A:
Subcommittee for Review of Epidemiology Portfolio
B: Experts in Epidemiology
C: NIAAA Program Staff
D: NIAAA Staff, Representatives from other
NIH Institutes, and Guests
EPIDEMIOLOGY
REPORT OF A SUBCOMMITTEE OF THE NATIONAL ADVISORY COUNCIL
ON ALCOHOL ABUSE AND ALCOHOLISM
EXECUTIVE SUMMARY
The National Institute on Alcohol Abuse and Alcoholism's (NIAAA) Subcommittee
for the Review of the Extramural Research Portfolio for Epidemiology
met on 5-6 May 1999. The charge to the Subcommittee was to examine
the appropriateness of the breadth, coverage, and balance of the epidemiology
portfolio, identifying research areas that are well covered and others
which are either under-investigated or which otherwise warrant significantly
increased attention. The Subcommittee was asked also to provide specific
advice and guidance on the scope and direction of the Institute's extramural
research activities in the epidemiology area.
The Subcommittee for the Review of the Extramural Research Portfolio
for Epidemiology consisted of a chair, NIAAA Advisory Council member,
and an advisory group of six individuals. Three of these individuals
have demonstrated expertise in alcohol-related areas, and three individuals
have demonstrated expertise in non-alcohol-related areas (see
Appendix A).
The review process was initiated by having experts (see
Appendix B) in epidemiology prepare written assessments of the state
of knowledge, gaps in knowledge, and research opportunities. NIAAA program
staff (see Appendix C) presented
the current extramural portfolio, categorized into the areas of methodology/nosology;
moderate alcohol consumption, sexually transmitted diseases, disability,
and comorbidity; intentional/ unintentional injuries; and special populations.
All information was shared with experts, selected NIAAA staff, and the
chair and advisory group before the meeting.
A summary of FY 98 epidemiology awards is detailed below.
Epidemiology
|
Percentage of Epidemiology to Total
|
|
No.
|
Amount
(in thousands)
|
No.
|
Amount
|
Research Project Grants1
|
103
|
$30,460
|
18%
|
22%
|
Cooperative Agreements
|
0
|
0
|
0%
|
0%
|
Research Centers
|
1
|
1,716
|
7%
|
8 %
|
Research Careers
|
9
|
705
|
15%
|
11%
|
Research Training
|
3
|
210
|
4%
|
4%
|
Total
|
116
|
$33,091
|
16%
|
19%
|
1 includes SBIR awards and reimbursable funds.
On 5-6 May 1999, experts and NIAAA program staff made abbreviated presentations
of their material followed by discussion among all of the participants,
including representatives from other NIH Institutes and guests (see
Appendix D).
PRIORITIES RESULTING FROM REVIEW OF
EPIDEMIOLOGY PORTFOLIO
It is noted that as epidemiology has matured as a discipline, it has
evolved from descriptive to hypothesis-driven research. Alcohol-related
epidemiological research is encouraged to continue to emphasize an analytic
or hypothesis-driven approach.
The following five areas were recommended for major emphasis.
· Identify patterns, risk factors,
and protective factors for alcohol use and escalating consumption
among 8 - 12 year olds. Secondary analyses of existing data sets as
well as new studies are needed.
· Emphasize positive and negative
consequences associated with moderate alcohol consumption. Consideration
should be given to influence of interacting variables, such as genetic
factors, diet, and physical activity. There is minimal need for additional
correlative studies of moderate alcohol consumption and coronary heart
disease.
· Determine relations among excessive
alcohol consumption, hepatitis C, and alcoholic liver disease.
· Conduct longitudinal natural
history studies with emphasis on developmental transitions and risk
factors that precipitate or protect transitions from moderate to excessive
alcohol consumption.
· Determine relations between
alcohol consumption and violence, including spousal and child abuse.
Additional recommendations included:
· Identify factors that modify
relations between risk factors, alcohol use, and consequences, including
multiple levels of context, patterns of consumption, and comorbidity.
· Improve measurement of alcohol
consumption and associated outcomes; validity and reliability of measures
need to be documented. It would be useful to convene a consensus conference
to determine preferred measures of alcohol consumption, especially
for longitudinal studies.
· Further refine relations between
alcohol consumption and injuries, morbidity, mortality, social roles,
social functioning, and disability.
· Conduct a joint workshop between
epidemiologists and geneticists to insure that epidemiologists collect
data on genetically informative samples.
· Investigators should be encouraged
to share epidemiological data with all interested and qualified parties.
Back to Top
OVERVIEW OF EPIDEMIOLOGY RESEARCH AT NIAAA
(Mary Dufour, M.D., M.P.H.)
Epidemiology is the study of a disease, injury, or other health-related
condition in human populations and of those factors that increase the
likelihood that such a condition will occur. Thus the primary aim of
alcohol epidemiology is to identify and explain factors that shape the
distribution of alcohol use, abuse and dependence and their consequences
in various populations. Such a goal necessarily involves first defining
the distribution of alcohol consumption and its related problems in
the population. Knowledge of the nature and magnitude of alcohol's impact
on the individual and on society is necessary for developing effective
prevention, intervention and treatment strategies. It is also critical
for informing policy makers and the general public of the need for and
importance of alcohol research.
Epidemiology has its roots in the study of infectious diseases. Such
research first used the public health model, which involves defining
a disease agent, host and environment, to study and control epidemics.
During the early and mid-20th century, medical advances and improvements
in sanitation led to the mastery of many infectious diseases, such as
tuberculosis. Soon thereafter, cancer and heart disease gained recognition
as common killers. This resulted in establishing a new discipline--chronic
disease epidemiology. In addition, the field of epidemiology's focus
shifted to assessing the general health of communities under normal
conditions rather than only under specific epidemic circumstances.
Alcohol epidemiology as a unique discipline is a relative newcomer
to the field, and it marks a logical progression in the science of epidemiology.
The epidemiology of many infectious diseases is relatively straightforward,
having a specific, well-defined, easily identifiable etiologic agent
(e.g., a bacterium or virus); a clear-cut case identification; a relatively
short clinical course; and a quickly effective prevention (vaccination)
or treatment (antibiotics). The epidemiology of chronic diseases such
as cancer and heart disease is more complex. Alcohol epidemiology, however,
is even more intricate and challenging because of the multiplicity of
its contributing factors. It encompasses alcohol use, abuse and dependence
as well as numerous medical, psychological, social, legal, and economic
consequences. The large number and variablilty of definitions in alcohol
research adds to the complexity of doing alcohol epidemiology.
Historical Perspective
The Division of Biometry and Epidemiology (DBE) began life as the Laboratory
of Population Studies in NIAAA's intramural research program. As the
missions and function of the Institute grew and changed, the activities
of DBE seemed more compatible with and supportive of the extramural
part of NIAAA. Prior to 1986, responsibility for the program portion
of all NIAAA extramural grants resided in a single division, the Division
of Extramural Research. Following his arrival in October of 1986, Dr.
Gordis reorganized the Institute by creating the Division of Clinical
and Prevention Research (DCPR) and distributing program responsibility
for the Institute's grant portfolio across three Divisions--DCPR, the
Division of Basic Research--DBR (formerly the Division of Extramural
Research) and DBE. He also commissioned a peer-review of DBE's internal
research. The review team of internationally recognized epidemiologists
gave the Division's work high marks. They were especially enthusiastic
about the data development, collection and surveillance activities and
urged that DBE better publicize its endeavors. There are two Branches
in DBE--the Biometry Branch and the Epidemiology Branch. Staff in the
Biometry Branch primarily do intramural research, while those in the
Epidemiology Branch both serve as program staff for epidemiology grants
and pursue their own research.
The Alcohol Epidemiologic Data System (AEDS)
Due to the relatively small size of the DBE staff, data collection,
analysis and reporting are facilitated by NIAAA's Alcohol Epidemiologic
Data System (AEDS)--supported by one of NIAAA's largest and most long-standing
contracts. Established in 1977, AEDS monitors trends in alcohol epidemiology
through surveillance of apparent per capita alcohol consumption, cirrhosis
mortality, alcohol-related morbidity among patients discharged from
short-stay community hospitals, and alcohol-related fatal traffic crashes.
These trends are reported in annual surveillance reports. AEDS also
acquires and analyses major population-based surveys and other data
collections that include alcohol as a major or minor component. Some
of the surveys are designed specifically to answer alcohol-related questions;
other surveys address wider issues but contain alcohol-related data.
In order to encourage the fullest possible utilization of these data,
every year AEDS publishes a Data Directory-- a listing of these
surveys including title, sponsoring agency, contact design, sample characteristics,
sample size, alcohol variables, other variables and limitations. AEDS
also manages the Quick Facts electronic bulletin board that provides
free online access to alcohol-related statistics collected by NIAAA
and other researchers.
1988 Extramural Science Advisory Board Review: Incidence and Prevalence
On November 29, 1988, NIAAA's Ad Hoc Extramural Science Advisory Board
met to ascertain research needs in the subject area of "Incidence
and Prevalence." That meeting, the ninth in a series of external
reviews of NIAAA's recent portfolio, marked the completion of the first
cycle of review of NIAAA extramural research. Although the primary purpose
of the review was to assess the "state of the science" of
extramural alcohol epidemiologic research, the recommendations stemming
from the meeting were quite global and many have been met through DBE
intramural as well as extramural activities, some of which span Divisions.
These recommendations are listed below.
General
Launch a major effort to standardize research and diagnostic measures
Increase support for longitudinal and cross-sectional surveys
Facilitate secondary analyses of existing data sets
Encourage interdisciplinary collaboration
Study design and analysis
Encourage the analysis of aggregate data
Support aggregate analyses at the State level
Encourage multi-occasion longitudinal research
Provide training opportunities
Drinking behavior
Support up-to-date reviews on drinking norms and contexts
Support research on long-term changes in drinking norms and contexts
Define drinking problems in terms of norms and contexts
Clarify the roles of formal and informal controls
Investigate international trends
Broaden the scope of drinking surveys
Encourage research on multiple measures of drinking patterns
Investigate the chronicity of heavy drinking
Investigate lagged changes in problem prevalence
Emphasize cultural influences on drinking behavior
Adverse consequences
Continue support for general population and subpopulation surveys
Facilitate the joining of the two traditions of measurement
Study large samples of heavier drinkers
Include alcohol data in other reporting systems
Encourage epidemiological research on cirrhosis
Expand epidemiological research efforts on alcohol and the
immunesystem
Support theoretical studies on vehicular unintentional injuries
Actively encourage research on non-vehicular unintentional injuries
Improve clinical sampling and reporting methods
Investigate the course of alcohol-related disorders
Compile a database on treatment statistics
In the intervening ten years, aspects of most recommendations have
been addressed. Under the general recommendations heading, NIAAA has
developed the capacity to effectively measure alcohol and other drug
use disorders in general population surveys and has fielded it's own
first ever national population-based survey, the 1992 National Longitudinal
Alcohol Epidemiologic Survey. In May of 1997, DBE hosted an international
workshop on consumption measures and models for use in policy development
and evaluation that will significantly advance efforts in the alcohol
measurement arena. Grantees as well as DBE staff have conducted numerous
secondary analyses of existing databases.
