PATTERNS OF ALCOHOL CONSUMPTION AMONG THE GENERAL POPULATION OF CASTILE AND LEON (SPAIN

A total of 2500 individuals, aged 14–70, who live in Castileand Leon (Spain), were surveyed in the spring of 1989 with regardto their alcohol consumption and its patterns. Among those surveyed26.2% were 'daily' drinkers and 66.0% ‘weekly’ drinkers.Differences of alcohol use (frequency) and intake were reviewedwith regard to sociodemographic factors such as gender, age,and marital status. Beer (52.6%) was the favourite drink, withwine (20.6%) the second most commonly consumed alcohol beverage.Most of those surveyed (54.6%) were ‘light’ drinkers(1–39 g/day of pure alcohol), while 3.0% had an intakeof over 80 g/day (‘heavy’ drinkers). The averageage at which they started drinking was 16 2 years The resultsallow a better understanding of the pattern of alcohol consumptionin Spain.     

THE SWEDISH ALCOHOL USE INVENTORY (AVI), A SELF-REPORT INVENTORY FOR DIFFERENTIATED DIAGNOSIS IN ALCOHOLISM

AVI is a self-report inventory intended for standardized anddifferentiated assessment and diagnosis in alcoholism; it includes75 items adapted from Horn and Wanberg's Alcohol Use Inventory(AUI) and an assessment of the alcohol intake during a typicalweek of heavy drinking. The drinking profile is presented infive second-order factor scales: ‘alcohol abuse’,‘psychological benefits’, ‘interpersonal complications’,‘social drinking’ and ‘daily drinking’and in 17 first-order factor scales. The reliability and specificityof the scales are satisfactory. Preliminary norms based on asample of more than 600 alcoholic patients are available. Usingthe original American scoring and norms the results indicateimportant similarities in the alcoholism pattern between Swedenand the U.S.A.     

FETAL ALCOHOL SYNDROME: THE 'AMERICAN PARADOX'

Nearly all cases of fetal alcohol syndrome (FAS) identifiedin prospective epidemiological studies have been conducted inthe United States of America. The very high incidence rate forFAS in the USA and the relatively low rate in other countriesdoes not correspond to measures of alcohol consumption. By analogywith the ‘French paradox’, we have termed the highrate of FAS in the USA coupled with its relatively low levelof alcohol consumption, the ‘American paradox’.     

RACIAL DIFFERENCES IN ALCOHOL SENSITIVITY

The existence of racial differences in alcohol sensitivity betweenOriental and Caucasian populations has been well documented.The primary manifestation is a highly visible facial flushing(47–85% in Orientals vs 3–29% in Caucasians) accompaniedby other objective and subjective symptoms of discomfort. Evenamong different Oriental groups, subtle differences in the flushingresponse and alcohol consumption can exist. North and SouthAmerican Indian populations differ in phenotypes for alcoholdehydrogenase and aldehyde dehydrogenase, but systematic studiescomparing degree of flushing, alcohol elimination rates andblood acetaldehyde levels in these populations are lacking.Although flushing does not automatically ‘immunize’an individual against alcohol use, those susceptible tend toconsume less alcohol, at least in Orientals. However, the flushingphenomenon cannot be the sole explanation for differences inincidences of alcoholism among different racial groups. Socio-cultural,environmental and genetic factors also have to be considered.An increased incidence of flushing has been found to associatewith a familial risk of development of future alcoholism ina Caucasian population. It remains to be determined whetherthe same is true in Orientals. Most biochemical investigationsof the flushing phenomenon have focused on aspects of alcoholmetabolism. Based on recent findings, a convincing mechanismis the higher accumulation of acetaldehyde in flushing subjectsbecause they have an unusual, less-active liver aldehyde dehydrogenaseisozyme (ALDHI). The possibility that an ‘atypical’alcohol dehydrogenase, which is present in 85–90% of Orientalsubjects, can contribute to increased blood acetaldehyde levelsin flushing subjects cannot be ruled out. Based on results ofa small number of pedigree studies which demonstrated familialresemblances in flushing, a pharmacogenetic defect in ALDHIhas been proposed to be responsible for flushing. Other possiblebiochemical mechanisms (e.g. prostaglandins) and genetic defectsneed to be investigated.     

