FIGURE 1: EXAMPLES OF TYPES OF INDIVIDUAL-LEVEL PROBLEMS COMMONLY RELATED TO DRINKING EVENTS AND TO DRINKING HISTORY

Type of alcohol-related problem --

Physiological Mental & Casualty Soc.Demeanor

Consequences Existential Probs. Problems & Role Probs.

related to:

Drinking overdose remorse & guilt broken leg arrest: distur-

Event bing the peace

Drinking cirrhosis feelings of suicide loss of family

History loss of control relations

In a clinical frame of reference, it is quite usual to interpret a pattern of events -- of symptoms and behaviors -- as signifying a disease condition. In everyday life, also, the repetition of behaviors will eventually earn for their performer a summary label or master identity. Often, then, what we consider as a condition is actually a description of a sequence of events. Arriving at appropriate criteria for characterizing drinking behaviors and events as a condition is a perplexing conceptual and methodological problem. Frequently, attributions of a condition -- for instance, "alcoholism" or "alcohol dependence" -- both in research and in life are based on a relatively small base of events. Perhaps the extreme in this regard is the assumption in some drunk-driving studies that anyone arrested with a blood-alcohol level over .25% should be considered as an alcoholic (see Cameron, 1977, p. 236). A disposition to see events only as potential indicators of conditions may divert attention away from promising prevention strategies: it is worth keeping in mind that events are often more easily prevented than conditions.

The four major types of alcohol problems each have a different conceptual location and raise different problems of methodology and measurement. The conceptual location of physiological consequences of drinking is not problematic: such problems are in principle physically measurable problems of the individual's body. At least the most extreme indicator -- death -- is measured and recorded in the health statistics in most countries, and measures of morbidity are also sometimes available. But while the fact of death is incontrovertible, the attribution to alcohol is not; alcohol-specific attributions, in fact, are so subject to cultural definition that cross-cultural comparisons usually fall back on total cirrhosis mortality, whether or not alcohol-related, rather than using "cirrhosis with mention of alcoholism". For mortality, at least, a blood-alcohol reading can establish alcohol's presence in the events of death. This is appropriate for acute physiological consequences of drinking bouts such as alcohol poisoning; but for the numerically more important chronic physiological consequences of drinking, drinking history rather than alcohol in the event is the relevant aspect of alcohol to be measuring.

Alcohol's presence in the event is far more relevant in establishing an alcohol attribution for casualty problems -- whether they are classified as unintended ("accidental") or intentionally inflicted ("criminal"). In terms of the resultant injuries and impairments, such problems are also located in the individual's body. As occurrences, however, they fall in the class of what Haddon terms "energy damage processes" -- the too-rapid transfer of energy between the individual's body and the physical environment (Haddon, 1973). In this sense, attention to the physical and social environment of behavior while and following drinking is as important as attention to the behavior itself in understanding the occurrence of alcohol-related casualties. From a preventive standpoint, making the environment safer may often be a more effective strategy for reducing rates of alcohol-related casualties than attempting to alter drinking behavior (Ross, 1982).

The category of mental and existential problems related to drinking is usually seen as located in the individual -- whether in the mind, the body, or the soul -- although there are schools of thought such as transactional analysis or family process theories which would tend to see such problems as located in social interactions between two or more parties. But wherever such problems are seen as being located, the problem is defined not only by the pattern of behaviors and experiences but also by the interpretation of them by the drinker or by others. At the heart of the modern disease concept of alcoholism has been the concept of a consciously experienced loss of control over drinking, and over one's life as a result of drinking. Similarly, the concept of addiction represents a clinical or self-"diagnosis" of repeated behaviors which are presumptively harmful (Room, 1973). Such concepts may be seen as quite culture-bound -- addiction conceptions of alcoholism only became established in European thought in the early nineteenth century (Levine, 1978; Room, 1985).

Apart from the issue of loss of control, a variety of other mental problems are also seen as alcohol-related. In part reflecting its pharmacological action, alcohol is deeply entwined with depressive disorders. Some neurological disorders reflect physiological changes due to long-term heavy drinking. Drinking is also seen as causing various kinds of "disinhibition", and particularly as leading to aggression and violence. While this link is a widely and firmly held belief, drunken comportment has been shown to vary greatly in different cultures (MacAndrew and Edgerton, 1969), and convergent lines of evidence suggest that the link between drunkenness and aggressive mental states is a matter of cultural interpretation and belief more than of pharmacology (see Room and Collins, 1983; Critchlow, 1986).

