Research Paper About Alcohol Consumption

The Risks Associated With Alcohol Use and Alcoholism

Jürgen Rehm, Ph.D.

JÜRGEN REHM, PH.D., is director of the Department of Social and Epidemiological Research at the Centre for Addiction and Mental Health and chair and professor in the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada, and is a section head at the Institute for Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany.

Alcohol consumption, particularly heavier drinking, is an important risk factor for many health problems and, thus, is a major contributor to the global burden of disease. In fact, alcohol is a necessary underlying cause for more than 30 conditions and a contributing factor to many more. The most common disease categories that are entirely or partly caused by alcohol consumption include infectious diseases, cancer, diabetes, neuropsychiatric diseases (including alcohol use disorders), cardiovascular disease, liver and pancreas disease, and unintentional and intentional injury. Knowledge of these disease risks has helped in the development of low-risk drinking guidelines. In addition to these disease risks that affect the drinker, alcohol consumption also can affect the health of others and cause social harm both to the drinker and to others, adding to the overall cost associated with alcohol consumption. These findings underscore the need to develop effective prevention efforts to reduce the pain and suffering, and the associated costs, resulting from excessive alcohol use.

KEY WORDS:alcohol and other drug (AOD) use; alcohol use disorders; alcoholism; heavy drinking; AOD induced risk; AOD effects and consequences; health; disease cause; disease factor; disease risk and protective factors; burden of disease; health care costs; injury; social harm; drinking guidelines; prevention

 

Alcohol consumption has been identified as an important risk factor for illness, disability, and mortality (Rehm et al. 2009b). In fact, in the last comparative risk assessment conducted by theWorld Health Organization (WHO), the detrimental impact of alcohol consumption on the global burden of disease and injury was surpassed only by unsafe sex and childhood underweight status but exceeded that of many classic risk factors, such as unsafe water and sanitation, hypertension, high cholesterol, or tobacco use (WHO 2009). This risk assessment evaluated the net effect of all alcohol consumption—that is, it also took into account the beneficial effects that alcohol consumption (primarily moderate consumption) can have on ischemic diseases1 and diabetes (Baliunas et al. 2009; Corrao et al. 2000; Patra et al. 2010; Rehm et al. 2004). Although these statistics reflect the consequences of all alcohol consumption, it is clear that most of the burden associated with alcohol use stems from regular heavier drinking, defined, for instance, as drinking more than 40 grams of pure alcohol per day for men and 20 grams of pure alcohol per day for women2 (Patra et al. 2009; Rehm et al. 2004). In addition to the average volume of alcohol consumption, patterns of drinking— especially irregular heavy-drinking occasions, or binge drinking (defined as drinking at least 60 grams of pure alcohol or five standard drinks in one sitting)—markedly contribute to the associated burden of disease and injury (Gmel et al. 2010; Rehm et al. 2004). This article first defines which conditions necessarily are caused by alcohol use and for which conditions alcohol use is a contributing factor. It then looks more closely at the most common disease risks associated with excessive alcohol use, before exploring how these risks have influenced guidelines for drinking limits. The article concludes with a discussion of the alcohol-related risk of harm to people other than the drinker.


1 Ischemic diseases are all conditions that are related to the formation of blood clots, which prevent adequate blood flow to certain tissues.

2 In the United States, a standard drink usually is considered to contain 0.6 fluid ounces (or 14 grams) of pure alcohol. This is the amount of ethanol found in approximately 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of distilled spirits. However, many drinks, as actually poured, contain more alcohol. Thus, for example, a glass of wine often contains more than 5 fluid ounces and therefore may correspond to one and a half or even two standard drinks.

Disease and Injury Conditions Associated With Alcohol Use

Conditions for Which Alcohol Is a Necessary Cause

More than 30 conditions listed in the WHO’s International Classification of Diseases, 10th Edition (ICD–10) (WHO2007) include the term “alcohol” in their name or definition, indicating that alcohol consumption is a necessary cause underlying these conditions (see table 1). The most important disease conditions in this group are alcohol use disorders (AUDs), which include alcohol dependence and harmful use or alcohol abuse.3 AUDs are less fatal than other chronic disease conditions but are linked to considerable disability (Samokhvalov et al. 2010d). Overall, even though AUDs in themselves do not rank high as a cause of death globally, they are the fourth-most disabling disease category in low- tomiddle-income countries and the third-most disabling disease category in high-income countries (WHO 2008). Thus, AUDs account for 18.4 million years of life lost to disability (YLDs), or 3.5 percent of all YLDs, in low- and middle-income countries and for 3.9 million YLDs, or 5.7 percent of all YLDs, in highincome countries. However, AUDs do not affect all population subgroups equally; for example, they mainly affect men, globally representing the secondmost disabling disease and injury condition for men. In contrast, AUDs are not among the 10 most important causes of disabling disease and injury in women (WHO 2008).

Alcoholic liver disease and alcoholinduced pancreatitis are other alcoholspecific disease categories that are of global importance. However, no global prevalence data on these disease categories exist because they cannot be validly assessed on a global level. Thus, these conditions are too specific to assess using verbal autopsies and other methods normally used in global-burdenof- disease studies (Lopez et al. 2006; Rajaratnam et al. 2010). Nevertheless, the prevalence of alcohol-attributable liver cirrhosis and alcohol-induced pancreatitis can be estimated indirectly via the prevalence of alcohol exposure and relative risk for the wider, unspecific disease categories (Rehm et al. 2010a).