PREVENTION OF ALCOHOL ABUSE-RELATED BIRTH EFFECTS -- I. PUBLIC EDUCATION EFFORTS

Maternal alcohol abuse during pregnancy can result in a patternof anomalies in children called ‘fetal alcohol syndrome’(FAS) and more recently, ‘fetal alcohol abuse syndrome(FAAS)’. FAAS as well as individual alcohol-related anomalies,called ‘alcohol abuse-related birth effects’ (AARBEs),are widely considered to be totally preventable, because theystem from a behaviour that is presumably modifiable. However,current strategies to reduce their occurrence are more palliativethan preventive, because their underlying premise, viz, thatraising public awareness of the potential dangers of commonlyused substances such as alcohol is enough to reduce their use,lacks empirical support. Moreover, in some cases they are alsocounter-productive. After considenng the relevant literature,this review contends that ‘universal’ public educationefforts will only be effective in reducing FAAS and AARBEs ifthey focus on the cause of these disorders, which is alcoholabuse rather than the currently open-ended message that anyamount of alcohol consumption during pregnancy constitutes adanger to an unborn child. This argument lays the ground workfor an alternative and more pragmatic strategy set forth inthe following paper for preventing FAAS and AARBEs.     

AN OBSERVATIONAL STUDY OF YOUNG ADULTS' DRINKING GROUPS--II. DRINK PURCHASING PROCEDURES, GROUP PRESSURES AND ALCOHOL CONSUMPTION BY COMPANIONS AS PREDICTORS OF ALCOHOL CONSUMPTION

Quantitative observations were made of 200 groups in bars cateringfor young adults. Most drinkers were members of groups in whichround-buying procedures were used. Purchasing procedures weregood predictors of alcohol consumption among males, accountingfor 15% of the variance in consumption. Males who purchasedrounds tended to consume more alcohol than did males who didnot purchase drinks for others. Drinkers with companions whoconsumed large amounts of alcohol tended to consume more alcoholand tended to have higher drinking rates. Considered alone,the average amount consumed by companions accounted for 62%and 48% the variance in alcohol consumption by males and femalesrespectively. Qualitative observations and interviews with 200 patrons arealso described Findings from the interviews indicate that therewere considerable pressures on males and females to conformto the ‘institution’ and to the ‘rules’of round-buying. However, the quantitative observations showedthat the majority of females did not openly purchase drinks.This suggests that observational procedures can provide usefulchecks on findings obtained from questioning procedures.     

ALCOHOL CONSUMPTION AND THE PERCEIVED SITUATIONAL APPROPRIATENESS OF CONSUMING DIFFERENT TYPES OF ALCOHOLIC BEVERAGES

Based on a 1986 national probability sample of 2401 Americansaged 21 years and over (1069 of whom were deemed ‘drinkers’on the basis of having drunk at least one alcoholic beveragein the past seven days), this study analyses the relationshipbetween respondents' perceptions of how appropriate it is toconsume either beer, wine, distilled spirits, or wine coolersin each of six social contexts (namely, at a bar, at a bailgame,‘when the party's really rolling’, at a celebration,as a perfect complement to a nice dinner, and after a particularlyrough, i.e. difficult, day) and subsequent alcohol consumptionby these same individuals. It was hypothesized that people who considered it appropriateto drink a given beverage type would drink more of that beveragethan those individuals who deemed consumption of that type ofalcohol to be inappropriate. Results indicated that this isvalid for certain of the social occasions, in terms of the useof beer, distilled spirits and wine. Wine cooler consumption,however, was found to be unrelated to people's perceptions ofhow appropriate it is to drink in different social situations.     

PATTERNS OF ALCOHOL USE AMONG UNIVERSITY STUDENTS IN SPAIN

A total of 545 university students in Valladolid, Burgos andPalencia (Spain) were surveyed in 1985 with regard to theirconsumption of alcohol. Alcoholic drinks were taken frequently(daily, 13.6% of the subjects; weekly, 66.2%; monthly, 71.3%),the per capita consumption being 8.4 litres of pure alcoholper year. Consumption was higher among males and during theweekend. Beer, wine and, among spirits, gin, were the favourites.Most students started drinking before the age of 18 (81.2%),most commonly taking alcoholic drinks when ‘going outin the evening’ (62.2%); their principal reason for drinkingwas ‘because the people I am with are drinking’(71.6%) and 52.8% admitted to having been drunk within their‘lifetime’. Most of the differences in patternsof alcohol consumption were related to sex, and more infrequentlywere related to the different faculties, cities and academicyears.     

