Alcohol

Alcohol: Getting Wetter?

There are signs of a healthy shift away from hostility toward alcohol in the United States.

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A traditional anecdote tells of a congressman who answered a constituent's inquiry about his position on whiskey: "If you mean the demon drink that poisons the mind, pollutes the body, desecrates family life and inflames sinners, then I'm against it. But if you mean the elixir of Christmas cheer, the shield against winter chill,…then I'm for it. This is my position and I will not compromise!"

Unlike this apocryphal congressman, Americans and their government have staked out strong positions on alcohol. But these positions have fluctuated wildly from era to era.

There are signs that, after several decades of anti-alcohol crusading, the United States is swinging back toward a more positive attitude. The most conspicuous indicator of this shift was the federal government's acknowledgment in its 1995 dietary guidelines that alcohol has beneficial effects. Long overdue, this recognition marks a significant change from previous government decrees on the subject. Other signs of a thawing in attitudes toward alcohol are still preliminary: Several small pilot programs in the United States are challenging the dominant approach to alcohol problems, which offers abstinence as the only cure for the "disease" of alcoholism. And leading researchers, noting that the risks of fetal alcohol syndrome have been greatly exaggerated, are questioning conventional advice about drinking during pregnancy.

These positive signs should be regarded with caution. America's ambivalence about "demon rum" is deeply imbedded in our culture. For two centuries, we have fought about the role alcohol should play in our lives. Just as we turn in one direction, forces are set in motion that pull us back the opposite way.

The colonial era was the golden age of American drinking. Americans consumed three to four times as much alcohol (mostly beer and cider) as they do today, with few social problems. Legislators drank while in session; communion wine was part of Protestant services; the tavern was a family-oriented gathering place; and tavern keepers were highly respected members of the community. There was no anti-alcohol movement in pre-revolutionary America. There were drunkards, but responsibility for excessive drinking was laid at their feet and not blamed on alcohol. The distinguished Puritan cleric Increase Mather warned against drinking too much but in the same breath referred to alcohol as "God's Good Creature."

Drinking became less benign following expansion of the United States after the War of Independence. Industrialization and the institution of regular work hours made heavy drinking less compatible with daily obligations. At the same time, the social forces that kept drinking under control in colonial America began to wane. In the fabled saloons and dance halls of the West, unlike in the family tavern, the only women present were prostitutes; drunken unruliness, fist fights, and gunplay were commonplace.

The temperance movement arose in the 19th century in response to growing problems related to drinking. Despite its name, the movement rejected the idea of moderation, maintaining that any drinking inevitably progressed to excess and ruin. Several states enacted–and repealed–alcohol prohibition. At the national level, the war between the "drys" and the "wets" translated into regional and group conflict–the South and Midwest versus the West and urban East, Protestants versus Catholics, native-born Americans versus new European immigrants.

When the nation embarked on "the Noble Experiment" of Prohibition in 1920, reactions were mixed, but there was little organized opposition to the 18th Amendment. Thirteen years later, wets and drys alike had become so disenchanted with Prohibition that few opposed repeal. The temperance promise that sin and poverty would be eliminated along with booze was simply not borne out, and the attempt to suppress alcohol consumption had brought a host of unintended costs. In the aftermath of Prohibition, drinking became acceptable once again.

But the feelings that gave rise to Prohibition remained just beneath the surface of the American psyche, and in the 1970s a new temperance movement emerged, manifested in the rapid growth of the recovery movement and Alcoholics Anonymous, of private alcoholism treatment à la the Betty Ford Center, and of government efforts to limit alcohol consumption. The United States quadrupled its hospital beds for alcoholics between 1978 and 1984, placed warning labels for pregnant women on alcoholic beverages, and made anti-alcohol education programs a staple not only for high school students but for children as young as six. Banners proclaiming that "alcohol is a liquid drug" appeared in schools nationwide, while "Just Say No" became a national slogan.

But the seeds of an opposing trend were being sown just as the new anti-alcohol movement flowered. Medical epidemiologists tracking health outcomes in large groups of people repeatedly found that abstainers suffered more heart disease than moderate and light drinkers. Since heart disease is by far America's leading cause of death, moderate drinkers had lower overall mortality rates (although mortality rates among excessive drinkers were higher than average). Such findings, which began appearing in medical journals by the 1980s, presented public health officials with a dilemma: How was it possible to tell children drinking was bad but that people who drank lived longer?

Despite much evidence to the contrary, in 1990 the dietary guidelines compiled by the U.S. Department of Health and Human Services in conjunction with the Department of Agriculture asserted that "drinking has no net health benefit." But the government faced increasing difficulty sustaining its blanket condemnation of alcohol, and the latest dietary guidelines, issued in January, announced that drinking could be beneficial. The report even went so far as to note that "alcoholic beverages have been used to enhance the enjoyment of meals by many societies throughout human history." The change occurred in part because additional scientific evidence appeared after the 1990 report. But the real obstacle had been cultural resistance. According to Assistant Secretary of Health Philip Lee, "There was a significant bias in the past against drinking." Marion Nestle, a guidelines committee member and chair of New York University's nutrition and food science department, said the change represented "a triumph of science and reason over politics."