Headway has also been made on all of the recommendations regarding
study design and analysis. In addition to funding fellowships and individual
training grants, DBE has provided long-term funding for two institutional
training grants, that of Dr. Nancy Day at the University of Pittsburgh
which is currently in its 17th year of funding (T32AA07453 Alcohol
Research Training Grant) and that of Dr. Constance Weisner
at the University of California, Berkeley which is currently in its
21st year (T32AA07240 Graduate Research Training on Alcohol Problems).
Over the years, these two programs have trained at least 50 scientists
currently in the alcohol field.
The NIAAA Alcohol Research Center "Epidemiology of Alcohol
Problems" also at U.C. Berkeley, among many significant
accomplishments, has contributed importantly to the advancement of the
study of drinking behavior. Research examining international trends
in alcohol use and consequences has increased, as has examination of
lagged changes in problem prevalence.
Responding to recommendations in the area of adverse consequences,
NIAAA has invested a great deal of effort in inserting quality alcohol
measures in many data collection efforts across multiple federal agencies.
NIAAA's portfolio on all aspects of alcohol and the immune system has
burgeoned. In 1993, NIAAA added a research center more focused on the
epidemiology of alcohol-related medical consequences--the "Center
for Clinical and Medical Epidemiology" at the Research Institute
on Addictions in Buffalo, New York. Extensive additional research
has been done on drinking and driving and headway has been made in studying
other alcohol-related unintentional injuries. Research on alcohol and
intentional injuries including family violence, homicide and suicide
is also under way. Clinical sampling and reporting falls under the preview
of DCPR while the responsibility for compiling treatment statistics
was ceded to SAMHSA when NIAAA, the National Institute on Drug Abuse
(NIDA), and the National Institute on Mental Health (NIMH) joined NIH.
The Big Picture
Due to the relatively small size of the DBE grant portfolio and its
variability from year to year, and in order to afford the broadest possible
overview, the entire portfolio for the ten years since the last review
is presented. However, prior to discussing the specifics of DBE's grant
portfolio, it is necessary to put this activity into perspective. Although
DBE's extramural grant portfolio represents the single largest piece
of NIAAA's investment in epidemiologic research, by no stretch of the
imagination does it comprise the entire investment.
The ten-year average distribution of the resources committed to the
DBE epidemiology program by mechanism is discussed below. Research Project
Grants represent 58.5% of DBE's epidemiology investment. Included here
are grants having a program class code AE as well as those of other
Institutes being co-funded by DBE.
The next largest portion is that of Interagency Agreements with 13.5%
of the resources. Items in this category include NIAAA funding provided
to the Centers for Disease Control and Prevention's (CDC) National Center
for Health Statistics (NCHS) for participation in national surveys such
as the 1988 National Health Interview Survey, the National Maternal
and Infant Health Survey and the 1993 National Mortality Followback
Survey. Funding to the Bureau of the Census to field the 1992 National
Longitudinal Alcohol Epidemiologic Survey (NLAES) and the national survey
currently under development also fall into this category.
Only slightly smaller, with 13.3% of the resources, is the portion
representing NIAAA Research Centers. As mentioned earlier, the two NIAAA
Research Centers which focus on epidemiology are "Epidemiology
of Alcohol Problems" (P50AA05595) at the
University of California, Berkeley and the "Center for
Clinical and Medical Epidemiology"
(P50AA09802) at the Research Institute on the Addictions in Buffalo,
New York.
Research and Development Contracts represent 10.3% and include
activities such as the AEDS contract. Careers and Training mechanisms
make up the remaining 4.5%. The two previously mentioned long-standing
institutional training grants comprise a significant portion of this
funding.
Since the answers to epidemiology questions provide the foundation
for much of NIAAA-supported research, additional epidemiology research
is supported outside DBE. Each year NIAAA grant program staff code each
funded application for a variety of variables including keywords, human
subjects/special populations, human subjects age and various budget
categories such as genetics, epidemiology, treatment of alcoholism,
behavior, alcohol and pregnancy, alcohol-related medical disorders,
etc. In order to get a sense of the magnitude of this portion of NIAAA
epidemiology research, a search was done to find all 1998 projects with
> 20% coded to the epidemiology budget category but without
AE program class codes. Although the portion of the funding for research
project grants (RPG's) shrank a bit relative to the ten-year amounts,
it still represents over half (52.4%) of epidemiology funding. Among
the RPG's, 14.2% reside outside of DBE with 38% of those having a program
class code of AS (Health Services Research) and 49% AP (Prevention).
The remaining 3% are AC (treatment) and special collaborative minority
programs. Research Center Grants are 25.8%, representing an additional
18.1% in center resources. Resources for training/careers also increase
a bit with 21.5% of these funds going for epidemiology training/careers
outside of the purview of DBE. The proportions of the resources for
DBE research and development contracts and interagency agreements decrease
to 5.7% and 9.6%, respectively.
From time to time extramural researchers have voiced concerns that
alcohol epidemiology research project grants get shortchanged in favor
of intramural epidemiologic research. The above information clearly
documents that the bulk of NIAAA epidemiology resources are used to
fund RPG's, centers and career/training grants.
Topic Areas
The research supported in DBE falls into a variety of categories. The
selection of categories and the placement of grants within categories
are to some extent arbitrary. Many other classification schemes are
possible. In addition, very few grants belong exclusively in one category:
overlap is extensive. For example, relatively few grants are "pure
methodology" but grants in every topic area have methodological
components. Certain grants included under "Injuries" could
just as easily have been placed under
"Family", "Race/Ethnicity" or "Women."
Some of the grants under "Women" could be in "Morbidity/Disability/Mortality"
or "Elderly." Selected grants in "Race/Ethnicity"
could be in "Youth/Family" and vice versa. Following
is a table of the eleven broad topic areas selected as well as the number
and percentage of grants assigned to each category. Grants from FY 1989
to the present are included.
DBE Grants
|
Number of DBE grants
|
Percent
|
Alcohol and Pregnancy/FAS
|
4
|
3.2
|
Genetics
|
13
|
10.4
|
Methodology/Nosology
(including Dependence)
|
15
|
12.0
|
Morbidity/Disability/ Mortality
|
15
|
12.0
|
Injuries/Violence
|
11
|
8.8
|
Youth/Family
|
22
|
17.6
|
Elderly
|
3
|
2.4
|
Women
|
9
|
7.2
|
Race/Ethnicity
|
15
|
12.0
|
Workplace
|
5
|
4.0
|
Other
|
13
|
10.4
|
DBE Total
|
125
|
100
|
FORMAT FOR THE PROGRAM PRESENTATION
For each of the topic areas, a brief introduction is followed by a
listing of PAST GRANTS--these are grants for which funding
was completed sometime during the 10-year period. Next is a summary
of CURRENT GRANTS that includes not only new grants but long-standing
continuations that are presently funded. For past and current grants,
information provided includes principal investigator, grant number and
title and a brief summary. Sections on SELECTED FINDINGS and
GAPS complete the narrative. Only certain
findings are highlighted to provide a flavor of the nature of the research.
Likewise only selected gaps are mentioned. Clearly additional gaps will
be identified over the course of the review meeting. The DBE grants
in "Alcohol and Pregnancy/FAS" and "Genetics" have
already been presented in earlier reviews of these areas. Brief summaries
are included here only for the sake of completeness.
FUTURE DIRECTIONS
Substantial progress has been made over the past ten years in alcohol
epidemiology. The purpose of this meeting is to assess the "state
of the science" of alcohol epidemiology, to identify gaps in DBE's
portfolio and suggest future directions for research. In preparing for
this review, DBE staff has identified several gaps. Additional gaps
will be articulated over the course of the meeting and in the final
report of the committee. In addition to identifying gaps in existing
areas of research, new areas must be considered as well. Small Area
Epidemiology is coming of age.
All areas of alcohol research are rapidly advancing and it is important
to utilize the fruits of research in other disciplines to advance alcohol
epidemiology. For example, increasing incorporation of the measurement
of genetic material and other biomarkers in general population surveys
would enhance the value of the data collected.
Back to Top
METHODOLOGY/NOSOLOGY
METHODOLOGY AND ANALYSIS IN ALCOHOL EPIDEMIOLOGY:
RECENT ADVANCES AND OPPORTUNITIES
State of Knowledge (Tom K. Greenfield, Ph.D.)
Epidemiology of alcohol use and alcohol-related consequences descriptively
monitors use, abuse, dependence, and acute and chronic problems associated
with drinking and investigates mechanisms involved in alcohol consumptive
behavior and outcomes, or potential harms. Recently, there have been
several methodological developments including (1) improvements in measurement
of human alcohol consumption and related problems; (2) use of relevant
explanatory constructs such as individual differences in attitudes and
expectancies, and features of communities or the contexts where alcohol
use occurs; and (3) use of improved methods for analyzing differences
between subgroups with varying risk factors on the one hand and changes
over time, on the other, or both, using either repeated cross-sectional
series or longitudinal panel designs.
Issues concerning the assessment of alcohol consumption (volume, pattern,
lifetime estimates) have been reviewed (Rehm, 1998), and research to
improve the quality of these data, including cognitive studies of how
to ask questions concerning consumption parameters is underway. Measurement
of alcohol-related problems is beginning to focus on using a continuum
of severity and dissecting relations among various drinking-related
problems (Caetano, 1997).
There have been recent conceptual advances in understanding the role
of cognitive factors, attitudes, and expectancies in assessing individual
differences and risks for developing alcohol-related problems (Goldman
et al., in press). However, for a considerable time those concerned
with a more complete specification of influences on alcohol consumption
and problem rates have recognized that individual-level variables should
be supplemented with influences occurring at broader social levels (Johnstone,
1994) based on an ecological understanding of alcohol use (Gruenewald
et al., 1993).
Multilevel, contextual, and hierarchical modeling techniques are now
being applied to alcohol-related epidemiology and prevention research.
A new generation of computer programs (Arbuckle, 1995) allow for analysis
of continuous and categorical measures, analysis with multiple groups,
and adjustments for non-normal and/or missing data. There has been a
convergence of growth curve modeling (study of individual change over
time where growth parameters vary) and structural equation modeling
(involving relationships between observed and latent variables) within
a single analytic framework (Muthen, in press).
There are three specific recommendations: (1) Technology transfer of
user friendly, new analytical strategies should be encouraged. (2) Severity
of alcohol-related problems needs to be better characterized and measured.
(3) It is important to avoid population-specific instrument bias when
collecting epidemiological data.
NOSOLOGY
State of Knowledge (John E. Helzer, M.D.)
The major nosological systems for substance use disorders and for mental
health in general have been clinically rather than empirically derived.
There has been great progress in the last two decades in the development
of a much more uniform language for classification in mental health
and in the development of instruments to accomplish this systematically.
In spite of these advances, there is growing concern about the continuing
adequacy of nosological systems. Although the DSM-IV and its predecessors
create a nosology that serves the clinical needs of rapid decision-making
and communication, it is somewhat problematic for research purposes,
which requires a dimensional system that utilizes differential scores
on several parameters simultaneously, is predominantly empirical, and
can be successfully administered and processed by computer. There is
continuing evidence that categorical nosologies are insufficient in
capturing important distinctions among alcoholics and they demonstrate
poor sensitivity in adolescents (Martin et al., 1995).
In correspondence with the refinement of categorical nosologies, increasingly
sophisticated instruments have been developed to gather necessary clinical
data. Measurement of current consumption patterns and longitudinal estimates
of consumption can be difficult because of retrospective recall. However,
results from a variety of new techniques are promising, e.g., computer-assisted
collection of sensitive data (Turner et al., 1998); wearable electrochemical
devices that monitor alcohol levels over time (Swift, 1993); telephone
interactive voice response systems to collect sensitive information
on a daily basis (Searles, in press).