3 The condition referred to as “harmful use” in the ICD–10 loosely corresponds to “alcohol abuse,” as defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Diseases, 4th Edition (DSM–IV).

Table 1 Disease Conditions That by
Definition Are Attributable to Alcohol (AAF = 100%)

ICD–10 CodeDisease
E24.4Alcohol-induced pseudo-Cushing’s syndrome
F10Mental and behavioral disorders attributed to use of alcohol
F10.0Acute intoxication
F10.1Harmful use
F10.2Dependence syndrome
F10.3Withdrawal state
F10.4Withdrawal state with delirium
F10.5Psychotic disorder
F10.6Amnesic syndrome
F10.7Residual and late-onset psychotic disorder
F10.8Other mental and behavioral disorders
F10.9Unspecified mental and behavioral disorder
G31.2Degeneration of nervous system attributed to alcohol
G62.1Alcoholic polyneuropathy
G72.1Alcoholic myopathy
I42.6Alcoholic cardiomyopathy
K29.2Alcoholic gastritis
K70Alcoholic liver disease
K70.0Alcoholic fatty liver
K70.1Alcoholic hepatitis
K70.2Alcoholic fibrosis and sclerosis of liver
K70.3Alcoholic cirrhosis of liver
K70.4Alcoholic hepatic failure
K70.9Alcoholic liver disease, unspecified
K85.2Alcohol-induced acute pancreatitis
K86.0Alcohol-induced chronic pancreatitis
O35.4Maternal care for (suspected) damage to fetus from alcohol
P04.3Fetus and newborn affected by maternal use of alcohol
Q86.0Fetal alcohol syndrome (dysmorphic)
R78.0Finding of alcohol in blood
T51Toxic effect of alcohol
T51.0Ethanol
T51.1Methanol
T51.8Other alcohols
T51.9Alcohol unspecified
X45Accidental poisoning by and exposure to alcohol
X65Intentional self-poisoning by and exposure to alcohol
Y15Poisoning by and exposure to alcohol, undetermined intent
Y90Evidence of alcohol involvement determined by blood alcohol level

Note: ICD codes in italics represent subcodes within a main code of classification. Abbreviations: AAF = alcohol-attributable fraction.

 

Conditions for Which Alcohol Is a Component Cause

Disease and injury conditions for which alcohol consumption is a component cause contribute more to the global burden of disease than do alcohol-specific conditions. Overall, the following are the main disease and injury categories impacted by alcohol consumption (listed in the order of their ICD–10 codes):

  • Infectious disease;
  • Cancer;
  • Diabetes;
  • Neuropsychiatric disease;
  • Cardiovascular disease;
  • Liver and pancreas disease; and
  • Unintentional and intentional injury.

For all chronic disease categories for which detailed data are available, those data show that women have a higher risk of these conditions than men who have consumed the same amount of alcohol; however, the differences are small at lower levels of drinking (Rehm et al. 2010a). The following sections will look at these disease categories individually.

Individual Disease and Injury Conditions Associated With Alcohol Use

Infectious Diseases

Although infectious diseases were not included in the WHO’s comparative risk assessments for alcohol conducted in 2000 (Rehm et al. 2004) and 2004 (Rehm et al. 2009b), evidence has been accumulating that alcohol consumption has a detrimental impact on key infectious diseases (Rehm et al. 2009a, 2010a), such as tuberculosis (Lönnroth et al. 2008; Rehm et al. 2009c), infection with the human immunodeficiency virus (HIV) (Baliunas et al. 2010; Shuper et al. 2010), and pneumonia (Samokhvalov et al. 2010c). In fact, recent studies (Rehm and Parry 2009; Rehm et al. 2009a) found that the overall impact of alcohol consumption on infectious diseases is substantial, especially in sub-Saharan Africa.

One of the pathways through which alcohol increases risk for these diseases is via the immune system, which is adversely affected by alcohol consumption, especially heavy drinking (Rehm et al. 2009c; Romeo et al. 2010). As a result, although risk for infectious diseases does not differ greatly for people drinking less than 40 grams of pure alcohol per day compared with abstainers, this risk increases substantially for those who drink larger amounts or have been diagnosed with an AUD (Lönnroth et al. 2008; Samokhvalov et al. 2010c). In addition, alcohol consumption is associated with poorer outcomes from infectious disease for heavy drinkers by way of social factors. Thus, people with alcohol dependence often are stigmatized and have a higher chance of becoming unemployed and destitute; as a result, they tend to live in more crowded quarters with higher chances for infection and lower chances of recovery (Lönnroth et al. 2009).

The relationship between alcohol consumption and HIV infection and acquired immunodeficiency syndrome (AIDS) is different from that with other infectious diseases. To become infected with HIV, people must exchange body fluids, in most cases either by injecting drugs with a contaminated needle or, more commonly in low-income societies, engaging in unsafe sex. Thus, although significant associations exist between alcohol use, especially heavy drinking, and HIV infection via alcohol’s general effects on the immune system (Baliunas et al. 2010; Kalichman et al. 2007; Shuper et al. 2009, 2010), it cannot be excluded that other variables, including personality characteristics, psychiatric disorders, and situational factors may be responsible for both risky drinking and unsafe sex (Shuper et al. 2010). Researchers frequently have pointed out that personality characteristics, such as a propensity for risk-taking, sensation-seeking, and sexual compulsivity, may be involved in the risk of HIV infection. Indeed, a recent consensus meeting determined that there is not yet sufficient evidence to conclude that alcohol has a causal impact on HIV infection (Parry et al. 2009). However, it can be argued that experimental studies in which alcohol consumption led to a greater inclination to engage in unsafe sex indicate that some causal relationship between alcohol and HIV infection exists (e.g., George et al. 2009; Norris et al. 2009).