Perhaps the most variegated among the four categories of alcohol-related problems we have outlined is the area of problems of social demeanor and role performance. Since such problems by definition represent an incongruity between an individual's actual performance in a given situation and the performance expected of him by others, these problems are as much located in the relevant social norms and in the reactions of others to the drinker's behavior as they are in the drinker's behavior. From the point of view of prevention, this implies the possibility of reducing the level of problems by changing the normative reactions to the drinker's behavior, or by insulating the behavior from potential reactions, as well as by changing the behavior itself.

In some cultures and times, the fact of drinking is itself considered a problem. In most societies, drinking is considered problematic in particular situations (e.g., in a law court) and for particular statuses (e.g., children). A legal prohibition on having more than a limited blood-alcohol level while driving an automobile is now nearly universal in industrialized societies. In many societies, drunkenness -- particularly drunkenness in public places, and particularly when associated with a disruptive demeanor -- has been regarded as a crime or at least as warranting police attention.

These varied proscriptions and prescriptions regarding drinking events and associated behaviors are the threads which form much of the tapestry of alcohol's position in a particular culture. But at least as important in most societies are the social problems related to longer-term cumulative drinking patterns. In many industrial societies, indeed, the most common stimulus for referral to alcoholism treatment is a perception that the individual has defaulted on major social roles -- responsibilities in the family and in the work setting -- as a result of repeated drinking episodes. It is this empirical connection which underlay the tendency, criticized by Seeley, for classic definitions of "alcoholism" as a disease to "include such social consequences . . . in the definition of a disease" (Seeley, 1959, p. 355).

TRADITIONS OF MEASUREMENT OF ALCOHOL-RELATED PROBLEMS

Social and health statistics

The extraordinary range of social, health and personal problems related to drinking is matched by the wide variety of social and health agencies that respond to the problems. But these agencies tend to vary considerably in the attention they give to record-keeping, and in the specific attention they give to the role of alcohol in the problems. The most widely available statistical series with data directly related to alcohol problems are mortality statistics by cause of death. While few categories in these series are alcohol-specific (and those that are -- e.g. death from "alcoholism" -- are often ill-defined), a number of causes of death are sufficiently alcohol-related to have been used as indicators of alcohol problems trends, and -- with somewhat less confidence -- in cross-cultural and other comparisons of geographic units. Indicators of chronic health consequences of drinking have included mortality from cirrhosis, from head and neck cancers, and from alcoholism and alcoholic psychosis. Cirrhosis mortality has been the most widely used of these indicators, although the earlier tradition of treating it as an adequate indirect indicator of a globally-defined "alcoholism" has been largely abandoned (see Popham, 1970). Suicide and homicide mortality statistics have sometimes been used as indicators of alcohol's role in violent events. In many places with well-developed death recording systems, statistics are now available on the blood alcohol level in the decedent at the time of death. The best-developed vital statistics in this respect are those on road traffic deaths; for such deaths, blood alcohol level is now routinely determined in many places. Such measurements greatly improve the utility of casualty death series as alcohol problems indicators, although it must be kept in mind that alcohol's presence does not necessarily imply even conditional causation of the event.

In general, morbidity data are far less comprehensively available than mortality data. The most widely available alcohol-related morbidity statistic has been for admissions to psychiatric hospitals with a diagnosis of "alcoholism", "alcoholic psychosis" or related conditions. This statistic used to be more widely useful than it is now; in the decades before the 1960s, psychiatric hospitals were probably the main location of state-provided treatment for alcohol-related mental problems in most industrialized countries. In some countries, such as Poland (Moskalewicz, 1981), these statistics remained useful indicators of alcohol-related problems into the 1980s -- at least as such problems are manifested in state-supported treatment facilities. But in some countries, the decentralization of mental problems treatment into community institutions, often combined with the growth of alcohol-specific community treatment agencies, has made psychiatric admissions indicators unavailable, or irrelevant as indictors of the whole alcoholism treatment population (see Bunce et al., 1981; Morgan, 1982).