Statistical models are being developed that can examine psychiatric
signs and symptoms for latent structure (Anthony et al., 1995). These
methods can result in models that assume an underlying categorical or
a dimensional typology. Another important area for typological improvement
is environmental variables. Multiple studies attest to the potential
importance of a better understanding and classification of environmental
variables in the nosology of alcoholism and in further clarification
of the interaction of genetics and environment in the etiology of alcoholism.
Nosological issues are important in cross-national epidemiology where
the needs and opportunities are especially great in the field of alcoholism.
In the past two decades, the field has moved beyond the problem of making
coherent cross-national comparisons based on illness rates defined and
assessed in each country independently. There is a growing number of
instruments that have been cross-nationally developed and validated
including the CIDI, SCAN, AUDADIS-ADR, and AUDIT (Cottler et al., 1997;
Allen et al., 1997).
There are two specific recommendations: (1) There is an ongoing need
for accurate clinical diagnostic approaches that facilitate rapid decision-making
and communication; such classification schemes tend to be categorical.
(2) New research diagnostic criteria should be developed empirically
and require assessing several parameters simultaneously; criteria tend
to be dimensional rather than categorical.
Back to Top
NIAAA PORTFOLIO ON METHODOLOGY/NOSOLOGY
(Mary Dufour, M.D., M.P.H.)
METHODOLOGY
Major foci of the grant program in methodology have been the investigation
of factors related to non-response to survey questionnaires concerning
alcohol consumption, alcohol use problems and comorbidity; the influence
of measurement factors (e.g., order of response options) in self-reports
of alcohol use; reliability and validity of commonly used alcohol screening
instruments in surveys (i.e., CAGE, Short MAST and AUDIT); and identification
of characteristics of abstainers, other than their non-use of alcohol,
which may confound associations between drinking and mortality. Another
focus has been the use of meta-analysis to predict drinking patterns/problems
across time; integrate individual and societal level explanations of
drinking patterns/problems; reconcile differences in findings across
studies; and synthesize findings on research questions.
Past Grants
Ronald D. Hays (R01AA07852), "Microcomputer Assessment
of Alcohol Use" developed an interactive, computerized
assessment program for investigating and improving the validity of
self-reports of alcohol use. The program was then administered by
microcomputer, and measurement factors such as order of items, quantitativeness
of responses, and providing feedback were investigated.
Current Grants
Kaye M. Fillmore (R01AA07034), "Collaborative Alcohol
Related Longitudinal Project" is continuing the
meta-analytic study of an archive of raw data from 40 longitudinal
general population data sets and two adoptee studies from 18 countries.
The project, now in its 12th year, addresses two substantive domains.
The first domain involves social change and gender roles, including
examination of cross-study variation in the prediction of gender-specific
drinking patterns/problems. The second domain uses meta-analysis to
combine research results in longitudinal studies containing information
on mortality, morbidity, and other health characteristics, as well
as social characteristics. One objective of the research is to identify
characteristics of abstainers (e.g., subjective health, social class,
social integration, and mental health) that may account for their
excess mortality over moderate drinkers. In addition, gender roles
are being linked to social structure and to social change, comparing
different societies and periods of history. Dr. Fillmore is
also in the 6th year of a program of research (K05AA00172), "Situational
and Contextual Factors in Drinking Practices" involving
synthesis of raw data from multiple, international treatment evaluation
studies. The project's aims include the prediction of drinking patterns/problems
across time; integrating individual and societal level explanations
of drinking patterns/problems; systematically reconciling differences
in findings across research studies and methodologies; and synthesizing
findings on research questions. Design effect is being used to differentiate
the effects of societal change on drinking behavior from confounding
factors.
Three new studies are also being supported:
Cheryl S. Alexander (R21AA10939), "Adolescent Drinking-Analytic
Models, and Longitudinal Data" is developing and
applying marginal, latent variable and transition models to an investigation
of alcohol behavior using data from a longitudinal study of rural
adolescents. Objectives include investigating whether standard alcohol
questions on use, attitudes or associated problems have the same meaning
for adolescents at different developmental stages and among different
gender or racial/ethnic groups, and whether information about drinking
is remembered and retrieved in a similar manner. In addition, the
study explores ways these adolescents understand and process questions
about their alcohol use and the predictors of use.
Steven S. Henley (R43 AA11607), "Exploiting Hidden Structures
in Epidemiological Data" is developing an advanced
data recoding algorithm using techniques that combine pattern recognition,
stochastic optimization, and genetic algorithms to exploit structural
relationships between continuous and categorical predictor variables
and categorical outcomes in a Phase I SBIR grant.
Bengt O. Muthen (K02AA00230), "Advanced Analysis of the
Development of Alcohol Problems" is developing
new statistical methods to answer substantive questions regarding
the development and prevention of alcohol problems and collaborating
with alcohol researchers on advanced statistical analysis of their
longitudinal data sets. Information on the new methods will be disseminated
via articles, a book and training sessions.
Selected Findings
Measurement. When drivers court-ordered into alcohol treatment
were interviewed by microcomputer about alcohol frequency, analysis
revealed that more precise response options and standardized location
of items within the questionnaire improved the quality of data. Results
of another analysis showed that response quantitativeness, order of
presentation of response options, and relative placement of alcohol
use items in the questionnaire had minimal influence on the quality
of self-report data. When this study was replicated with a sample of
university students, results indicated that presentation of high frequency
response options prior to lower frequency options increased self-reports
of frequency.
Recalled perceptions of intoxication, impairment and reported BAC on
the day or night of their arrest were studied in drivers convicted of
DUI. Recalled levels of intoxication and impairment corresponded to
their reported BAC across drinking pattern categories. Factor analysis
identified a factor for "cogent risk-taking" in which people
were aware of their level of intoxication and impairment and drove nonetheless.
Non-Response. Demographic characteristics and history of
alcohol problems and psychiatric disorders were compared in responders
and non-responders in an 11 year follow-up study. Few differences were
found. Non-response was greater in men, those with less education and
in low users of medical care. Non-response was also greater among those
reporting drinking and driving trouble or a history of barbiturate use
or dependence. The findings were not changed by refusal conversion,
suggesting that efforts to enlist participation of initial refusers
might not be needed.
Meta-analyses. Meta-analysis of eight general population
surveys of men evaluated all-cause mortality rates by drinking patterns.
The most consistent finding was the association of heavy drinking with
mortality among youth. Among adults, drinking 43 or more drinks per
month and drinking 21 or more times per month were associated with increased
mortality risk. No evidence was found to support the hypothesis that
abstinence is associated with greater mortality risk than light drinking.
There was no association of former drinking with mortality across studies.
Across ten general population studies, adult male former drinkers were
consistently more likely to be heavier smokers, depressed, unemployed,
lower SES and to have used marijuana than long-term abstainers. Adult
female former drinkers were consistently more likely to be heavier smokers,
in poorer health, not religious, and unmarried than long-term abstainers.
Both long term abstainers and former drinkers tended to be of lower
SES than light drinkers and report poorer health. Thus, characteristics
of these two groups of abstainers, other than non-use of alcohol, may
confound associations found between drinking and mortality.
Meta-analysis of three general population surveys of adult women evaluated
all-cause mortality rates by drinking pattern. In models in which age
was controlled, odds of death for long-term abstainers and former drinkers
was greater than for light drinkers; odds of death for moderate and
heavy drinkers was greater than for light drinkers. When other psychosocial
attributes were controlled, odds of death for heavy drinkers were greater
than those for light drinkers. When interactions of age and the two
forms of abstinence were introduced, results were consistent with the
hypothesis that characteristics of abstainers other that their non-use
of alcohol may account for their higher mortality risk.
Two measures of alcohol consumption were used to predict groups of
alcohol problems in 21 general population studies from 11 countries.
When only individual-level variables were controlled (age and sex),
both quantity and frequency were risk-factors for each drinking problem.
However, except in the case of the association of quantity with alcohol
treatment, the magnitude of these risks was heterogeneous across studies.
When blocking for societal-level traits, each had more relevance than
some, but not all of the associations between consumption and problems.
These findings suggest that impact of norms and societal stress in groups
have different but significant consequences for the relationships between
consumption and problems.
Gaps
Research opportunities in methodology abound. The rapid pace of development
of computer-based technology makes this a dynamic and exciting area.
Better methodologies for measuring alcohol use across the lifespan are
needed, as are techniques for calculating alcohol-related risks and
benefits in various stages of life. Refinement of methodologies for
calculating alcohol-related morbidity and mortality are sorely needed.
Many opportunities exist for methodology research to contribute to the
advancement of each of the topic areas outlined in this review.
NOSOLOGY
During the past ten years, a major focus of DBE's nosology grant program
has been the validity of DSM conceptualizations and measurements of
alcohol abuse and dependence. The validity of DSM dependence has generally
received support from research evidence, whereas abuse has not. In the
past, diagnostic criteria for alcohol use disorders were developed largely
by research with adult clinical populations. In order to provide more
balance, NIAAA has supported studies of general populations. Other areas
of emphasis have been the role of comorbidity (e.g., abuse of other
drugs and psychiatric conditions) in the development and course of alcohol
use disorders, familial and psychophysiological precursors and other
predictors of alcohol problems, predicting drinking patterns/problems
across time-periods, and integrating individual and social level explanations
of drinking patterns/problems.
Past Grants
Kathleen K. Bucholz (R01AA08752), "New Alcohol Problems
and Disorders -- 11 Year ECA Follow-up" followed
a group of subjects who were interviewed eleven years earlier as part
of the St. Louis ECA study in order to identify new cases of alcohol
problems or alcohol use disorders. Specific aims included estimating
the 11-year cumulative incidence of alcohol problems and alcohol use
disorders; identifying predictors of onset and determining whether
predictors would be the same regardless of diagnostic classification
system.
Deborah S. Hasin (R01AA08159), "Alcohol Dependence: General
Population Validity" examined reliability, validity,
and prognostic implications of the DSM-III-R and ICD-10 definitions
of alcohol dependence. Dr. Hasin (R01AA08910), "Validating
Epidemiologic Measures of Alcohol Dependence" also
provided information on the reliability and validity in clinical samples
of the Alcohol Use Disorders and Associated Disabilities Interview
Schedule (AUDADIS), the survey instrument utilized in NIAAA's large,
national, general population survey, the National Longitudinal Alcohol
Epidemiology Survey (NLAES), which is administered by lay interviewers.
Vicki Eileen Pollock (R01AA08031), "Alcoholism Risk:
Psychobiological Alcohol Effects in Men" assessed
the general hypothesis that psychological and physiological characteristics
distinguish men at high risk for developing alcoholism from controls
while sober, and also after acute alcohol administration. Her related
K-award (K02AA00146), "Psychophysiological Factors In Alcoholism
Development" tested the validity of predictions drawn
from normalization theory which holds that certain individuals are
susceptible to developing alcoholism because acute alcohol intake
normalizes their psychophysiological functions.
Two additional studies supported were grants by:
Arthur Alterman (R01AA03736), entitled "Risk Factors
and Development of Problem Drinking," and Ronald Drabman
(R03AA07683) entitled "Taste Preference in High Risk
Groups for Alcoholism."