Once a person is infected with HIV, alcohol clearly has a detrimental impact on the course of the disease, especially by interfering with effective antiretroviral treatment (Pandrea et al. 2010). A recent meta-analysis found that problem drinking—defined as meeting the National Institute on Alcohol Abuse and Alcoholism (NIAAA)’s criteria for at-risk drinking or having an AUD—was associated with being less than half as likely to adhere to antiretroviral treatment guidelines (Hendershot et al. 2009). Because the level of adherence to the treatment regimen affects treatment success as well as outright survival, alcohol consumption clearly is associated with negative outcomes for people living with HIV and AIDS.

Cancer

Recently, the Monograph Working Group of the International Agency for Research on Cancer concluded that there was sufficient evidence for the carcinogenicity of alcohol in animals and classified alcoholic beverages as carcinogenic to humans (Baan et al. 2007). In particular, the group confirmed, or newly established, the causal link between alcohol consumption and cancer of the oral cavity, pharynx, larynx, esophagus, liver, colorectum, and female breast. For stomach and lung cancer, carcinogenicity was judged as possible but not established. For all sites where alcohol’s causal role in cancer is established, there is evidence of a dose-response relationship, with relative risk rising linearly with an increasing volume of alcohol consumption (Corrao et al. 2004).

The molecular and biochemical mechanisms by which chronic alcohol consumption leads to the development of cancers of various organs are not fully understood. It has been suggested that these mechanisms differ by target organ and include variations (i.e., polymorphisms) in genes encoding enzymes responsible for ethanol metabolism (e.g., alcohol dehydrogenase, aldehyde dehydrogenase, and cytochrome P450 2E1), increased estrogen concentrations, and changes in folate metabolism and DNA repair (Boffetta and Hashibe 2006; Seitz and Becker 2007). In addition, the International Agency for Research on Cancer group concluded that acetaldehyde—which is produced when the body breaks down (i.e., metabolizes) beverage alcohol (i.e., ethanol) but also is ingested as a component of alcoholic beverages— itself is carcinogenic. It likely plays an important role in the development of cancers of the digestive tract, especially those of the upper digestive tract (Lachenmeier et al. 2009; Seitz and Becker 2007).

Diabetes

The relationship between alcohol consumption and diabetes is complex. A curvilinear relationship exists between the average volume of alcohol consumption and the inception of diabetes (Baliunas et al. 2009)—that is, lower alcohol consumption levels have a protective effect, whereas higher consumption is associated with an increased risk. The greatest protective effect has been found with a consumption of about two standard drinks (28 grams of pure alcohol) per day, and a net detrimental effect has been found starting at about four standard drinks (50 to 60 grams of pure alcohol) per day.

Neuropsychiatric Disorders

With respect to neuropsychiatric disorders, alcohol consumption has by far the greatest impact on risk for alcohol dependence. However, alcohol also has been associated with basically all mental disorders (e.g., Kessler et al. 1997), although the causality of these associations is not clear. Thus, mental disorders may be caused by AUDs or alcohol use, AUDs may be caused by other mental disorders, or third variables may be causing both AUDs and other mental disorders. This complex relationship makes it difficult to determine the fraction of mental disorders actually caused by alcohol consumption (see Grant et al. 2009).

The relationship between alcohol and epilepsy is much clearer. There is substantial evidence that alcohol consumption can cause unprovoked seizures, and researchers have identified plausible biological pathways that may underlie this relationship (Samokhvalov et al. 2010a). Most of the relevant studies found that a high percentage of heavy alcohol users with epilepsy meet the criteria of alcohol dependence.

Cardiovascular Diseases

The overall effect of alcohol consumption on the global cardiovascular disease burden is detrimental (see table 2). Cardiovascular disease is a general category that includes several specific conditions, and alcohol’s impact differs for the different conditions. For example, the effect of alcohol consumption on hypertension is almost entirely detrimental, with a dose-response relationship that shows a linear increase of the relative risk with increasing consumption (Taylor et al. 2009). A similar dose-response relationship exists between alcohol consumption and the incidence of atrial fibrillation4 (Samokhvalov et al. 2010b). On the other hand, for heart disease caused by reduced blood supply to the heart (i.e., ischemic heart disease), the association with alcohol consumption is represented by a J-shaped curve (Corrao et al. 2000), with regular light drinking showing some protective effects. Irregular heavy drinking occasions, however, can nullify any protective effect. In a recent systematic review and meta-analysis comparing the effects of different drinking patterns in people with an overall consumption of less than 60 grams of pure alcohol per day, Roerecke and Rehm (2010) found that consumption of 60 grams of pure alcohol on one occasion at least once a month eliminated any protective effect of alcohol consumption on mortality. The authors concluded that the cardioprotective effect of moderate alcohol consumption disappears when light to moderate drinking is mixed with irregular heavy-drinking occasions. These epidemiological results are consistent with the findings of biological studies that—based on alcohol’s effects on blood lipids and blood clotting—also predict beneficial effects of regular moderate drinking but detrimental effects of irregular heavy drinking (Puddey et al. 1999; Rehm et al. 2003).