OUT-PATIENT ALCOHOL DETOXIFICATION--OUTCOME AFTER 2 MONTHS

We assessed the outcome after 2 months of 28 alcohol-dependentsubjects following out-patient detoxification using an uncontrolledfollow-up study with data collected at the time of detoxification(T1) and after 2 months (T2). We also determined the cost ofout-patient versus in patient detoxification. The setting wasa psychiatric emergency clinic at a South West London UniversityHospital. Self-reported alcohol consumption in the week beforeT1 and T2, score on the ‘Alcohol Problems Inventory’measuring alcohol-related relational, occupation, legal andmedical problems in the 2 months prior to T1 and T2, mean corpuscularvolume and gamma-glutamyl transferase at T1 and T2 were usedas outcome measures. Eight subjects had a ‘good’outcome (seven were abstinent and one only drank four unitson one day). Nine subjects were ‘improved’ by eitherhalving their alcohol consumption, or halving their ‘AlcoholProblems Inventory’ score at T2. ‘Good’ and‘improved’ outcome were confirmed by mean corpuscularvolume and gamma-glutamyl transference results. Eleven subjectswere ‘not improved’. Engagement following detoxificationwith voluntary alcohol agencies was associated with a betteroutcome. In-patient detoxification is calculated to be six timesmore expensive than out-patient detoxification. Out-patientdetoxification is a cost-effective step in the treatment ofalcohol-dependent patients.     

THE DUBLIN PRINCIPLES OF COOPERATION AMONG THE BEVERAGE ALCOHOL INDUSTRY, GOVERNMENTS, SCIENTIFIC RESEARCHERS, AND THE PUBLIC HEALTH COMMUNITY

A 3-day Meeting held in Dublin, Ireland on 26–28 May 1997was organized by the National College of Industrial Relationsof Ireland and the US-based International Center for AlcoholPolicies. During this Meeting, the 24 participants representingthe beverage alcohol industry, governmental organizations andthe scientific and public health communities discussed cooperationamong all those concerned with alcohol consumption and its effects.These discussions led to the formulation of the ‘DublinPrinciples of Cooperation’. This special article describesthese Principles and comments on them.     

SEVERITY OF ALCOHOL DEPENDENCE IN THE EAST END OF GLASGOW

A survey of 100 consecutive admissions for alcohol abuse in1990 highlights the severity of alcohol dependence in the EastEnd of Glasgow. The survey identifies a specific sub-group ofheavy drinkers who consume strong lager, usually in open spaces,referred to locally as ‘garden parties’. In thetotal population, males outnumbered females 3:1 with a meanconsumption of 268 and 230 units of alcohol per week, respectively.The severity of alcohol abuse was reflected in their social,physical and central nervous system complications. Two-thirdsof the population had a family history of alcohol abuse. Overthree-quarters of the population showed self neglect with nearlyhalf the males ascribing their marital breakdown or family neglectdirectly to their drinking problem. Both sexes showed a highprevalence of history of paraesthesiae, while half the malepopulation had clear signs of peripheral neuropathy on admission.A history of delirium tremens in over 50% of the populationwith a history of seizures in 21% of males and 35% of femalesindicates central nervous system involvement. Three sub-groupswere identified: history of delirium tremens, history of persecutoryideation and history of serious criminality. All three sub-groupshad a shorter length of drinking with higher consumption andincreased frequency of ‘garden parties’ than thegroup as a whole. This survey reinforces the need for appropriatein-patient detoxification and rehabilitation facilities forpatients with severe alcohol dependence, to reduce their impacton other health, social work and criminal justice services.     

VIOLENT CRIME: THE ROLE OF ALCOHOL AND NEW APPROACHES TO THE PREVENTION OF INJURY

Almost all evidence of a link between alcohol consumption andviolence is available only in the form of aggregate data. Thisis unsatisfactory and case-control investigations and studieswhich relate injury severity to blood alcohol levels are needed.In the few closely controlled studies which have been performed,increased risk of injury in assault has been linked with bingeconsumption of more than about 8 units, and above average weeklyconsumption only in those over 25 years. Raising the minimumpurchasing age for alcohol to 21 years, learning to drink responsiblywith parents, especially fathers, and the adoption of temperedglassware are all achievable objectives which would reducedalcohol-related injury. The use of sobriety-checkpoints (breathtesting though not by the police) and other situational preventionprogrammes need to be evaluated in relation to reducing injurysustained in violet crime. Proactive, community policing hasbeen shown to reduce levels of alcohol-related violent crime,in contrast to more reactive, defensive and confrontationalpolicing. The concept of ‘capable guardianship’to establish and maintain social control of young delinquentsneeds to be extended, particularly near known foci of violencesuch as bars and adjacent fast-food outlets and taxi-ranks.     