Current Grants
Deborah S. Hasin (K02AA00161), "Epidemiologic Studies
of Alcohol Use Disorders" is now in the 6th year
of a program of research focused on investigating validity of concepts
and definitions of alcohol use disorders; instrument development;
measures for the reliable and valid diagnosis of psychiatric disorders
in heavy drinkers and drug users; and investigation of the effects
of psychiatric comorbidity on the course of alcohol and drug disorders.
The current study includes development of reliable and valid measures
of HIV sex risk behaviors in alcohol and drug abusing samples and
investigation of the effects of acculturation on drinking and the
prevalence of alcohol disorders among Russian immigrants to the United
States and Israel.
Two new grants are also being supported:
Eric O. Johnson (R03AA11846), "Alcoholism Typology"
is refining a typology of alcoholism that has promise for distinguishing
subtypes based on relative genetic and environmental influence.
Christopher S. Martin (K02AA00249), "Quantitative Methods
in Alcohol Research" is developing expertise in
advanced quantitative methods to address theoretical and conceptual
issues in ways traditional statistical techniques cannot. In both
adolescent and adult data sets, these methods are being used to contrast
the validity of existing systems such as DSM-IV and ICD-10 with a
new model of the diagnosis and taxonomy of alcohol use disorders in
which abuse and dependence diagnoses represent milder and more severe
manifestation of the same core addiction constructs.
Selected Findings
Reliability and Validity Studies. A number of findings
were based on a sample of community residents screened for heavy drinking
in the previous twelve months and diagnosed for alcohol use disorders
by different sets of diagnostic criteria (i.e., DSM III, III-R, IV;
and ICD-10). Agreement for most comparisons involving diagnoses for
current dependence ranged from good to excellent; this finding held
across gender, age, and racial subgroups. Evaluation of the association
of a set of seven criterion variables external to the alcohol diagnostic
criteria and DSM-IV dependence and abuse diagnoses revealed that dependence
diagnosis was significantly associated with all criterion variables
when compared with no diagnosis, even though cases of dependence were
mild. In contrast, the abuse diagnosis did not show a pattern of association
with the criterion variables when compared to no diagnosis.
When a modified version of the Structural Clinical Interview for
the DSM was used to assess DSM-IV alcohol abuse and dependence symptoms
in adolescent drinkers with varying levels of alcohol consumption
and alcohol related problems, results generally supported the utility
of DSM-IV criteria for alcohol dependence. However, those with DSM-IV
alcohol abuse diagnoses displayed quite heterogeneous patterns of
symptomatology, suggesting limitations of the criteria for DSM-IV
alcohol abuse in adolescents. Although, they are not in the DSM-IV
criteria, alcohol-related blackouts, craving and risky sexual behavior
were common in adolescents with DSM-IV alcohol dependence and abuse
diagnoses and are an important focus for assessment and treatment
efforts. Another study involving male and female adolescent drinkers
identified three stages of alcohol problems distinguished by time
to onset: heavy and heedless drinking with associated social and role
obligation problems, psychological dependence, and withdrawal.
Development of Alcohol Abuse and Dependence. An investigation
of the influence of gender, comorbidity, drinking history and age
on the clinical manifestations of DSM-IV alcohol abuse or dependence
based on a sample drawn from the NIMH Epidemiologic Catchment Area
Study showed that gender and comorbidity had independent effects on
problem drinking. Gender contributed to the age of onset of problem
drinking and the rate of its development. Comorbidity, drinking history
and age contributed independently to its severity. The effects of
these variables in this community sample paralleled those reported
in treatment samples. Another study comparing three samples of alcohol-dependent
individuals revealed similarities among clinical, family study, and
community samples in terms of appearance of milestones of alcohol
dependence.
Comorbidity. The study of lifetime prevalence of other
psychiatric disorders in three samples (clinical, family study, and
community) of alcohol-dependent individuals found that for females
ages 45 or younger, lifetime prevalence of major depression was high
in both clinical and family study alcoholics compared with community
alcoholics; male alcoholics from the community study had excess of
drug dependence. Findings suggest that, although alcoholics identified
in clinical setting may have more severe alcohol dependence, certain
types of psychiatric comorbidity are present to a greater degree in
samples of untreated alcoholics.
Analysis of adolescents admitted for inpatient treatment of alcohol
abuse showed that 96 percent reported use of drugs other than alcohol
during their lives. Findings also indicated that extensive polydrug
use characterized the large majority of male and female adolescent
alcohol abusers. In another investigation of adolescent drinkers with
DSM-IV alcohol dependence, alcohol abuse, and no alcohol diagnosis,
findings revealed that the total number of illicit drugs ever used
was greater in the alcohol dependence and abuse groups. A consistent
pattern of psychoactive substance use was also found in which alcohol
was followed by marijuana, which was followed by other drugs. Frequency
and extent of polydrug use was associated with being older and having
higher levels of behavioral under control and negative emotionality.
In national study, a significant association between depression and
DSM-III-R alcohol dependence was found.
Gaps
Much research remains to be done in alcohol-related nosology. Development
of enhanced measures of alcohol use disorders would be valuable as would
better measures of the chronicity of drinking patterns and problems.
Additional research on the roles of various comorbid conditions in the
etiology and consequences of alcohol problems is also critically needed.
Back to Top
CHRONIC DISEASES, AIDS, DISABILITY, AND COMORBIDITY
THE EPIDEMIOLOGY OF MODERATE ALCOHOL CONSUMPTION
AND RISK OF CHRONIC DISEASE
State of Knowledge (Eric Rimm, Sc.D.)
Twenty-five years ago, Klatsky et al. (1974) observed an inverse association
between alcohol and coronary heart disease and later Baboriak et al.
(1979) found that moderate alcohol consumption was associated with reduced
occlusive disease in patients with coronary angiography. These findings
sparked a new era in alcohol research which focused on identifying the
health effects (risks and benefits) associated with moderate alcohol
consumption.
Today, a large body of evidence from epidemiological studies suggests
that alcohol in moderation (2 drinks/day for men and 1 drink/day for
women) is associated with a lower risk of coronary heart disease, diabetes,
and ischemic stroke. However, there is now convincing evidence that
consumption at this level also may lead to modest increases in risk
of breast (among women) and colorectal cancer. Because cardiovascular
disease is the leading cause of death among men and women, results from
large prospective studies of alcohol and all-cause mortality consistently
find the lowest risk of death among moderate drinkers.
Further research is needed to help clarify the importance of drinking
patterns, dietary interactions, and genetic susceptibility on reported
associations between moderate alcohol consumption and risk of chronic
disease.
There are two specific recommendations: (1) Develop better measures
of alcohol consumption patterns for different populations in ongoing
longitudinal studies, with repeated assessment of consumption throughout
the lifespan. (2) Determine influence of selected factors (e.g., diet,
lifestyle, genetic factors) that may modify relations between alcohol
consumption and chronic diseases.
ALCOHOL IN THE EPIDEMIOLOGY OF AIDS AND
OTHER SEXUALLY TRANSMITTED DISEASES
State of Knowledge (Karen F. Trocki, Ph.D.)
A decade and a half ago, when work began on the epidemiology of AIDS
and sexually transmitted diseases (STDs), there was a strong focus on
"disinhibition" and the possibility that alcohol use in conjunction
with sex was a key factor contributing to disease risk because of interference
with use of condoms. The finding that alcohol use is not a particularly
good predictor of condom use patterns has been fairly consistent (Leigh
and Stall, 1993). Less than half of the studies have shown any association
whatsoever; even then, the association is often for a few subgroups
within the population studied and/or the strength of the association
is marginal.
Other aspects of the alcohol/risky sex association have shown strong
and consistent patterns. There is a clear relationship between number
of sexual partners and use/abuse of alcohol. In virtually every study,
there has been a strong association between that aspect of sexual risk
and quantity/frequency of drinking (Bailey et al., 1998). Furthermore,
heavy alcohol use and/or number of sexual partners is the most important
variable marking STD history and predicting future STDs (Ericksen and
Trocki, 1994).
Evidence is accumulating that the context of alcohol consumption (e.g.,
bars, clubs, parties) can be a source of multiple partners, partner
change, and other aspects that are known to play an important role in
the dynamics of STD transmission (Stall et al., 1990).
There are two specific recommendations: (1) Determine relations among
impulsivity, alcohol intoxication, multiple sexual partners, and sexually
transmitted diseases (STDs).
(2) Identify environmental risk factors for STDs that interact with
alcohol consumption and determine influence of age, gender, and racial/ethnic
differences.
EPIDEMIOLOGY OF ALCOHOL-RELATED BEHAVIORS AND DISABILITY
State of Knowledge (Paul M. Roman, Ph.D.)
There are few scientifically sound data on the prevalence of drinking
and alcohol problems among those who are disabled. Although most of
the available literature has a clinical orientation, there is an apparently
large unmet need for dealing with alcohol dependence among the disabled.
Limited survey data suggest there are no differences among disabled
and non-disabled in reported lifetime prevalence of alcohol use/abuse
(Gilson et al., 1996).
Acquired disability may be more linked to drinking problems than congenital
disability, and predictors of post-injury drinking problems may include
such variables as sociopathy, thrill-seeking, family background of alcohol
problems, and other individual traits that are independent of disabling
events (Babor, 1993). Most investigators agree that pre-injury drinking
problems are the strongest predictors of post-injury drinking problems,
especially in individuals experiencing traumatic brain injury (Kreutzer
et al., 1996) and spinal cord injuries (Hubbard et al., 1996).
There are two specific recommendations: (1) Secondary analyses of existing
data sets should be conducted in order to gain information on disability,
disablement, and alcohol consumption and related problems. (2) A major
epidemiological study of alcohol consumption and related problems in
the disabled is needed.
COMORBIDITY OF ALCOHOL ABUSE/DEPENDENCE AND OTHER DISORDERS
State of Knowledge (Linda B. Cottler, Ph.D.)
Comorbidity describes the co-occurrence of two or more disorders in
a single individual (Feinstein, 1970). Comorbidity is meant to be restricted
to disorders, and not symptoms, and each disorder should have the characteristic
pattern and etiologic basis typically present when each disorder is
found by itself. Illnesses may be described as lifetime comorbid or
simultaneously, i.e., currently comorbid. Lifetime comorbidity may describe
two or more illnesses that have occurred at some time, but not necessarily
at the same time in one's lifetime. Simultaneous or current comorbidity
describes two (or more) illnesses in which criteria for each are fully
met together at the same time (past year).
Comorbidity of psychiatric disorders and alcohol-use disorders can
be explained by (1) psychiatric disorders leading to the use of alcohol
and thus alcohol-use disorders, (2) psychiatric disorders and alcohol-use
disorders are correlated because both conditions share common etiologic
factors, or (3) alcohol use and its consequences can lead to other psychiatric
disorders (Reiger et al., 1990). To differentiate among these alternatives,
one must understand causal associations.
The Epidemiologic Catchment Area (ECA) study (landmark study of psychiatric
disorders among the general population (N=20,000) in the early 1980s)
found that, on a lifetime basis, 37% of those who met criteria for alcohol
abuse or dependence also met criteria for a mental disorder other than
drug abuse or dependence (Reiger et al., 1990), with the most common
disorder being any anxiety disorder (19%), followed by antisocial personality
disorder (14%) and affective disorder (13%). Conversely, persons with
antisocial personality disorder (ASPD) were 21 times as likely to have
an alcohol-use disorder than persons without ASPD, with a rate of 74%.