The effects of alcohol consumption on ischemic stroke5 are similar to those on ischemic heart disease, both in terms of the risk curve and in terms of biological pathways (Patra et al. 2010; Rehm et al. 2010a). On the other hand, alcohol consumption mainly has detrimental effects on the risk for hemorrhagic stroke, which are mediated at least in part by alcohol’s impact on hypertension.

Overall, the effects of alcohol consumption on cardiovascular disease are detrimental in all societies with large proportions of heavy-drinking occasions, which is true for most societies globally (Rehm et al. 2003a). This conclusion also is supported by ecological analyses or natural experiments. For example, studies in Lithuania (Chenet et al. 2001) found that cardiovascular deaths increased on weekends, when heavy drinking is more common. Also, when overall consumption was reduced in the former Soviet Union (a country with a high proportion of heavy-drinking occasions) between 1984 and 1994, the death rate from cardiovascular disease declined, indicating that alcohol consumption had an overall detrimental effect on this disease category (Leon et al. 1997).


4 Atrial fibrillation is an abnormal heart rhythm involving the two upper chambers (i.e., atria) of the heart.

5A stroke is the disruption of normal blood flow to a brain region. In the case of an ischemic stroke, this is caused by blockage of a blood vessel that prevents the blood from reaching neighboring brain areas. In the case of a hemorrhagic stroke, rupture of a blood vessel and bleeding into the brain occurs, which prevents normal blood supply to other brain regions.

Diseases of the Liver and Pancreas

Alcohol consumption has marked and specific effects on the liver and pancreas, as evidenced by the existence of disease categories such as alcoholic liver disease, alcoholic liver cirrhosis, and alcohol-induced acute or chronic pancreatitis. For these disease categories, the dose-response functions for relative risk are close to exponential (Irving et al. 2009; Rehm et al. 2010b), although the risks associated with light to moderate drinking (i.e., up to 24 grams of pure alcohol per day) are not necessarily different from the risks associated with abstention. Thus, the incidence of diseases of the liver and pancreas is associated primarily with heavy drinking.

It is important to note that given the same amount of drinking, the increase in the risk for mortality from these diseases is greater than the increase in risk for morbidity, especially at lower levels of consumption. This finding suggests that continued alcohol consumption, even in low doses, after the onset of liver or pancreas disease, increases the risk of severe consequences.

Table 2 Global Burden of Alcohol-Attributable Disease in Disability-Adjusted Life Years (DALYs) (in 1,000s) by Sex and Disease Category for the Year 2004

 World
Disease CategoryMWT%M%W%
Infectious disease7,0571,1868,24310.29.510.1
Maternal and perinatal conditions  (low birth weight)64551190.10.40.1
Cancer4,7321,5366,2686.912.37.7
Diabetes  0*282800.20
Neuropsychiatric disorders23,2653,41726,68233.727.332.7
Cardiovascular diseases5,9859396,9248.77.58.5
Cirrhosis of the liver5,5021,4436,945811.58.5
Unintentional injuries15,6942,91018,60422.823.222.8
Intentional injuries6,6391,0217,6609.68.19.4
Total detrimental effects  attributable to alcohol68,93812,53681,474100100100
Diabetes  -238-101-34022.28.114.6
Cardiovascular diseases-837-1,145-1,98177.891.985.4
Total beneficial effects  attributable to alcohol-1,075-1,246-2,321100100100
All alcohol-attributable  net DALYs67,86311,29079,153
All DALYs 799,536730,6311,530,168
Percentage of all net   DALYs attributable to alcohol 8.50%1.50%5.20%
For comparison without  infectious disease 7.60%1.40%4.60%

NOTE: M = men; W = women; T = total.
* Numbers are rounded to the nearest thousand. Zero (0) indicates that fewer than 500 alcohol-attributable DALYs in the disease category.
SOURCE: Rehm et al. 2009a,b.

 

Unintentional Injuries

The link between alcohol and almost all kinds of unintentional injuries has long been established. It depends on the blood alcohol concentration (BAC) and shows an exponential dose-response relationship (Taylor et al. 2010). Alcohol affects psychomotor abilities, with a threshold dose for negative effects generally found at BACs of approximately 0.04 to 0.05 percent (which typically are achieved after consuming two to three drinks in an hour); accordingly, injury resulting from alcohol’s disruption of psychomotor function could occur in people with BACs at this level (Eckardt et al. 1998). However, the epidemiological literature shows that even at lower BACs, injury risk is increased compared with no alcohol consumption (Taylor et al. 2010).

The acute effects of alcohol consumption on injury risk are mediated by how regularly the individual drinks. People who drink less frequently are more likely to be injured or to injure others at a given BAC compared with regular drinkers, presumably because of less tolerance (Gmel et al. 2010). This correlation was demonstrated with respect to traffic injuries in a reanalysis (Hurst et al. 1994) of a classic study conducted in Grand Rapids, Michigan (Borkenstein et al. 1974). It also is important to realize that even if the absolute risk for injury may be relatively small for each occasion of moderate drinking (defined as drinking up 36 grams pure alcohol in one sitting), the lifetime risks from such drinking occasions sums up to a considerable risk for those who often drink at such a level (Taylor et al. 2008).