Morbidity statistics on alcohol-related injuries, including blood-alcohol levels or at least a medical notation of drunkenness, are gradually becoming more widely available, particularly for road accident injuries (see NIAAA, 1979, p. 23; Aarens et al., 1977). Nevertheless, reporting-system data on the alcohol component in casualties are generally inadequate for tracking trends. Morbidity statistics on cirrhosis and other long-term physiological consequences of drinking are also gradually becoming more available. Special studies in several countries have suggested that a heavy drinking history is part of the background of a large fraction of health conditions requiring hospitalization (see Rice et al., 1990; Gervois et al., 1985).

The other statistical system which routinely provides data on alcohol-related problems in a number of countries is the system of police and court statistics. Two major alcohol-specific charges -- drunk driving and public drunkenness arrests -- are the most widely available statistics, with the public drunkenness series being partly or completely replaced by sobering-up station statistics in countries that have decriminalized public drunkenness. While statistics on all classes of non-alcohol-specific crime are widely kept, it is only in countries -- such as Finland and Poland -- where there is a special cultural association of and concern about alcohol as a cause of violence that a systematic effort has been made to keep statistics specifying whether drinking is associated with the crime.

It will be seen that the social and health statistics relevant to alcohol-related problems which are usually available cover only a fraction of the total range of alcohol-related problems outlined above. The coverage is also very uneven across the various types of problems. Health and mental health statistics provide indicators in the physiological consequences, mental problems, and casualty problems areas, but with a heavy bias towards the most serious consequences -- death and commitment to inpatient psychiatric treatment. Police and court statistics provide indicators only concerning the criminal aspects of alcohol-related social and casualty problems. The most glaring deficiency is the lack of adequate indicators of alcohol's impact on family and work role functioning (Cook, 1991) -- or, viewed at a societal level, on the tasks of production and reproduction (Mäkelä and Viikari, 1977).

Apart from this deficiency, the most notable drawback of social and health statistical series is that they measure the operation of major agencies of rehabilitation and social control in the society; indeed, often the primary purposes of the collection of the statistics are as "management information" and as accounting controls for these institutions. There is a lengthy literature on validity and reliability problems in mortality statistics -- and certainly alcohol-related deaths are especially likely to be misrecorded -- but, among statistical series we have been discussing, mortality statistics are probably the least sensitive to policy shifts in the societal response to health and social problems, and thus the most closely tied to "real" changes in the prevalence of alcohol-related problematic behaviors and conditions. Morbidity statistics, and police statistics even more, are notoriously sensitive to policy shifts in the societal priorities on and handling of different social and health problems. As such, they provide valuable information; but it is not information that readily forms a reliable indicator of the problematic behaviors and conditions. Sometimes internal evidence will suggest a partialing out of a trend between changes in underlying behavior and changes in social response -- for instance, a lowering of the average blood-alcohol level of arrested drunk drivers suggests that there has been a stepping up of enforcement attention to drunk driving. But in general, routinely-collected social and health statistics do not distinguish between changes in problematic behaviors and conditions in the population and changes in the societal response mechanisms. Special studies, with a much more elaborate data collection, often separate from the case-handling procedures, for a sample of cases, provide one means of periodic "recalibration" of the relative contributions to the routine statistics.

Surveys of general populations

Recent years have seen the emergence in a number of countries of traditions of population surveys concerning problems related to drinking, though these traditions are less widespread than the well-established traditions of surveys on drinking practices. As we have noted, some population surveys have been conducted within a tradition of psychiatric epidemiology, with an emphasis on defining and measuring the prevalences of psychiatrically relevant conditions -- "alcoholism", "alcohol dependence", etc. (e.g., Helgason, 1964; Weissman, Myers and Harding, 1980; Room, 1991; Grant et al., 1992). The alternative social epidemiological tradition of measurement of a range of alcohol-related problems has also been particularly active in North America (Mulford and Miller, 1960; Knupfer, 1967; Clark, 1966; Cahalan, 1970; Cahalan and Room, 1974; Clark and Hilton, 1991. See Edwards, 1973 and Room, 1977a).