Still, the revision does not represent a flip to Mediterranean-style attitudes. For one thing, the recommended daily consumption limits–one drink for women and two for men–are quite low. In Britain (hardly a Mediterranean culture), the government's "sensible drinking" limits are about twice the American levels: two to three drinks daily for women and three to four for men. Furthermore, the U.S. guidelines emphasize that children should not consume alcohol. This is far from a universal belief. In Spain, children of any age may drink beer or wine with a parent at a cafe. This is also true in New Zealand, provided a meal is being eaten. In Switzerland, children may drink on their own at 16, and in some cantons at 14. No industrial nation other than the United States restricts drinking to people 21 and older.

Forbidding drinking by children does not seem to reduce alcohol abuse. Psychiatrist George Vaillant, who tracked a group of Boston adolescents for four decades, found that Irish-Americans were seven times as likely to become alcoholic as were Italians, Greeks, and Jews. Yet the latter groups typically introduce children to alcohol, while in Irish culture children traditionally do not drink in the home.

Despite a legal drinking age of 21, youthful overdrinking is a common feature of American life. In national surveys, about half of male high school seniors and college students say they have consumed at least five drinks at a sitting in the previous two weeks. More than a third of female students say they've had four or more drinks at a time. The figure for sorority and fraternity members is 80 percent or higher. It stands to reason that teenagers who learn to drink with friends are less likely to acquire responsible habits than teenagers who learn to drink at home in a family setting.

Among other anomalous features of Irish drinking, Vaillant's Boston study found that there were more abstainers in this group as well as more alcoholics. One reason for this dichotomy was that many excessive drinkers had sworn off drinking altogether. The Italians, on the other hand, were more likely to react to a drinking problem by cutting down.

This cultural difference reflects a larger battle in American alcoholism treatment. For many years, behavioral psychologists have claimed considerable success in teaching problem drinkers to reduce their intake. A.A. members and others who subscribe to the medical model of alcoholism, including the staffs of innumerable private treatment centers, insisted that this was impossible. But in 1992, the World Health Organization announced the results of an international study of "brief interventions" in both developed and Third World countries. Brief interventions are carried out in a general health care setting, rather than at alcohol treatment centers. A physician or other health care worker inquires about a patient's level of drinking, then informs heavy drinkers about healthy levels of drinking. In subsequent visits, the doctor asks about the patient's progress in reducing his or her drinking. The WHO study found that brief interventions are substantially more effective than standard alcoholism treatment of the kind practiced in the United States. They reach more drinkers with less folderol, and they avoid the conflicts associated with reformers-cum-therapists accusing heavy drinkers of being alcoholics in denial.

Despite these promising results and some success at offering controlled drinking as an alternative in pilot programs at several American universities, the U.S. alcoholism treatment industry is not likely to wither away any time soon. For the foreseeable future, recovering alcoholics and expensive private hospitals will continue to hold sway over how Americans deal with problem drinkers.

Another manifestation of temperance-movement thinking is the advice given to women about drinking during pregnancy. Predictably, the 1995 U.S. dietary guidelines confirm the instruction that appears on every bottle of beer, wine, and liquor: "According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects."

Americans started hearing about the dangers of fetal alcohol syndrome (FAS) beginning in the 1980s. But subsequent investigations have revealed that FAS is exceedingly rare, even among alcoholic women. In 1995, Ernest Abel, a pioneering FAS researcher at Wright State University, performed a meta-analysis of 59 studies in various countries that looked at the relationship between maternal drinking and birth weight. Not only was there no evidence that light drinking harmed the fetus, but mothers who consumed up to one drink per day actually had heavier babies than mothers who abstained. (However, pregnant women who average two drinks a day tend to have lighter babies.) Those findings led Abel to question the wisdom of public health efforts to discourage all women from drinking during pregnancy. Once again, the evidence does not support an official U.S. health proclamation about alcohol.

American attitudes toward alcohol are aberrant even when compared to those of cultures, such as Britain and Scandinavia, that share elements of the temperance tradition. Consider: Among the NATO soldiers in Bosnia, only the Americans are forbidden to drink. According to The New York Times, "the Norwegian soldiers here can drink in moderation, as can the French, the Danes, and the British." Apparently, other nations accept the logic that adults who are allowed to fly large aircraft and fire heavy artillery can also be trusted to consume alcohol moderately. We do not. But then, the Danes, French, British, and Norwegians have never enacted national prohibition.