Intentional Injuries

Alcohol consumption is linked not only to unintentional but also to intentional injury. Both average volume of alcohol consumption and the level of drinking before the event have been shown to affect suicide risk (Borges and Loera 2010). There also is a clear link between alcohol consumption and aggression, including, but not limited to, homicides (Rehm et al. 2003b). Several causal pathways have been identified that play a role in this link, including biological pathways acting via alcohol’s effect on receptors for the brain signaling molecules (i.e., neurotransmitters) serotonin and γ-aminobutyric acid or via alcohol’s effects on cognitive functioning (Rehm et al. 2003b). Cultural factors that are related to both differences in drinking patterns and beliefs and expectations about the effects of alcohol also influence the relationship between drinking and aggression (Bushman and Cooper 1990; Graham 2003; Leonard 2005; Room and Rossow 2001).

Implications of Alcohol-Related Risks for Drinking Guidelines

Overall, the various risks associated with alcohol use at various levels can be combined to derive low-risk drinking guidelines. Such analyses found that overall, any increase in drinking beyond one standard drink on average per day is associated with an increased net risk for morbidity and mortality in highincome countries (Rehm et al. 2009). Moreover, at any given consumption level this risk increase is larger for women than for men. NIAAA has translated the epidemiological findings into lowrisk drinking limits of no more than 14 standard drinks per week for men and 7 standard drinks per week for women (NIAAA 2010). These guidelines also specify that to limit the risk of acute consequences, daily consumption should not exceed four standard drinks for men and three for women (NIAAA 2010).

Overall Global Impact of Alcohol Consumption on Burden of Disease

The most recent systematic overview on the effects of alcohol on global burden of disease was based on data for the year 2004 (Rehm et al. 2009a,b) (see table 2). The analyses found that although AUDs (which constitute the major part of the neuropsychiatric disorders listed in the table) clearly are important contributors to global burden of disease, they only account for less than one-third of the overall impact of alcohol consumption. Almost equally important are the acute effects of alcohol consumption on the risk of both unintentional and intentional injury. In addition, alcohol has a sizable effect on the burden of disease associated with infectious diseases, cancer, cardiovascular disease, and liver cirrhosis. However, alcohol consumption also has beneficial effects on the burden of disease, mainly on diabetes and the ischemic disease subcategory of cardiovascular diseases. Yet these effects are by far outweighed by the detrimental consequences of alcohol consumption.

Effects of Alcohol on People Other Than the Drinker

So far, the discussion has centered on alcohol’s effects on health as measured by indicators that primarily are based on the records of hospitals and health systems. Reflecting the information contained in those records, most of the effects considered refer to the health of the drinker. However, this analytic approach omits two large classes of adverse consequences of alcohol: social harm to the drinker and social and health harms to others that result from the drinker’s alcohol consumption. According to the Constitution of theWHO (WHO 1946), health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (p. 100); this definition therefore takes into account not just physical and mental harms but also social harms, both for the drinker and for others.

A few examples of harm to others are included in the analysis of alcohol’s contribution to the global burden of disease listed in table 2. These include perinatal conditions attributable to the mother’s drinking during pregnancy and injuries, particularly assault injuries. However, the scope of alcohol-related social harm and of harm to others stretches well beyond these items. Thus, a recent study in Australia (Laslett et al. 2010) identified the following harms to others associated with drinking:

  • Harms identified based on records— these included deaths and hospitalizations (e.g., attributed to traffic injuries because of driving under the influence), child abuse or neglect cases involving a caregiver’s drinking, and domestic and other assaults; and
  • Harms based on survey reports— these included negative effects on coworkers, household members, other relatives and friends, strangers, and on the community as a whole.

These effects were quite prevalent. Thus, the researchers estimated that within 1 year, more than 350 deaths were attributed to drinking by others, and more than 10 million Australians (or 70 percent of all adults) were negatively affected by a stranger’s drinking (Laslett et al. 2010).

Social Harm

Drinkers also experience a range of social harms because of their own drinking, including family disruption, problems at the workplace (including unemployment), criminal convictions, and financial problems (Casswell and Thamarangsi 2009; Klingemann and Gmel 2001). Unfortunately, assessment of these problems is much less standardized than assessment of health problems, and many of these harms are not reported continuously. Social-cost studies provide irregular updates of alcohol-attributable consequences in selected countries (for an overview, see Rehm et al. 2009b; Thavorncharoensap et al. 2009). These studies regularly find that health care costs comprise only a small portion of the overall costs associated with alcohol use and that most of the alcohol-associated costs are attributable to productivity losses. In total, the costs associated with alcohol use seem to amount to 1 to 3 percent of the gross domestic product in highincome countries; the alcohol-associated costs in South Korea and Thailand, the only two mid-income countries for which similar studies are available, were at about the same level.