LABORATORY MARKERS OF ALCOHOL ABUSE

A number of routine laboratory markers provide objective informationabout alcohol use and abuse. The usefulness of these markersis discussed One such marker recently developed is serum carbohydrate-deficienttransferrin (CDT). which has a greater overall marker potentialthan other existing tests. The use of CDT in combination withsome of the other markers is likely to enhance the detectionof alcohol abuse or heavy consumption.     

LONGITUDINAL COMPARISON OF CARBOHYDRATE-DEFICIENT TRANSFERRIN AND GAMMA-GLUTAMYL TRANSFERASE: COMPLEMENTARY MARKERS OF EXCESSIVE ALCOHOL CONSUMPTION

The utility of carbohydrate-deficient transferrin (CDT) andgamma-glutamyl transferase (GGT) as biochemical markers of excessivealcohol consumption was studied in alcohol-dependent subjects.Serum samples were collected once weekly from 10 male out-patientsundergoing a 6-month alcohol treatment programme. Frequencyof relapse into drinking (defined as any intake of alcoholicbeverage) was assessed by self-reports during patient interviewsthree times per week and by daily determination of the 5-hydroxytryptophollevel in urine. A marked decrease in mean CDT and GGT valueswas observed during the initial month. Only one patient remainedtotally abstinent throughout the observation period, while fourhad sporadic relapses (2–5 days with alcohol consumption).Both CDT and GGT remained below the respective reference limitsin those patients. The other five patients drank more frequently(range 22–57 days) and increased their mean levels ofCDT and GGT after the initial decrease. As determined from thevalues at admission and during the course of the study, CDTappeared to be the most sensitive marker in six out of the 10patients. In one patient, both markers were affected in a parallelway, whereas two of those with frequent relapses responded toalcohol consumption with a marked increase in GGT, but withno or only a slight increase in CDT. One patient did not showany abnormal CDT or GGT values. In 54 female and 60 male serumsamples collected at random from patients during admission atan alcohol detoxification unit, 35% and 58% of the CDT valuesexceeded the reference limits for females and males, respectively.For GGT, 59% of the female and 67% of the male values were abovecut-off. Carbohydrate-deficient transferrin and GGT were notsignificantly correlated. Taken together, the present resultsindicate that measurement of both CDT and GGT will increasethe possibility of identifying excessive alcohol consumption.By following changes in CDT and GGT values during a period ofalcohol withdrawal, the most sensitive individual marker canbe determined. This in turn allows for improved detection ofrelapse into heavy drinking dunng long-term monitoring of out-patients.     

COMPARISON OF CAGE AND MAST WITH THE ALCOHOL MARKERS CDT, {gamma}-GT, ALAT, ASAT AND MCV

Many alcoholics deny abuse. To screen greater samples for alcoholdependence, short questionnaires, e.g. the CAGE or MAST areoften applied. Frequently laboratory parameters [i.e. ‘alcoholmarkers’, such as carbohydrate-deficient transfemn (CDT),     

SENSITIVITY AND SPECIFICITY OF LABORATORY TESTS FOR ALCOHOL ABUSE

Alcohol ingestion can cause widespread metabolic changes whichform the basis of most laboratory tests for alcohol abuse, e.g.measurement of concentrations or activities of serum urea, urate,aspartate transaminase and gamma-glutamyl transpeptidase andmean cell volume. The use of these tests for the detection ofalcohol abuse is growing and yet little is known of their value,particularly in population studies. The aims of this study wereto determine the magnitude of various metabolic responses todifferent levels of alcohol consumption and to determine thesensitivity and specificity of biochemical and haematologicaltests for alcohol abuse based on such responses. The populationinvestigated was a group of government employees. Significantdifferences in the distribution of analyte concentrations ofbiochemical/haematology profiles between alcohol abusers andothers were demonstrated. The sensitivity and specificity ofcommonly used tests for alcohol abuse, serum GGT, AspT, urate,urea and mcv were found to be poor, although specificity couldbe improved by using combinations of tests. The use of thesetests for the detection of alcohol abuse may be more effectivein screening ‘at risk’ populations in which theprevalence of alcohol abuse is high.     