Alcohol-use disorders were also common among persons with any affective
disorder (22%). The National Comorbidity Survey, conducted in the mid-1990s,
found that the most common disorders were alcohol dependence and depression;
moreover, the estimates of comorbid disorders were even higher than
in the ECA.
Comorbidity of alcohol abuse and dependence with other drug abuse and
dependence is 41% in men and 47% in women (Kessler et al., 1997). In
addition to the comorbidity described above, the literature also documents
comorbidity between alcohol-use disorders and suicide (17%; Berglund,
1984), HIV and other STDs (Shillington et al., 1995), personality disorders
(44%; Verheul et al., 1995), pathologic gambling (Crockford and el-Guebaly,
1998), and ADHD (Biederman et al., 1995).
A specific recommendation is that comorbidity needs to be assessed
within a longitudinal project involving diverse cultures from early
childhood to death.
NIAAA PORTFOLIO ON MORBIDITY/DISABILITY/MORTALITY
(Mary Dufour, M.D., M.P.H.)
This heading subsumes an eclectic collection of grants that fall into
the broad categories of Moderate Drinking, Nutrition, HIV/AIDS, and
Comorbidity. Comorbidity is a crosscutting theme, aspects of which are
interspersed throughout the entire DBE portfolio. The study of the relationship
between alcohol use and abuse and Attention Deficit Disorder is included
here. Other comorbid conditions are covered elsewhere. DBE has no grants
in the area of Disability.
MODERATE DRINKING
Past Grants
In 1990, Douglas Coate's grant (R01AA08366) entitled "Moderate
Drinking and Coronary Heart Disease Mortality" was funded
to attempt to ascertain whether the statistical association between
moderate drinking and coronary heart disease (CHD) mortality could be
explained by a correlation with confounding variables such as income,
education, life style and diet which underlie the relationship but which
had not been controlled for in earlier studies. The investigator also
hoped to determine whether the statistical association held up across
different socioeconomic, age and sex groups and whether the direction
of the causality in the moderate drinking-CHD relationship runs from
moderate drinking to improved CHD health or from good health to moderate
drinking. This work which utilized two large national data sets, the
first National Health and Nutrition Examination Survey (NHANES I) and
the NHANES Epidemiologic Follow-up Survey (NHEFS), found evidence for
a beneficial effect of moderate drinking in white men with accelerated
time-to-failure models showing 3-4% longer life spans for moderate drinkers
compared to nondrinkers or light drinkers.
Dorit Carmelli's grant (R01AA08925) entitled "Alcohol
Consumption and Mortality in Veteran Twins" was also funded
in the early 1990's. Utilizing the National Academy of Sciences-National
Research Council's World War II Twin Registry, the work examined alcohol
consumption and mortality in 4960 pairs of adult, male, veteran U.S.
twins born between 1917 and 1927. Analyzing the first or only deaths
in twin pairs discordant for drinking disclosed a relative risk (RR)
of 1.93 for death in abstainer twins compared to their light-moderate
drinking cotwins. Excess mortality in twin abstainers was also found
for deaths from cardiovascular disease (RR=2.0) and other causes of
death excluding cancers (RR=3.2). The protective effect of light-to-moderate
drinking was not found for twins who were smokers at baseline.
Wendy Carman's small grant (R03AA08630) entitled "Alcohol
Use in Tecumseh, Michigan: 1959-1978" which was funded
about the same time endeavored to assess the alcohol data in the Tecumseh
Study and using database management systems, create alcohol use histories
for each individual and family in the study in an attempt to enhance
usefulness of the data for the study of the impact of alcohol consumption
on diabetes, hypertension, cancer, osteoporosis, osteoarthritis and
other aging-related conditions.
Current Grants
In response to a growing body of scientific research and increasing
interest in the topic of moderate alcohol consumption, in the summer
of 1995, NIAAA issued a Request for Applications (RFA) (AA-95-004) entitled
"Moderate Alcohol Consumption: Benefits and Risks". Two grants
in the DBE portfolio which were received in response to this RFA are:
Eric Rimm's grant (R01AA11181) entitled "Alcohol
Consumption Patterns, Biomarkers and Health" and Arthur
Klatsky's grant (R01AA10830) entitled "Alcohol Drinking
and Risk of Cerebrovascular Disease." Dr. Rimm is evaluating
prospectively the impact of moderate daily alcohol consumption, regular
weekly patterns of consumption and usual percent alcohol consumed with
meals on the risk of diabetes mellitus, hypertension, cardiovascular
disease and total mortality in two large cohorts--the Health Professionals
Follow-up Study (51,529 middle-aged men) and the Nurses Health Study
II (116,601 women age 25-42 in 1989). The investigators are also planning
to examine the impact of moderate alcohol consumption on plasma lipids
and thrombotic factors thought to be related to risk for coronary heart
disease. Dr. Klatsky and colleagues are prospectively examining the
relationship between quantity and type of alcohol consumption and hospitalization
and death from cerebrovascular disease in a large (128,934 men and women),
multiethnic population in Northern California.
Other current active grants in the DBE portfolio which are examining
some aspect of moderate drinking include those of:
Youlian Liao (R01AA11141) entitled "Alcohol--Benefits
and Risks--Analytic Studies"; Dr. Ken Mukamal (F32AA05534)
entitled "Cost Effectiveness Changes in National Alcohol
Use"; and Marcia Russell (R21AA11684) entitled
"Guidelines for Moderate Drinking--Influence of Patterns."
Dr. Liao is utilizing data from several large national population
surveys in order to better define the overall risks and benefits and
possible trade-off of moderate drinking for the population as a whole
and for specific subgroups. Dr. Mukamal is examining the probable
effects of changes in national alcohol consumption through the Coronary
Heart Disease Policy Model, a model which uses data from national
surveys and published cohort studies to predict coronary heart disease
incidence and mortality. In the past, many studies have reported alcohol
consumption in terms of average daily amount without assessing volume
per occasion. Dr. Russell plans to assess the impact that determining
actual volume of alcohol consumption per occasion would have on recommendations
for moderate drinking.
NUTRITION
Two of DBE's grants fall under the broad heading of nutrition.
Katherine Flegal's grant (R23AA07018) entitled "Measuring
Alcohol as a Risk Factor Using Dietary Data" assessed
the reliability and validity of the measures used to assess alcohol
consumption in national food consumption surveys. Dr. Flegal found
that alcohol is among the best reported of dietary items and that
these methods, while not ideal, produce reasonably reliable and valid
measures of alcohol consumption. She also recommended revisions of
survey items to further improve reporting.
Bryan Johnstone's FIRST award (R29AA08475) entitled
"Alcohol and Diet: General Population Relationships"
attempted to examine hypothesized relationships between alcohol consumption,
intake of alcohol-independent total calories, and principal nutrient
and selected food item categories. Also included is body mass index
using data from several large national population surveys.
Gaps
To date, few data sources used in moderate drinking research contain
adequate measurement of all potential confounds particularly diet and
exercise. Broader inclusion and better measurement of potential confounds
in a single data source is now needed. In addition, alcohol consumption
is often assessed at one point in time and mortality assessed many years
hence. More work needs to be done on measurement of alcohol consumption
over the lifespan and how this impacts on mortality. Methodological
work which permits risk/benefit analysis of moderate alcohol consumption
across the lifespan for specific individuals taking gender, various
health conditions; etc. into account would be a welcome contribution.
Much of epidemiologic research remains to be done on alcohol and diet/nutrition.
Improvements in survey instrument design would be of value. Also
of interest is the impact of diet composition on alcoholic organ damage.
Some animal and human research suggests, for example, that the amount
and type of dietary fat intake impacts on the development and severity
of alcoholic liver damage. The DBE portfolio currently has no grants
in alcohol-related chronic disease epidemiology so this area has great
potential for expansion. Refinements of the existing methodologies for
deriving alcohol-related mortality and morbidity statistics are especially
critical.
HIV/AIDS
Stephen Hulley's grant (R01AA08238) entitled "HIV
Risk and Infection Among Alcoholics Seeking Therapy"
ascertained the seroprevalence of HIV infection in alcohol dependent
individuals seeking treatment in alcohol treatment facilities in the
San Francisco Bay area as compared to that of a general population
sample drawn from the corresponding area. This work, which was funded
in the early 1990's, was among the first to report that the seroprevalence
of HIV infection was dramatically higher in the treatment sample than
the general population sample. In addition to making a substantive
contribution, the investigators also made significant methodological
contributions. Since this research began in the relatively early days
of AIDS research, the investigators were forced to wrestle with difficult
issues of keeping the strictest confidentiality of the patient information
and at the same time maintaining the necessary linkages between the
patient data and the biological test results. The investigators were
extremely creative in devising a coding strategy to meet these disparate
needs--so successful that others have since adopted these methods.
Over the past ten years, the primary focus of Karen Trocki's grant
(R01AA08564) entitled "Epidemiology of Alcohol Problems--Risk
of AIDS" has been to explore how drinking behaviors are
associated with sexual risk behaviors. This work has demonstrated
that a critical factor in sexually transmitted disease (STD) risk
is the number of sexual partners and that the context of drinking
strongly influences the availability of certain types of sexual partners
and plays a role in determining the nature of the interpersonal relationships.
Although still tracking general population trends in disease risk,
more detailed work on the role of bars, clubs, taverns, and other
locales is currently in progress to elucidate more fully the epidemiology
of AIDS and other STDS as related to alcohol consumption. Both qualitative
and quantitative methods are being employed to study both heterosexual
and homosexual populations in order to gain the broadest overview
of specific risk patterns.
Gaps
It is now well established that alcohol consumption contributes to
risky behavior, which, in turn, increases risk of exposure to HIV infection.
Additional information regarding important individual, situational and
contextual factors should be forthcoming from ongoing research mentioned
above. Critical questions which remain to be answered include: (1) given
exposure to HIV infection, what is the impact of alcohol consumption
on the likelihood of acquiring infection and (2) given HIV infection,
what is the impact of alcohol consumption on the development and clinical
course of AIDS?
COMORBIDITY
Earlier work on alcohol and Attention Deficit Hyperactivity Disorder
(ADHD) has suggested that children with ADHD are at increased risk for
alcohol abuse relative to children without the disorder; however, small
sample sizes and methodological limitations have hampered generalizability.
Brooke Molina's recently awarded grant R0AA11873 "Development
of Alcohol Use and Abuse in ADHD Adolescents"aims to
address the large knowledge gaps by more adequately describing the
risk of ADHD children for alcohol use and abuse and elucidating the
extent to which emergence and development of alcohol abuse is associated
with other domains of functioning by yearly interviewing 500 children
who have been previously diagnosed with ADHD and for whom a large
battery of standardized assessments exist. Dr. Molina also has a Scientist
Development Award (K21AA00202) "Adolescent Alcohol Abuse
and Attention Deficit Disorder"to support a follow-up
study comparing adolescents with ADHD with non-ADHD adolescents matched
from the probands' schools. ADHD and comorbid psychopathology will
be examined as risk factors for adolescent alcohol use, abuse and
dependence.
Gaps
Some aspects of comorbidity are addressed in other sections of this
review, particularly Nosology and Methodology. Clearly, however, there
is ample opportunity for future research. Research on the impact
of various comorbid conditions on the clinical course and outcome of
alcohol use disorders would be a valuable addition.