Conclusions

As this review has shown, alcohol use is associated with tremendous costs to the drinker, those around him or her, and society as a whole. These costs result from the increased health risks (both physical and mental) associated with alcohol consumption as well as from the social harms caused by alcohol. To reduce alcohol’s impact on the burden of disease as well as on other social, legal, and monetary costs, it therefore is imperative to develop effective interventions that can prevent or delay initiation of drinking among those who do not drink, particularly adolescents, and limit consumption to low-risk drinking levels among those who do consume alcohol. The remaining articles in this journal issue present several such intervention approaches that are being implemented and evaluated in a variety of settings and/or are targeted at different population subgroups. Together with alcohol-related prevention policies, the implementation of specific interventions with proven effectiveness can help reduce the pain and suffering, and the associated costs, resulting from excessive alcohol use.

Acknowledgements

Financial support for this study was provided by NIAAA contract HHSN267200700041C to conduct the study titled “Alcohol- and Drug- Attributable Burden of Disease and Injury in the U.S.” The views expressed here do not necessarily reflect the views of the funding agency.

Financial Disclosure

Jürgen Rehm, Ph.D., received a salary and infrastructure support from the Ontario Ministry of Health and Long- Term Care. No potential conflicts of interest relevant to this article were reported.

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Example research paper on Alcoholism:
Alcohol’s importance in our social history is significant. Even more significant is the abuse of alcohol and the how alcoholism has effected modern society. However, before the word “alcoholism” was ever spoken, alcohol was used for many purposes such as settling battles, giving courage in battles, celebrating festivals and wooing lovers. The history of alcohol can be traced all the way back to the Egyptians. In Egyptian burials, it was used to help the dead’s journey to the afterlife. There is also evidence that the Babylonians, around 1600 BC, knew how to brew 20 different types of beer.

It was also around this time that alcohol was tied to abuse. The Babylonians made their laws include punishments against drunkenness. The Greeks and the Romans drank mostly wine, and they loved it so much that they worshipped Dionysus, the god of wine. When they worshipped, the Greeks and Romans would become extremely intoxicated. Their writings are full of warnings against drinking too much. In 55 BC, the Romans introduced beer, right before alcohol become important in religious cultures.

The Old Testament refers to alcohol numerous times, and wine plays an important role in the rituals of many religions. Wine was sanctified by Jesus in the New Testament, and many Roman Catholics still drink wine today as part of their worship. Some religions, like Judaism and Christianity, wanted to keep alcohol sacred, so they made drinking too much alcohol into a sinful act. But alcohol’s popularity grew fast, and by the Middle Ages, many monasteries were making beer to give to the monks and to sell to pilgrims. Soon, home breweries were showing up, and they became taverns and other public places where people could gather to drink.

The making of alcohol, specifically beer, was not modernized until the time of the Renaissance. Science played an important role in forming breweries that could produce high-quality and large amounts of alcohol. The industrial revolution also brought along steam power and refrigeration, and technology soon allowed for much purer and stronger alcohol, likes gin, brandy and rum. Soon, other countries throughout Europe, like Germany and Britain, created their own unique alcohol. Russian vodka, Scottish whiskey, Mexican tequila and Italian sambuca are a few examples. Today there is even a wider selection to choose from.

These new drinks helped to develop trade between Western Europe and the Far East. Also, as colonies developed in America, European nations produced alcoholic drinks to ship over to the new colonies. This became a very lucrative business. From this, we can trace the origins of alcohol and how our culture became familiar with it. People continue to use alcohol in rituals and traditions, just like hundreds of years ago. But it has turned into a disease that punishes those who enjoy it too much.

The development of alcohol from religious rituals to today, where there are a wide variety of alcoholic drinks, shows how alcohol abuse has increased as well. Alcoholism has been a continuous problem for centuries due to its harmful effects. In moderation, alcohol is used by some to relax and considered safe. However, misusing alcohol can cause harm not only to the drinker, but also to anyone close to the drinker, and society in general.

There are three stages of ingestion that happen once a drink is downed. First, it is quickly absorbed into the blood stream through the cell membranes of the digestive tract. As it passes through the digestive tract, some of is absorbed by the mouth and stomach, and most of it is absorbed by the small intestine. The amount of food in the stomach affects the rate of absorption. If a drinker has a pint of beer without having dinner first, the absorption rate of the beer will be much faster. The drinker will get drunk much faster, and maybe even vomit. Most of the alcohol is absorbed by the bloodstream within an hour of ingestion.

The second stage is distribution. Once the circulatory system absorbs the alcohol, it is sent out to all parts of the body. Some parts, like the brain, liver and kidney receive larger amounts of alcohol than other parts of the body because they receive more blood. And the third stage is metabolism. As the alcohol travels throughout the body, enzymes released by the liver metabolize the alcohol. This breaks down the alcohol and turns it into a food source for the body. Most of the alcohol ingested is released through the liver.

The effects of alcohol on the liver can be deadly. In large amounts, alcohol can damage major organs, particularly the liver. There are three different alcohol-related liver diseases: fatty liver disease, alcoholic hepatitis, and cirrhosis. Fatty liver disease is one of the first signs that alcohol is being abused. Fat builds up due to alcohol metabolism. This hurts the liver’s ability to work at full strength. Fatty liver disease can lead to cirrhosis of the liver.

When the liver is too damaged from alcohol abuse, scar tissue forms, causing cirrhosis, and eventually causing the liver to shut down. Symptoms include loss of energy, loss of appetite, upset stomach, weight loss and weakness. Cirrhosis is one of the ten leading causes of death by disease in the United States. The third liver disease, alcoholic hepatitis, is the inflammation of the liver, the stage right before cirrhosis. Jaundice, mental confusion and swelling of the abdomen are common symptoms.

