Utilizing Culture and Behaviour in Epidemiological Models of Alcohol Consumption and Consequences for Western Nations

Conclusions

This study demonstrates that culture is a primary force shaping both the way alcohol is used and the consequences of its use in a given society. The present effort represents a first step in deconstructing and operationalizing the pervasive influence of culture on drinking. Nonetheless, this application of Levine's cultural taxonomy in an epidemiologic model has generated stronger correlations with behavioural consequences, and equally strong correlations with some health consequences, to those achieved with the primary predictors of consumption level and beverage type.

Thus, religious and cultural variables (specifically the Temperance/non-Temperance distinction) have strong independent predictive power for drinking outcomes such as AA membership, and also for mortality from several diseases. Overall these differences in mortality appear to balance out, yielding about equal total mortality rates for the two major cultural categories. The Temperance distinction bespeaks broader differences than drinking behaviors, including dietary and other lifestyle differences, which are independently related to CHD cross-culturally (Criqui and Ringel 1994).

The substantial reduction in CHD mortality and elevation in cirrhosis deaths found cross-culturally due to drinking replicate findings based on cohort and case-matching epidemiologic studies. However, this study also finds mortality from diabetes and stroke to be related to alcohol consumption, findings inconsistent with epidemiological research (cf. Perry et al. 1995; Rimm et al. 1995). This same discrepancy between cross-cultural and epidemiological research is found as well in the absence of a relationship between drinking and overall mortality. The advantages of moderate drinking for overall mortality have now been firmly established by over a dozen prospective studies (Poikolainen 1995), including the American Cancer Society (Boffetta and Garfinkel 1990), Kaiser (Klatsky et al 1992), Nurses (Fuchs et al. 1995), and several European (Doll et al. 1994; Grønbæk et al. 1994) studies. The discrepancy between prospective epidemiologic and cross-cultural studies may occur because elevation in societal alcohol consumption does not necessarily lead to a proportional increase in moderate drinkers.

Another casualty of the shift to a cross-cultural research design is the "mind-body" effect found in epidemiological research in the United States by Harburg and the present author. This research demonstrates that drinking in a setting and manner resembling the socialized drinking of non-Temperance nations can produce better physiological outcomes, such as less severe hangover (Harburg et al. 1993) and lower blood pressure (Harburg et al. 1994). The Temperance outlook may reflect deep-seated perspectives and feelings about alcohol that influence how alcohol consumption and intoxication are experienced and even how alcohol is processed by the body. However, not all individual differences measurable within cultures can be established cross-culturally with society-wide data.

Most if not all countries, but particularly Temperance nations, seek to improve behavioural and health outcomes by modifying alcoholic beverage consumption patterns. However, such policies can also have iatrogenic effects. One popular policy is to raise taxes so as to reduce overall consumption, an application of the "Ledermann hypothesis" which holds that the impact of reduced overall consumption in a society will be felt mainly at the high end of the consumption curve as an alleviation of the most severe alcohol problems experienced by that society. However, this policy runs the risk that it will increase cardiovascular mortality, since a reduction in alcohol consumption is experienced broadly throughout the society. In the current study, the level of revenue-generating taxes on alcohol in a nation strongly predicts CHD mortality.

Some societies, taking a different approach to encouraging healthier drinking patterns, enact a policy preference for wine and/or beer over spirits. Yet alcohol consumed as beer (as opposed to spirits) is associated with greater premature adult (age 55-64) mortality. Even where one beverage has positive health correlates- such as beer's inverse relationship to cirrhosis mortality-a shift away from wine consumption toward beer does not prevent, but actually increases death from cirrhosis. And, while overall mortality is inversely predicted by percentage wine consumption, absolute increases in wine consumption from 1980-1990 are significantly correlated with all age morality.

Policy changes must overcome a heavy weight of cultural inertia to have their intended impact. Cultural patterns of alcohol consumption have such integrity and equilibrium that trying to transform what appear to be less healthful to more healthful levels and forms of consumption, without sensitive attention to the cultural context, often is futile or worse. Specifically, the following iatrogenic results may occur:

1. there are benefits to alcohol consumption (e.g., in preventing CHD) that lowering consumption may reduce;
2. at the same time, raising consumption does not necessarily produce health benefits that outweigh negative outcomes for a society;
3. policies geared towards encouraging one type of beverage alcohol over another may lead to disease mortality specifically associated with that type of alcohol (wine and cirrhosis) or to greater overall mortality (beer and total mortality in the 55-64 age group);
4. however, even when the proportion consumed as a type of beverage alcohol is associated with lower or higher levels of mortality (beer and wine, respectively, with cirrhosis deaths; wine and beer with overall mortality), absolute increases or decreases in consumption of the beverages may not enhance these benefits, or may even reverse them.

This study indicates dangers in social engineering directed abstractly at modifying alcohol consumption, at least when it does not take into account existing societal drinking styles. Nonetheless, a future paper based on these data will explore potential health and mortality benefits associated with a variety of beverage alcohol policies.