The primary approach to measuring the prevalence and patterning of alcohol-related problems in surveys has been to ask respondents about their experiences of problems which they see as related to their own drinking. (In some surveys, a respondent has been asked to report on problems related to drinking for each household member; U.S. validity studies comparing data from such "collateral informants" with that from the drinker suggest that the collateral data is if anything less complete than the drinker's responses). Surveys have thus tended to rely on the drinker or a close informant to determine the issue of "attribution" -- to make the connection between the drinking and the problem. Though this is probably a sensible decision, it would be interesting to know more about the bases on which such attributions are likely to be made. An alternative approach to the survey measurement of social and casualty problems would be surveys of the "victims" and bystanders. Only a beginning on such an approach has been made (see Fillmore, 1985), and the empirical relation between the alternative perspectives remains to be mapped.

In terms of the conceptual framework laid out above, drinking-problems surveys tend to have been oriented more to the measurement of conditions than of events (although many of the concrete items interpreted as indicating conditions actually reflect events). In English-language studies, under the influence of the disease concept of alcoholism, much attention has been given to asking questions indicating dependence on or loss of control over drinking, and to measuring behaviors seen as symptomatic of dependence. While interpretations of what respondents may mean when they report drinking "because I need it when I'm tense or nervous" or worrying "about not being able to get a drink when I need one" have changed over time (Cahalan and Room, 1974; Room, 1977a), it is certainly true that considerable numbers of respondents in English-speaking countries will answer positively to questions such as these, which indicate some degree of self-consciousness and concern over their drinking.

From their inception in the 1960s, general-population surveys of drinking problems in English-speaking countries have also included items measuring what have sometimes been called "tangible consequences" of drinking -- that is, "consequences of drinking which are at least in principle verifiable by someone other than the respondent" (Cahalan and Room, 1974, p. 27). Items covering each of the three domains of such problems outlined above -- physiological consequences, casualty problems, and social problems -- have usually been included; but it is clear that the coverage has been most adequate for the last of these three domains. In a cross-section of the general population, experience of severe physiological consequences at any one time is relatively rare. Even for such severe consequences, there is a problem of attribution; did a doctor or other health worker think the problem was related to alcohol, and if so was the respondent told of the connection? On the other hand, at least in the U.S., less stringently worded items tend to pick up vague fears and worries rather than concrete experiences of physiological problems. With respect to casualties, also, the emphasis tends to have been on relatively stringent summary items in the general drinking-problems surveys, although special analyses concentrating on the casualty area suggest a much wider experience of bumps and cuts related to drinking in the population, which could profitably be pursued with survey methods (see Aarens et al., 1977, pp. 60-62, 556-566, 591-592).

Both in U.S. data (e.g., Cahalan 1970) and elsewhere (Roizen, 1981), the most common "tangible consequence" of drinking in survey studies is usually "spouse complaints" about the respondents' drinking -- in fact, predominantly wives' complaints about their husbands' drinking. The wives, when asked about the matter, confirm the high prevalence of such family disputes (Knupfer, 1968; Room et al., 1991). Studies of young couples in Finland and the Soviet Union have shown that in those societies, too, wives have the burden of being expected to try to control their husband's drinking (Holmila, 1987). Surveys also find substantial rates of dissatisfaction among other family members, and some complaints also from the work environment and from friends (Room et al., 1991). U.S. respondents are often willing to concur that their "drinking has harmed" significant roles and areas of their life, although concrete occurrences like divorce over drinking are considerably rarer. Problems with the police over drinking are also reported by only a small proportion of the U.S. population. Limited sample sizes have often constrained more extended analyses of particular problems of social demeanor and role performance. But, despite their limitations, survey research data are usually the best method available of estimating the prevalence of the social problems -- besides offering the possibility of a more extended correlational analysis.

To a considerable extent, then, the survey method and the health and social statistics method of measurement complement each other in their strengths and weaknesses. Thus health and social statistics make their best showing in measurements of chronic physiological conditions and of casualties, while surveys do better in measuring experiential and affective states and problems of social demeanor and role performance. Likewise, health and social statistics record problems that are very serious better than those which are mundane and everyday, while the rarity of any particular kind of serious event or condition makes it difficult to "capture" adequately in any but an extraordinarily large -- and thus expensive -- population sample.