Alcohol is known as a depressant, and its effects on the brain and central nervous system are serious. When intoxicated, drinkers experience a mild euphoria, or temporary “happiness”, and loss of inhibition. Alcohol impairs regions of the brain controlling behavior, judgment, memory, concentration and coordination. On the central nervous system, alcohol acts as a sedative. Large amounts of alcohol can cause respiratory failure, coma and death. Impaired vision, hearing, and motor skills also occur. The drinker may also experience numbness and tingling in the arms and legs caused by nerve damage. This results in the staggering walk often seen coming out of bars. Long-term drinking can cause brain damage (Korsakoff’s Syndrome) and drinking while pregnant is known to produce sick babies (Fetal Alcohol Syndrome).

Heavy drinking also has damaging effects on the stomach and intestinal system. Irritation of the stomach lining can cause peptic ulcers, bleeding lesions and cancer. Blood loss causes loss of iron, which can cause irritability, lack of energy, headaches and dizziness. Risk of pancreatitis is also increased. Other effects of alcohol abuse include irritation of the intestinal tract lining and the colon; nausea, diarrhea, vomiting, sweating and loss of appetite; and increase in blood pressure, risk of heart attack and stroke.

These symptoms develop over time. Alcoholism, however, can begin to develop after the first drink. There are many reasons why people start drinking, such as to increase self-confidence, relieve stress, escape from personal problems, overcome shyness, or to overcome a poor self-image. Abuse of alcohol is defined as the use of alcohol interfering with physical, social, academic, or economic functioning. The first stage of alcoholism involves the use of alcoholism as a way to deal with other problems. The abuser will drink more than the average amount and is usually preoccupied with partying or going out socially to drink. The abuser will also drink to cope with personal problems, have trouble stopping after one drink, and they’ll feel guilty about drinking so much. The drinker will usually deny that a problem exists.

The second stage of alcohol abuse begins to interfere with daily activities like work. The drinker finds it typically hard to get through the day without a drink. It also becomes difficult to get the same good feelings from drinking, so more alcohol is consumed. The drinker will start drinking alone and in secret. Ambition and drive are lost and interest in family and friends goes away. This leads to the third stage where the alcoholism takes over. The drinker lives for alcohol and nothing else. They experience loneliness and continue to drink even with disastrous results, including financial and personal problems. The alcoholic will experience physical symptoms in this stage, including difficulty sleeping, loss of appetite, malnutrition, the “shakes”, and sometimes blackouts and serious memory loss. Alcoholism is the most serious form of alcohol abuse. Once the drinker reaches this stage, serious treatment should be considered.

By tracing the steps leading to alcoholism, it is natural to ask what causes the alcoholic to pick up a drink in the first place. Of course, it is the own personal responsibility of each individual who chooses to ingest alcohol. There are however, outside influences that can effect that decision. The power of the media and the messages it sends out can influence any impressionable person, especially teenagers, to consume alcohol.

Characters in film and TV are seen smoking and drinking all the time. Signs and advertisements for alcohol use fun animals to pitch the drink, or they show a drinker looking sexy and cool. If everyone is doing it and having fun, then everyone else should do it too. That is the message advertisers want the teenager to pick up. Advertisers leave out the negative information on alcohol on purpose. As a result, teenagers often do not know what the health risks are when they use alcohol.

A study done by Washington drug and alcohol officials in 1998 showed that the media has major influences in all outlets. Some of their findings show that almost all, or 98% of movies depict some form of alcohol intake. They also show that nearly 30% of all songs contained messages about drinking. On the other hand, negative effects of drinking were only shown in half of the movies and only one-fifth of the songs. American consumers are heavy consumers of movies, music and TV. So the government is targeting the entertainment and advertising industries in order to change the positive image of alcohol being put out.

Anti-alcohol propaganda has proven to be not very effective. Advertisements promoting alcohol usually make you want to try the product. The ads convince the drinker to buy alcohol so they can feel glamorous, powerful and successful. The ads also use status symbols like cars, jewelries and mansions so that everyone will believe they can have the same lifestyle as long as they buy their products. Visual propaganda is very powerful. Unfortunately, people fall for it many times.
When you see advertisements against alcohol, they’re usually trying to scare the drinker away from alcohol. Often times bloody pictures of drunk-driving car accidents are shown. Images of badly torn up bodies can persuade someone to stop drinking for the moment. However, an alcoholic’s disease is more powerful than a picture. While the bloody pictures may make the drinker think twice, the effects are not huge in preventing alcoholism.

A lot of the anti-alcohol propaganda is about driving drunk. Drinking and driving is a combination that leads to horrible accidents. Driving while under the influence is a serious concern that has gained more and more attention. According to the U.S. Surgeon General, the leading cause of death for 15-24 year olds is drunk driving. Whether it’s New Year’s Eve, the prom, or a weekend pizza party, there is a good chance that alcohol will be served. Getting behind the wheel puts in danger not only the driver who is drunk, but any passengers and non-drinking bystanders as well.