DISABILITY
Although DBE has no NIAAA grants in the area of disability, we have
played a very active role in a long standing Cooperative Agreement between
the World Health Organization (WHO) and NIAAA, the National Institute
on Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA):
the WHO/NIMH/NIAAA/NIDA Joint Project on Diagnosis and Classification
of Disorders (U01MH35883). Among the major accomplishments during the
previous 12 years of funding, the Joint Project developed two international
diagnostic assessment instruments: the Schedules for Clinical Assessment
in Neuropsychiatry (SCAN), designed for use in clinical research, and
the Composite International Diagnostic Interview (CIDI), designed for
use in epidemiologic and other community based research. The primary
purpose of the current five years of funding, began late in 1995, is
to develop research instruments that assess "disablement"
associated with alcohol, other drug abuse and mental disorders, and
to design pilot studies in health services research with these instruments
utilizing the existing instrument development methodologies and international
research support network created under earlier funding cycles. [Disablement
is an umbrella term for "impairments, disabilities, and handicaps"
as used in the WHO International Classification of Diseases, Tenth
Revision (ICD-10).] Work is also continuing and expanding ongoing
in-depth analyses of results from the reliability and validity study
of the alcohol and other drug sections of the SCAN and CIDI conducted
earlier.
Gaps
Since the above cooperative agreement is our only disability-related
research, many research opportunities exist in the area of alcohol-related
disability. Extensive methodological work will be a necessary and critical
first step, since alcohol-related disability is even more difficult
to detect and measure than alcohol-related morbidity.
Back to Top
INTENTIONAL-UNINTENTIONAL INJURIES
EPIDEMIOLOGY OF INTENTIONAL AND UNINTENTIONAL INJURIES
State of Knowledge (Gordon S. Smith, Ch.B., M.P.H.)
Alcohol consumption can impair (1) judgement, (2) coordination, and
(3) ability to perceive and respond to hazards, with the risk of injury
increasing exponentially with increasing blood alcohol levels. It has
also been documented that persons may still be at risk even when blood
alcohol levels are zero due to the "hangover" effect. Research
examining alcohol habits (i.e., usual drinking quantity and frequency)
and chronic abuse is less common than research examining acute involvement
in injuries. However, there are data to suggest that chronic alcohol
abuse is more likely to result in death from injury than disease (Li
et al., 1994).
Alcohol involvement is generally more common in severe injuries than
in more minor injuries, e.g., 41% involvement in fatal automobile crashes,
9% in injury crashes, and 5% in property damage crashes (Fell, 1999).
Smith et al. (1999) estimated that 21-42% of fatal unintentional injuries
involved alcohol, and Hingson and Howland (1993) estimated that 17%
of nonfatal unintentional burns and 24% of nonfatal unintentional fall
injuries involved alcohol. Alcohol use is also implicated in fatal pedestrian
injuries (36%); non-commercial aviation pilot fatalities (10%, Holdener,
1993); bicycle fatalities (25%; Abel et al., 1984); and drowning (21-42%;
Hingson and Howland, 1993).
The association of alcohol use and intentional injuries has been known
for many years although the relationship is complicated. Alcohol involvement
in perpetrators of violence has been estimated to be 28-86% of homicide
offenders, 24-37% of assault offenders, 13-60% of sexual offenders,
and 6-57% of male domestic offenders (Roizen, 1997). Alcohol involvement
in victims of violent events is as prevalent as that for the perpetrator.
Alcoholism and alcohol abuse are second to depression and other affective
disorders as major risk factors identified for suicide (Blumenthal,
1988).
There are three specific recommendations: (1) Develop better measures
of alcohol consumption and alcohol involvement in injuries. (2) Develop
more innovative research designs to examine the causal role of alcohol
in suicide, homicide, and other violent events. (3) Determine relations
among patterns of alcohol consumption, inpulsivity, and injuries.
NIAAA PORTFOLIO ON INJURIES AND VIOLENCE
(Captain Darryl Bertolucci)
Injury and violence research has focused on the role of alcohol in
emergency room visits, alcohol and aquatic injury and deaths, costs
associated with alcohol-involved injury, and alcohol-related marital
violence. The current portfolio expands the focus to bicycle and boating
accidents; ethnicity and alcohol-related spousal abuse; alcohol and
injury in the U.S. Army; and the relationship between alcohol exposure
and injury risk, including risk associated with low levels of consumption.
Past Grants
Cheryl J. Cherpitel (R01AA07102), "Alcohol and Emergency
Room Admission in Kaiser Hospitals" conducted
a study whose goals were to describe and analyze the role of alcohol
in the event which brought the individual to the emergency room and
develop a system which would help to predict those who may be at risk
for alcohol-related injuries from both emergency room and general
population samples.
Jonathan Howland (R01AA08320), "National Survey of Drinking
in Aquatic Settings" studied the contribution
of alcohol to untoward aquatic events using a national random digit-dial
survey of the general population. Data were collected concerning drinking
in conjunction with aquatic activities, attitudes towards the propriety
of drinking on or near the water, perceptions of drinking as a risk
factor for drowning, knowledge of drinking and boating laws, and support
for these laws. In addition, the researchers explored whether people
are more likely to engage in risky aquatic behaviors when they had
been drinking than when they had not.
Glenda K. Kantor (R01AA08269), "Alcohol and Marital Conflict:
A Longitudinal Analysis" conducted a longitudinal
examination of marital conflict and assaults in alcohol abusing families
compared to other families in the general population. Data used included
a 1985 nationally representative sample of 6002 American families
(National Family Violence Survey), including an oversample of Hispanic
and Black families, and panel data collected in 1986 and 1987 on a
stratified subsample of 1408 violent and non-violent families.
Kenneth E. Leonard (R01AA07183), "Frequent Heavy Drinking
and Marital Violence in Newlyweds" provided epidemiological
information concerning the incidence of alcohol-related marital violence
and investigated prospectively the impact of frequent heavy drinking,
alcohol expectancies, hostility, and marital conflict on marital violence
among newly married couples 18-26 years old. Dr. Leonard (R01AA08128),
"Experimental Study of Alcohol and Marital Aggression"
also examined the impact of alcohol cues and alcohol administration
on the marital interactions of physically aggressive married couples,
distressed but not aggressive couples, and nondistressed couples.
Ted R. Miller (R01AA09812), "Injuries from Alcohol--Incidence
and Cost" developed and applied improved methods for
estimating the incidence and costs of injury from alcohol. He also
examined various approaches to attribution, and compared cost and
incidence estimates for attributable injury to the more commonly used,
but methodologically questionable, estimates for alcohol-related injuries.
Current Grants
One current study is a continuation of previous work.
Gordon S. Smith (R01AA07700), "Alcohol-Related Drowning
and Serious Boating Injuries" builds on earlier
FIRST award (R29AA07700) on alcohol and injuries that emphasized
alcohol-related drowning. The research program has successfully developed
a comprehensive statewide surveillance system for fatal injuries in
collaboration with the Maryland medical examiners' office. Dr. Smith
also extended the use of the surveillance system and methodology to
investigate occupational injuries. The current research extends the
work on drowning to include a case-control study of serious boating
injuries (fatalities and hospitalized cases).
In addition, four new studies are being supported.
Nicole C. Bell (R29AA11407), "Alcohol Use and Injury Outcomes
in the US Army" is combining data from the U.S. Army
Health Risk Appraisal (HRA) data, including self-reports of drinking
and other risk taking behaviors, with an existing computerized health-outcome
database. HRA data will be linked by social security numbers to hospitalization,
death, accident and disability data in order to quantify the relationship
between alcohol use and actual injuries and to identify subgroups
of men and women particularly at risk because of unhealthy drinking
behaviors.
Raul Caetano (R01AA10908), "Ethnicity, Alcohol and Spousal
Violence" is using a national survey to examine the association
between alcohol and spousal violence among Blacks, Hispanics, and
Whites in order to estimate nationwide rates of intimate partner
violence with data from both couple members.
Guohua Li (R29AA09963), "The Role of Alcohol in Bicycling
Injuries"examines the magnitude and factors related to
alcohol involvement in fatal and nonfatal bicycling injuries and tests
the hypothesis that alcohol intoxication is associated with significantly
increased likelihood of fatality given a serious bicycling injury.
Results to date indicate that alcohol plays an important role in fatal
and serious bicycling injuries.
Daniel C. Vinson (R01AA11078), "Alcohol and the Risk
of Injury--A Case-Crossover Study" is conducting
a study to quantify the association between acute alcohol exposure
and the risk of injury, including the relative risk at low levels
of alcohol consumption. In addition, the research examines the relationship
between chronic alcohol involvement and injury risk, with and without
simultaneously including acute alcohol exposure in the model, and
defines the extent of confounding due to other background variables
(such as personality traits) in the association between alcohol and
injury. The study utilizes a case-crossover design, in which each
injured person is both a case (at one point in time) and a control
(at prior times), within a population-based case control study.
Selected Findings Emergency Room (ER) Patients.
Alcohol's role in injury cases seen in the ER differed from its contribution
to non-injury ER cases. With the injured more likely than the non-injured
to have positive breath-analyzer readings and to report heavy drinking,
more frequent drunkenness, prior alcohol-related accidents and prior
treatment for an alcohol-related problem, but were no more likely to
report harmful consequences of drinking or alcohol dependence experiences
during the last year. No differences in drinking patterns, alcohol-related
problems or gender or age distribution were found between clinic patients
and the non-injured ER patients. Both the noninjured ER patients and
the clinic patients were less likely to report heavy and problem drinking,
or treatment for an alcohol-related problem during the last year, as
compared to those in the general population.
Alcohol and Drowning. In addition to having higher drowning
rates than women for most age groups, men had elevated risks for exposure,
risk taking, and alcohol use. It was concluded that several factors
contribute to their high drowning rates, including a possible interaction
between overestimation of abilities and heavy alcohol use.
Violence in the Family. Data analysis, which controlled for
a number of confounding risk factors such as low socioeconomic status,
found that children who had experienced corporal punishment in adolescence
had an increased risk later in life of depressive symptoms, suicidal
thoughts, and alcohol abuse. Results of a study on marital violence
indicated that problem drinking relates to the quality of the marital
relationship even in the early stages of relationship formation, and
that it was not the problem drinking, but the levels of anger and femininity
associated with the problem drinking that were responsible for less
effective relationships. Wives decreased their average alcohol consumption
over the first year of marriage; husbands did not decrease their average
alcohol consumption; alcohol dependency scores and alcohol problems
of both husbands and wives declined; children and pregnancy were related
to declining alcohol consumption by wives; the level of wife's intimacy
appeared to facilitate alcohol consumption by husbands; the level of
husband's intimacy led to lower levels of consumption by wives; and
husband's alcohol dependence was correlated to wife's dependence. Results
of other work indicated a significant relationship between husband's
heavy alcohol use and premarital aggression. In addition, there were
significant interactions between husband's heavy alcohol use and marital
dissatisfaction and between husband's heavy alcohol use, husband hostility
and husband belief in alcohol as an excuse for aggression. Overall,
alcohol played a role in marital violence, marital quality, and marital
disruptions, but high levels of individual alcohol consumption in a
marriage did not uniformly lead to lower marital quality.
