Rand Corporation report Alcoholism and Treatment, released in 1976. The National Institute on Alcohol Abuse and Alcoholism, a government agency, had commissioned the Rand Corporation to find out how patients fared a year and a half after treatment at NIAAA centers across the country. Alcoholics, the Rand report found, can—and do—return to healthy and moderate drinking habits. In fact, of those patients in the study in remission from alcoholism, almost half had become moderate drinkers—this despite the fact that the NIAAA treatment centers had encouraged only abstinence.

The furor these statistics caused was remarkable and can be understood only in terms of the battle lines that have been drawn over alcoholism. On the morning the report was released, the National Council on Alcoholism declared it "dangerous, misleading, and not scientific." The NCA, a large, influential, private alcoholism group that supports the disease theory, lobbies to raise money for medical studies of alcoholism. It also sponsors ad campaigns urging heavy drinkers to recognize that they have a disease, to seek help from their doctor, and to join the local chapter of Alcoholics Anonymous.

Though the wilder criticisms of the Rand report were politically motivated, officials of the NCA and others did raise serious questions about the Rand researchers' methods. There was no way of telling from their data whether a "recovered" alcoholic's moderate drinking would last and whether it was indeed moderate enough to be harmless. Responding to these criticisms with a thoroughness that is rare in the social sciences in general and alcoholism research in particular, the Rand researchers extended and deepened their investigation. They followed the alumni of NIAAA clinics for four years, not just one and a half; and they devised stricter standards for defining moderation in drinking. Of those patients who were still free from drinking problems after four years, the new results showed, 40 percent were drinking socially.