The government and police force have come up with several ways to prevent drinking and driving. One of the methods is through a blood test. This is the most difficult one to carry out because it usually requires the person to go to a hospital after being pulled over by the police. Another test police administer is a breathalyzer test. The policeman will make the driver breath into a tube that is able to read the level of alcohol in the blood. This is a valuable test because the police are able to do it as soon as they pull over the drunk driver.

The third test is less scientific. The police have the drunk driver attempt to walk a straight line and then cross their legs in the format of a number four. If they have been drinking, then they will be unable to stand up straight, their eyes will be redder, and they will lose their balance. Even though there should be more tests and more instructive propaganda on the subject of drinking and driving, the steps policemen take now do help to save lives.

Unfortunately, innocent people can be hurt by drunk drivers. But there are ways to prevent unnecessary accidents yourself. Some ways include volunteering to be a designated driver, trying to avoid driving on rural roads, using four lane highways, avoiding going on the road after midnight, and always wearing a seat belt. It is also helpful to recognize when friends may be in danger of drinking and driving. A good thing to do is to take away the car keys or simply call a cab.
Preventing drunk driving is only one way of fighting alcoholism. To really treat it well requires long-term care in almost every case. There are several treatments today for alcoholics to choose from. Three of the major forms of treatment are Alcoholics Anonymous, psychological treatment, and substance abuse clinics. Through treatment, alcoholics can lead normal, productive and happy lives. The ultimate goal of alcoholism treatment is to enable the patient to achieve lasting abstinence. Immediate goals, however, are to reduce the drinking in steps. It is very difficult to quit drinking ”cold turkey.”
If an alcoholic chooses a treatment program, there are several options out there. A short-term treatment that is popular is the 28-day in-patient treatment. This involves the patient going to a treatment facility for about a month to detox their bodies. This method can be helpful as sort of a crash course in alcoholism treatment, but care must continue following the month-long treatment. Other methods last longer, some for 6 months. These treatments include residential therapy, where the patient is living at a treatment facility for an extended amount of time. Many severe alcoholics need this kind of structure to succeed. The Betty Ford Clinic is an example of a treatment facility that allows patients to live there until they overcome their addiction to alcohol.

Another method to treating alcoholism is outpatient therapy. Outpatient therapy offers a wide variety of programs for patients who visit on a consistent basis. Almost all of the programs will offer psychological therapy of some sort, in the form of individual or group counseling. Often it is easier to talk about the addiction in a group of people with the same problems rather than alone. Out-patient therapy often is not effective by itself for the serious alcoholic. Usually this therapy is combined with another method.

The third method is the most popular one. Alcoholics Anonymous, also known as AA, was founded in 1935. It is based on the premise of the 12 steps to recovery. AA thinks of itself as a community of recovering alcoholics. They share their common problems with drinking and help each other recover from the addiction of alcohol. The main purpose of AA is to help people stay sober.

Alcoholics Anonymous consists of more than two million people all over the world. They meet in local groups that can be big or small, some having a handful of drinkers and others having hundreds attend a meeting. All of the meetings are free. Most Alcoholics Anonymous meetings are open to the public. However, some places have closed meetings in case members want to talk only about their alcohol problems and not be distracted by anyone there who may not be an alcoholic.
The 12-step program used by Alcoholics Anonymous is a world-renown treatment method that’s used for all kinds of addiction, not just alcohol. Alcoholics are encouraged to work the 12 steps. The first step involves admitting the powerlessness over alcohol, how it takes over the alcoholic’s life. The second step has the alcoholic believe that there is a greater power working that will help the alcoholic stay sober. This step is an example of the religious influence on the 12-step recovery process.

The steps continue to involve the healing process. One of them asks the drinker to go to any friends or family that have been hurt by alcoholism and apologize. Another step asks the drinker to take a sponsor. A sponsor is also an alcoholic who has been sober for a longer amount of time. The sponsor helps the recovering alcoholic make it through the steps. Throughout their recovery, alcoholics will also get chips. The chips are usually different colors, depending on how long the alcoholic has been sober.

The final two steps of AA involve “taking inventory” of your life and understanding why you did what you did when drunk. These are called the drinker’s motivations. Step 12 talks about three major parts the alcoholic should have accomplished. They are having had a spiritual awakening, practicing the lessons learned in AA, and carrying the message of recovery to other alcoholics. The final step seems like a lifetime step. It is practiced by the drinker, along with the other steps for the rest of their life. It stresses the amount of work they must put in for the program to work for them.

Once completed, the alcoholic has a lifetime of recovery. Alcoholism is a disease that most alcoholics will admit never goes away. Alcoholics need ongoing treatment and support. There is always a chance to fall off the wagon. Ideally, alcoholics should enter a long-term treatment facility, go through detox, and join Alcoholics Anonymous and attend meetings regularly. The longer an alcoholic receives treatment, the better the chances for becoming sober.

The best way to stay sober, though, is simply through abstinence. It is the only true cure of alcoholism. Drinking is classified as a disease by doctors and psychologists. It is a disease because once the drinker is addicted, they cannot stop drinking. It is beyond their control. They cause physical harm to themselves and others. Their health declines and death by alcoholism is not uncommon. That is why it is better if someone who is more likely to drink and enjoy it to abstain all together. Drinking in moderation works for some people, but for alcoholics, there really is no other choice. For the sake of their own lives, for their family and friends, and for society as a whole, alcoholics should pursue the most effective treatment and help everyone fight the terrible disease of alcoholism.

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