Cost of Alcohol-Related Injury. The incidence of alcohol-involved
highway crashes (those in which a driver or nonoccupant had been drinking)
was estimated from federal databases. The comprehensive cost of alcohol-involved
crashes was $148 billion in 1990, including $46 billion in monetary
costs and $102 billion in lost quality of life. This represents $1.09
per drink of alcohol consumed. Crashes where blood alcohol concentration
(BAC) exceeded .10% accounted for 32% of comprehensive crash costs,
and crashes with lower positive BAC accounted for another 8%. Averaged
across all drinks, other people collectively pay $0.63 in crash costs
every time someone takes a drink. Nonhospitalized medically treated
injuries averaged $579 in medical spending per case ($181 per visit,
3.2 visits per injury).
Gaps
Although over the past decade much progress has been made in the study
of alcohol- related injuries many gaps remain to be filled.
Better methodologies for ascertainment and surveillance of alcohol-related
injuries other than those involving alcohol-related traffic accidents
are needed. Better methodologies for determining causal relations between
alcohol consumption and various types of injuries are needed. Alcohol
and violence is a difficult and sensitive area to study but one in which
more work is important. More refined research on the role of childhood
physical/sexual abuse in later development of alcohol problems is also
critical.
Back to Top
SPECIAL POPULATIONS
EPIDEMIOLOGY AND ETIOLOGY OF ADOLESCENT ALCOHOL INVOLVEMENT IN THE
UNITED STATES
State of Knowledge (John E. Donovan, Ph.D.)
Adolescent alcohol involvement includes alcohol use, problem drinking,
and alcohol-use disorders.
Information concerning the nationwide prevalence of alcohol use among
adolescents comes from two major annual surveys (Monitoring the Future
[MTF] and National Household Survey on Drug Abuse [NHSDA]) and a biennial
national survey (Youth Risk Behavior Survey [YRBS]). The older the adolescents
the larger the percentage that reports experience with alcohol and more
likely are reports of having ever been drunk; largest increase is between
eighth and tenth grades, where prevalence rates either double or triple.
Gender differences emerge in the 10th grade, with males more
likely to be engaged in high volume or daily drinking. Acceleration
of rates of alcohol use among males but not females occurs from tenth
to twelfth grades. Annual prevalence of alcohol use in 12th
graders is less among African-American (72%) than among either Caucasian
(83%) or Hispanic American (80%). Despite differences in overall level,
patterning of use by gender, age, and ethnic/racial background is similar
in the two major national surveys.
Beverage alcohol consumed by the greatest number of students (7 - 12th
grades) was beer, followed in order by wine coolers, liquor, and wine
(OIG, 1991). Average weekly consumption was 3.9 beers for boys, 2.2
beers for girls, 1.4 wine coolers for boys, 1.8 wine coolers for girls,
1.4 glasses of wine for boys, 1.6 glasses for girls, and 1.4 drinks
of liquor for boys, 0.9 for girls. Almost two-thirds of underage students
who drink reported being able to buy their own alcohol.
There are no current data on the nationwide prevalence of problem drinking
among U.S. adolescents. According to MTF survey data from 1994 through
1997, one in three high school seniors, and almost two thirds of those
who have consumed alcohol ten or more times in their life, have experienced
problems due to their drinking (O'Malley et al., 1998). Three or more
problems were experienced by 18% of all seniors and by 34% of those
who had consumed alcohol 10 or more times in their life.
There are also no data on the prevalence of alcohol abuse and alcohol
dependence, as defined by standardized psychiatric diagnostic criteria,
among U.S. adolescents nationwide. In 1996 data from the NHSDA, 12-17
year old adolescents reported one or more problems related to a diagnosis
of alcohol dependence (12.7%), two or more problems (12.7%), and three
or more problems (4.3%) (SAMSHA, 1998). Kandel et al. (1997) reanalyzed
data from the NHSDA to determine proxy measures of alcohol dependence
(3 or more problems) and observed an overall prevalence of 2.9%. Although
more male than female adolescents had consumed alcohol in the past year,
more female than male adolescents reported 3 or more dependence symptoms.
It is useful to distinguish between risk factors for initiation versus
escalation of drinking. Risk factors for initiation of drinking include
(1) family factors (presence of stepparents, divorced or separated parents,
parental drinking, lack of parental support, as well as family density
of alcoholism); (2) peer factors (peer involvement in delinquent or
drug-using behaviors and perceived peer attitudes toward drug use);
(3) personality factors (lower levels of conventionality and higher
alcohol expectancies); and (4) behavioral factors (prior involvement
in delinquent behavior). Risk factors for the escalation of alcohol
use include (1) family factors (greater parental alcohol use, positive
parental attitudes toward child drinking, greater sibling alcohol use,
and less parental monitoring of child behavior); (2) peer factors (greater
susceptibility to peer pressure, association with older peers and working
peers, more frequent offers to drink, and exaggerated perceptions of
number of friends who drink); (3) personality factors (greater expectations,
greater disinhibition, lower law-abidance, less knowledge about alcohol,
and lower levels of personal competence and greater social skills);
(4) behavior factors (frequent earlier delinquent behavior and lower
school grades). Relatively little research has studied risk factors
for transitions into problem drinking.
There are three specific recommendations: (1) It is important to collect
data on alcohol use, problem drinking, and alcohol-use disorders among
adolescents. (2) Determine patterns of alcohol use in preadolescent
children. (3) Longitudinal studies of risk factors, beginning in preadolescence,
are important to initiate.
NIAAA PORTFOLIO ON YOUTH AND FAMILY
(Vivian Faden, Ph.D.)
YOUTH
Research in this area has focused on how much young people drink, the
etiology and development of drinking and problem drinking among youth,
vulnerabilities and pre-dispositions among youth in general and among
particular groups of young people, and the consequences of drinking
by the young. In particular, the relationship between alcohol use and
deviant behavior of adolescents has received attention, as has the relationship
between adolescent and parental drinking. In addition, DBE is supporting
two studies concerning alcohol use in homeless adolescents.
Past Grants
John S. Baer (RO1AA08632), "Prediction of Stability
of High Risk Drinking" studied high-risk adolescent drinkers
in order to predict chronicity of heavy drinking in this population.
As part of this study, subjective intoxication and stress response
dampening were evaluated in men and women college seniors during an
alcohol challenge study. All were regular drinkers who reported
being intoxicated at least twice a month by history.
Marie D. Cornelius (R29AA08284), "Alcohol Use Among Teenagers
and Infant Outcome" examined the relationship
between alcohol and other drug use by pregnant adolescents (both prior
to and during pregnancy) and physical and developmental abnormalities
among their offspring. Also explored was the relationship to actual
drinking of psychosocial variables, demographics, knowledge and attitudes
about drinking during pregnancy.
Frances M. Costa (R01AA10322), "Development of
Adolescent Problem Drinking" analyzed data from a four-wave
longitudinal study of adolescent health, collected from 1989-1992.
The goal of this study was to learn more about the role of psychosocial
risk and protective factors in accounting for variation in involvement
in and transition to problem drinking among male and female adolescents
of different racial/ethnic backgrounds. Risk and protective factors
were drawn from the framework of problem behavior theory.
Lisa Crockett (R01AA09678), "Young Adult Consequences
of Rural Adolescent Alcohol Use" studied drinking
behavior in a sample of rural adolescents as they entered young adulthood.
The goals of this three-year study were to identify developmental
patterns of alcohol use during this transitional period of life, to
examine the continuity/discontinuity in alcohol use from adolescence
to adulthood, and to predict young adult alcohol use/abuse and examine
the consequences of drinking in this population.
John E. Donovan and Richard Jessor (R01AA08007), "Drink-Driving
and Risky Driving in Adolescents and Youth" examined
the relationship of risky driving, including drinking-driving and
drug-driving, and behavioral and psychosocial conventionality/unconventionality.
Candace M. Fleming (R03AA08211), "Alcohol Abuse and Depression
in American Indians" performed secondary data
analyses on a longitudinal survey of American Indian boarding school
students to establish the incidence and prevalence of symptoms of
alcohol and other drug abuse, depression, and anxiety in an American
Indian adolescent population.
Joel W. Grube (R01AA08097), "Adolescent Drinking
in the United States and Ireland" studied the
development and maintenance of drinking, problem drinking and
drinking problems among adolescents in the United States and the Republic
of Ireland by following 2000 adolescents in each country over a period
of three years.
Thomas G. Power (R01AA07740), "Attachment, Autonomy
and Patterns of Adolescent Drinking" examined
the role of adolescent attachments and autonomy in the development
of adolescent alcohol consumption patterns, with a particular focus
on the differential prediction of normative and problem drinking.
Valley Rachal (R01AA07766), "Sequencing of Alcohol, Drugs,
and Tobacco among Youth" examined patterns of
initiation and maintenance of alcohol, other drug, and tobacco use
for all youth and subgroups of youth defined by gender, race and ethnicity.
John Schulenberg (R03AA09143), "Stability and Change
in Alcohol Use among Youth" analyzed longitudinal
data from the national Monitoring the Future project in order to examine
adolescent personality and social context predictors of changes in
binge drinking during the transition from adolescence to young adulthood.
John Welte (R01AA08157), "Drinking and Delinquency in
Young Men" studied drinking, other drug use, and delinquent
behavior in a sample of men aged 16-19 to elucidate the role of drinking
and other drug use in prolonging and intensifying delinquency in young
men.
Current Grants
The Division is currently supporting two new studies of alcohol abuse
among homeless youth, aged 13-20.
Ana Marie Cauce's grant (R01AA10253) entitled "Homeless
Youth-Alcohol and Psychosocial Risk" is currently
in its fifth year. This grant is focusing on the identification
and understanding of street youth's family histories, developmental
patterns and processes, and socio-environmental conditions that
are linked to their victimization on the streets, their involvement
in violence against others, and their alcohol use and abuse. Of
special interest in this study is the role played by alcohol abuse
in placing street youth at risk of becoming victims and/or perpetrators
of violence and of becoming homeless adults. This study is being
carried out in the Seattle area.
Paul A. Toro's grant (R01AA10597) entitled "Alcohol
and Homeless Youth-A Longitudinal Comparison"
is a longitudinal comparison of the drinking and other outcomes
of homeless adolescents (ages 13-17) and housed adolescents who
are matched on gender, age, race, and neighborhood socioeconomic
characteristics. This study is being carried out in Detroit.
Selected Findings
Adolescent Problem Drinking. Results of exploratory factor
analyses supported the conclusion that adolescent problem drinking is
a multidimensional phenomenon. Three dimensions measuring level or frequency
of alcohol use, problems related to drinking and symptoms of dependency
were identified; these factors were only moderately intercorrelated.
Regression models confirmed the uniqueness of the three measures and
suggested that the potency of specific risk factors vary for different
types of problem drinking.
Among adolescents who were not problem drinkers, higher risk and lower
protection accelerated the likelihood of becoming a problem drinker
in subsequent years. Protective factors moderated the impact of risk
factors in the cross-sectional account of problem drinking involvement,
but not in the longitudinal account of the transition into problem drinking.
Findings were similar for males and females and among White, Black and
Hispanic adolescents. It was concluded that since protective factors
play a role, independent of risk factors, in adolescent involvement
in and transition to problem drinking, intervention efforts to enhance
protection, especially for adolescents exposed to risk, should supplement
efforts to reduce risk. In terms of predictors of adolescent drinking,
both alcohol behavior and attitudes of parents and peers were significant:
Parental attitudes were more important than parental alcohol behavior
in predicting adolescent drinking, while peer alcohol behavior was more
important than peer attitudes. Overall, peers had more influence on
adolescent drinking than parents.