Developments in population surveys of alcohol-related problems

Recent years have seen the expansion to a broader range of countries and cultures both of social epidemiological surveys concerning alcohol-related problems ( e.g., Garretsen, 1983; Harford and Towle, 1988; Hauge and Irgens-Jensen, 1985; Roizen, 1981) and psychiatric epidemiological surveys concerning alcohol dependence and other diagnostic categories (e.g., Helzer and Canino, 1992). With the exception of inter-Scandinavian comparisons, relatively little advantage has yet been taken of the opportunities the spread of alcohol-related problems surveys offers for comparative analysis.

A recent development in North America has been the completion of psychiatric epidemiological surveys with sample sizes an order of magnitude greater than previous surveys in the alcohol field. Thus the 1988 National Health Interview Survey alcohol supplement was completed by 43,809 adults (Grant et al., 1991; Grant et al., 1992). Reports will be appearing shortly from the U.S. National Comorbidity Survey (N=8908), coordinated by Ron Kessler, and the equally large Ontario Health Survey supplement, and from the U.S. National Longitudinal Alcohol Epidemiology Survey (N=50,000), directed by Bridget Grant. All of these instruments are primarily oriented to the criteria for dependence and abuse diagnoses, but also include substantial data on drinking patterns and problems. Such large data-sets will allow analyses of rates and patterns in relatively small population segments, for instance specific ethnic groups and specific occupations, which have heretofore been mostly beyond the reach of survey analyses. They will also allow researchers to pick up Knupfer's challenge (1989) to study drinking problems in the relatively small proportion of general populations which are really heavy drinkers.

As with drinking patterns, the lengthening of the tradition of general-population surveys of drinking problems has made possible the development of a tradition of trend studies (Clark and Hilton, 1991:139-162). The trend-lines for different alcohol-related problems will not necessarily run in parallel; in particular, in an era of heightened consciousness of alcohol-related problems and a heightened problematization of heavy drinking in the U.S., there is some evidence that indicators of experienced loss of control and of interpersonal problems with drinking may go up even as consumption levels and indicators of alcohol-related physical problems such as cirrhosis or casualties are dropping.

From the first, epidemiological surveys of drinking problems have often been concerned with longitudinal patterns through the life-course (e.g., Robins et al., 1962; Knupfer, 1972; Cahalan, 1969). The contrast between the peak for drinking problems at ages 18-25 in general populations in many industrial countries and the peak for clinical population of alcoholics at ages 35-39 has posed the question of which young problem drinkers will "mature out", under what circumstances, and which will go on to join the clinical population. In U.S. data, it is clear that there is substantial "natural remission" (without clinical intervention) among general-population problem drinkers (Roizen et al., 1978), but that the turnover in drinking problems is smaller among middle aged than among younger respondents (Fillmore, 1987a; Fillmore, 1987b).

As noted above, the analysis of the relation of different drinking patterns to rates of different alcohol-related problems remains an understudied area, despite its crucial significance in policy discussions of "safe levels" of drinking (Pols and Hawks, 1992). A number of analyses of the relation between drinking levels and patterns (e.g., Clark and Hilton, 1991:194-246; Knupfer, 1989) have picked up the analytical traditions reviewed by Mäkelä (1978), and such analyses have recently been extended cross-nationally (Fillmore et al., 1992). But we are still a long way from specifying risk functions for particular kinds of alcohol problems by patterns of drinking in a particular group in a particular society -- the kind of information which would best inform policy and publicity on "safe levels" of drinking. As the discussion above indicates, it is clear that the amount drunk on and circumstances of heavier drinking occasions are more important than overall volume of drinking as a risk factor for casualties and for many social problems of drinking, and publicity on "safe levels" would be well advised to take this into account.

Apart from the broader research possibilities of multivariate and longitudinal analysis, the social importance of measuring trends in alcohol problems indicators constitutes a strong argument for periodic general-population drinking practices and problems surveys. As Edwards put it som time ago, "a case might be made for any country which uses alcohol as a recreational drug also accepting the need for a national sample survey repeated at, say, 5-year intervals" (Edwards, 1973, p. 51).

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1. Prepared for presentation at a meeting on "Social and Epidemiological Research on Alcohol and Drugs: Trends in Recent Years and Key Issues for Future Studies", sponsored by the Addiction Research Institute, Rotterdam, The Netherlands, March 18-19, 1993. This paper draws in part on published material (Room, 1989; Midanik and Room, forthcoming).