THE TERATOGENIC EFFECTS OF ALCOHOL FOLLOWING EXPOSURE DURING PREGNANCY, AND ITS INFLUENCE ON THE CHROMOSOME CONSTITUTION OF THE PRE-OVULATORY EGG

Much information has emerged over the years concerning the teratogenicityof acute and chronic alcohol exposure during pregnancy. Bothalcohol and its primary metabolite, acetaldehyde, are teratogenic.Exposure during pregnancy may lead to fetal alcohol syndrome(FAS), and this is said to occur in a substantial proportionof infants born to mothers who are chronic, heavy daily drinkers.Such infants usually survive to birth but are mentally retarded,often display growth retardation and additionally display acharacteristic range of clinical features, principally craniofacialabnormalities and neurological damage. We have recently beeninterested in the effect of exposure of pregnant female miceto a single high level of alcohol during pregnancy, equivalentto an episode of ‘binge’ drinking, on the opticnerve, and believe that our findings, which are outlined inthe first part of this review, may shed important light on thepathogenesis of some of the ocular features characteristicallyseen in infants with this syndrome. What is not generally appreciated, is that exposure to alcoholand other ‘spindle-active’ substances that havea similar action on the meiotic spindle apparatus during themenstrual cycle before conception can induce chromosome segregationerrors in the ovulated oocyte. The successful fertilizationof such eggs consequently results in the production of aneuploidembryos, which have a very high chance of being spontaneouslyaborted during the first trimester of pregnancy. Those relativelyfew aneuploid conceptuses that survive to term invariably showmoderate to severe degrees of mental retardation, craniofacialand other abnormalities, as well as having a significantly reducedlife expectancy. The findings from our experimental studiesthat have been carried out in mice draw attention to importantprinciples which are of general applicability to the situationin the human. These findings, and our conclusions drawn fromthem, arc discussed in detail in the second part of this review.     

AN OBSERVATIONAL STUDY OF YOUNG ADULTS' DRINKING GROUPS -- I. DRINK PREFERENCES, DEMOGRAPHIC AND STRUCTURAL VARIABLES AS PREDICTORS OF ALCOHOL CONSUMPTION

Two hundred groups were observed in bars catering for youngadults. Demographic, structural and drink preference factorsaccounted for about 30% of the variance in alcohol consumptionand about 20% of the variance in drinking rates. Among these,drink preferences were the best predictors — especiallyamong females. Female heavier drinkers tended to have drinkpreferences which are usually associated with males. Femaleswho consumed beer/lager — particularly those who consumedbeer/lager and spirits — tended to consume more alcoholand tended to have higher drinking rates than females who consumedspirits only. Other factors are also described and discussed. For example,members of same-sex groups tended to consume more alcohol; and,among males, group size was positively associated with alcoholconsumption and drinking rate. Suggestions that the ‘facilitatoryeffects’ of such structural factors are as important as‘drinking history’ in determining alcohol consumptionare questioned. Time spent in the bar accounted for 49% of the variance in alcoholconsumption. The art of appointing time and gracefully leavingbars may be an important skill.     

ISRAELI ARAB AND JEWISH YOUTH KNOWLEDGE AND OPINION ABOUT ALCOHOL WARNING LABELS: PRE-INTERVENTION DATA

This article presents baseline data on the opinion toward alcoholbeverage warning labels and on levels of knowledge of the risksdiscussed in the contents of the labels prior to the labels'introduction, and on levels of knowledge of additional alcohol-relatedhazards not included in the proposed warning labels, among asample of 3065 adolescents of four religions living in the northernregion of Israel. About 2220 Arab participants (Moslems, Christiansand Druze) and 845 Jewish respondents answered in the winterof 1996 a Hebrew version of an American questionnaire, whichhad been used to measure levels of knowledge of the label inthe United States. More respondents were in favour of warninglabels on alcohol containers than on advertisements. Arabs asa group were more in favour of warning labels on alcohol containersthan Jews. The initial knowledge levels among the participantswere not very high, especially concerning the item ‘Drinkingimpairs ability to operate machinery’ (74.4%) which isincluded on the proposed warning label, and concerning two hazardswhich are not included: ‘Drinking increases risk of cancer’(54.6%) and ‘Drinking increases risk of high blood pressure’(60.4%). Abstainers knew more than drinkers that ‘Pregnantwomen should not drink’, ‘Drinking increases riskof cancer’ and ‘Alcohol in combination with otherdrugs is hazardous’. Implications for public health arediscussed and alternative warning messages that might be usedto inform the Israeli public of several less well-known hazardsare suggested.     

'Self-monitoring' and 'recall' measures of alcohol consumption: convergent validity with biochemical indices of liver function

Gamma-glutamyl transpeptidase and high-density lipoproteinscholesterol were used to corroborate drinking reported by 40clients of an outpatient alcoholism clinic. Drinking data wereobtained by two methods: ‘recall’ (retrospectivereports) and ‘self-monitoring’ (daily records).The biochemical indices were found to correlate significantlyonly with self-monitoring data. This finding suggests that greaterattention should be paid in biochemical research to the methodof eliciting alcohol consumption data.