Findings regarding alcohol and violent crime indicated that usual drinking
pattern and drinking before offending are related to aggravated assault,
and that alcohol may have different roles in explaining different levels
of violence. Results also indicated that the age of onset of substance
use has significant effects on alcohol use, drug use, association with
delinquent peers, and deviant activities. Those who began alcohol and
other drug use at an early age are more likely to continue using, to
be associated with delinquent peers, and to participate in deviant activities.
In addition, early age of delinquency onset was a significant predictor
of associating with delinquent peers, alcohol use, and deviant activities.
In another study, drinking-driving, drug-driving and risky driving were
found to comprise a more general, second order factor of adolescent
problem driving behavior. Drinking-driving was found to be related to
problem drinking, marijuana use, other illicit drug use and delinquent-type
behavior. It was concluded that drinking-driving is part of a more general
lifestyle involving behavioral and psychosocial unconventionality.
Among adolescents, drinking decreased during the first and third trimesters
of pregnancy while binge drinking rose during the first trimester then
fell sharply. Women who were binge drinkers during pregnancy
were more likely to be White and heavier users of tobacco, cocaine and
marijuana. Rates of first trimester binge drinking were higher among
pregnant adolescents than adults. Rates for binge drinking and heavy
drinking were highest among White teenagers.
In an international comparison, Irish students began drinking at an
older age than American students, but reported higher prevalence rates
for lifetime drinking, more frequent drinking and more frequent intoxication.
Overall the Irish students were more likely to report alcohol problems.
American men and women were more similar in their drinking patterns
than Irish men and women.
Transition from Adolescence to Young Adulthood. Different
trajectories of frequent binge drinking were observed during the transition
to young adulthood: adolescents who were male, had low self-efficacy
and drank primarily to get drunk were found to be at greater risk for
increased binge drinking over time. In contrast, risk factors such as
low conventionality varied according to initial level of binge drinking.
Chronic and increasingly frequent binge drinking over time were found
to be associated with difficulties in negotiating the transition to
young adulthood. Among rural adolescents, a sharp increase was seen
in the frequency of getting drunk across the high school years and a
more gradual increase after high school for both males and females.
Those who were never married as compared to ever-married, and those
who were employed as compared to those who were unemployed reported
a higher incidence of drunkenness. Antisocial behavior and family problems
in rural adolescence were risk factors for problem drinking in adulthood.
Young Adults. During an alcohol challenge study, intersubject
variability was greatest early in the study; during ethanol absorption,
time to peak breath alcohol concentration (BrAC) varied from 10 to 91
minutes after drinking began and mean BrACs were significantly lower
in females than in males. Task persistence after alcohol consumption
among young adult offspring of alcoholics (COAs) and young adult offspring
of nonalcoholics (nonCOAs) revealed significantly greater acceleration
of response latencies after consumption of alcohol among COAs compared
with nonCOAs. This study also investigated prevention of alcohol abuse
among high-risk college students, with a focus on harm reduction. All
subjects completed a drinking questionnaire at the beginning of each
school year and some of them received feedback/advice three months later.
Students who received feedback/advice about their drinking reported
less drinking than those who did not, both in the year of the intervention
and in subsequent years. Results also indicated that male gender, residence
in a fraternity or sorority, and a history of conduct problems constituted
risk factors for increased drinking between high school and college.
An analysis of young adult college graduates showed that entering the
workforce full time, being male, and being less open to experience were
associated with decreased post-college drinking. Relatively extroverted
individuals were more likely to continue a pattern of frequent intoxication
for a longer period after college. In an assessment of neuropsychological
functioning of first-year undergraduates, participants with alcohol
use disorders showed deficits in visuospatial ability. Those who had
alcohol dependence showed deficits in both visuospatial ability and
motor speed relative to participants who met criteria for alcohol abuse.
FAMILY
With respect to family studies, over the past two decades, NIAAA has
supported a number of longitudinal, family-based studies of alcohol
use and alcohol use disorders. Each of these grants has followed a group
of subjects over a period of years ranging from five to as many as twenty-one
years. These studies are based on the theoretical foundation that an
understanding of the role of family variables in the etiology, maintenance
and exacerbation of alcohol problems is essential to a complete understanding
of alcohol use disorders and their impact on society. At the present
time, three longitudinal grants are continuing.
Past Grants
Ernest Harburg (R01AA06036), "Parent-Offspring Alcohol
Use across 17 Years" evaluated the SMAST as a tool
for the identification of problem drinking in persons who had never
sought help for drinking and assessed familial transmission of alcohol
use. The SMAST was administered to a sample of 1266 persons, which
included 190 three-member sets of father, mother and adult child
who had originally been interviewed in 1960 as part of another study.
Alan R. Lang (R01AA06267), "The Role of Alcohol in Adult-Child
Interactions" studied the relationship between alcohol
abuse in parents and problem behavior in children. Problem behavior
was defined as the kind of behavior characteristic of children with
attention deficit disorder or conduct disorder. As part of this
research, investigators examined the relationship between alcohol
consumption and interpersonal aggression.
David S. Salkever, (R01AA08371), "Child Health Impacts
of Parental Alcohol Use" explored the impact of parental
alcohol use on children's health levels using data from the 1988
National Health Interview Survey (NHIS) data supplemented with 1983
and 1985 NHIS data.
David Savitz (R03AA09758) "Parental Drinking, Toxicant
Interactions, and Pregnancy" analyzed data from
the Avon Longitudinal Study of Pregnancy and Childhood in order
to study the effects of parental (both mother and father) drinking
before and during pregnancy on pregnancy and birth outcomes.
Elizabeth Smith (R01AA06625) "Consequences of Maternal
Alcoholism for Adult Offspring" conducted a
controlled study of 215 offspring of alcoholic women and 135 offspring
of their non-alcoholic sisters. Offspring were assessed for health
status, educational and occupational achievement, marital stability,
characteristics of the [spouse], role function, drinking
patterns and attitudes, and self-esteem. Current and lifetime psychiatric
disorders were also evaluated. The goal of the study was to explore
the contribution of family psychiatric history, early home environment
and selected social and demographic variables to adult outcomes.
Current Grants
This Division is supporting several longitudinal studies involving
children of alcoholics (COAs) risk and protective factors influencing
COAs own alcohol use and abuse.
Ruth Seilheimer and Theodore Jacob (R01AA03037), "Alcoholism
and Family Interaction" began work in 1978,
and have collected in-depth assessments of 287 families including
individual, marital, parental, and whole family measures. Initial
assessments included psychiatric and family history assessments,
videotaped laboratory interactions under drinking and non-drinking
conditions, audiotaped home interactions, a variety of interview
and questionnaire self-reports, and neurological and academic assessments
of children. Five and ten year follow-up assessments have been completed
on the first sample (50 families of male alcoholics, 50 families
of male depressives, 50 families of non-distressed social drinkers),
and a five year follow-up was completed on the second sample (37
families of female alcoholics, 50 families of female depressives,
and another 50 families of male alcoholics). The grant is now in
its 21st year; the ten-year follow-up of the second sample and further
follow-up of the first sample are currently underway.
Kenneth Sher (R01AA07231) "Prospective Study of Offspring
of Alcoholics" has followed a mixed gender cohort of
children of alcoholics (COAs) and children of nonalcoholics (nonCOAs)
since their freshman year in college in 1987-1988 (Wave 1). The
study is now in its 12th year. Wave 6 data that included reassessment
of key psychosocial variables (personality, diverse aspects of alcohol
and other drug-related behavior, psychiatric symptomatology, life
stress, and motivations for alcohol use) were collected in 1997-98
when the participants were 28-29 years old. Natural recovery, which
appears to be the major path to recovery from alcohol use disorders,
is considered in this study of longitudinal outcome.
Michael Windle (R01AA07861), "Vulnerability
Factors and Adolescent Drinking" is conducting a prospective
longitudinal two-generation family study of alcohol use and other
problem behaviors that is now in its 10th year. The first phase
of the study included a four-wave panel design study of over 1000
adolescents and their primary caregivers, with measurement occasions
spaced at six-month intervals. The primary focus of this phase was
the understanding of the multiple and interacting vulnerability
and risk factors that contribute to the development of problem behaviors
across adolescence. Problem behaviors included both externalizing
(e.g., alcohol and substance use, delinquent activity) and internalizing
(e.g., depressive symptoms, suicidal behaviors) disorders/symptoms.
A range of vulnerability factors including family history of alcoholism,
childhood behavior problems, temperament, and family/friend support
were measured. Phase two of this study, which is currently underway,
seeks to focus on role transitions (such as moving from single to
married status, from student to employed status) and psychiatric
outcomes in this now young adult cohort.
Selected Findings
Effects of Parental Drinking on Offspring. Infants of women
who reported drinking 1-2 drinks a day consistently throughout their
pregnancies, with or without a binge, had an adjusted mean birth weight
about 150 grams less than the infants of women who abstained during
but not before pregnancy. Similar mean birth weights were found in the
infants of mothers who drank before pregnancy and those of mothers who
drank weekly in early pregnancy, or less than weekly or abstained. In
another study, fathers, but not mothers, of problem behavior children
were found to drink to higher blood-alcohol levels. Results also indicated
that acute alcohol consumption might have adverse effects on parents'
perceptions of children's behavior and on parenting disorders. Deviant
child behavior may be related to increased alcohol consumption in the
adult. A third study found that offspring drinking was related to fathers'
and mothers' drinking. Although offspring often did not fall into their
parent's drinking category, the mode of alcohol consumption reflected
the parent category. There was more imitation by adult offspring of
abstemious parents (both abstainers and low-volume drinkers) than of
high volume parents. Adult offspring drink significantly less, on the
average, than their high volume parents. This phenomenon was termed
"fall-off effect" and was seen in both men and women with
respect to either their fathers or mothers. The fall-off effect, when
offspring respond to parental high-volume drinking by moderating their
own drinking, was found to be highly predictable across generations
and mediated by both subsequent parent drinking level and offspring's
perception of problematic intake by their parents.
Effects of Parental Alcoholism on Offspring. An analysis
of data from parents and children of alcoholic and non-alcoholic families
revealed that dual parent and mother-only alcoholic families were more
impaired than father-only alcoholic and non-alcoholic families. Child
behavior problems did not differ significantly across the three alcoholic
family types. Father's behavior, as compared to mother's behavior, most
clearly moderated child outcomes, although a protective effect of having
a non-alcoholic mother was also noted. Children of alcoholic fathers
were similar to children of depressed fathers in their psychosocial
functioning; maternal depression exacerbated the risk associated with
paternal alcoholism and not all children were found to be similarly
affected by fathers' day-to-day drinking. Another study found that heavy
drinking primary caregivers who do not provide enough guidance and abstaining
caregivers who are overly strict may both result in greater alcohol
consumption in adolescents. Stressful life events were found to be associated
with internalizing (depressive symptoms) and externalizing (alcohol
use and delinquent activity) problem behaviors for adolescents and stressful
life events and low family support were significant predictors of problem
behavior for girls but not for boys.
Self-reported childhood stressors were strongly related to family history
of alcoholism, but only moderately and inconsistently related to the
development of an alcohol use disorder. Support was found for the role
of alcohol outcome expectancies as predictive of future alcohol use
and of alcohol consumption in the development and maintenance of expectancies.
Low self-esteem played a critical role in the etiology of alcohol problems
for women relative to men. The relationship of tobacco dependence and
alcohol use disorders may be understood by either shared vulnerability
or reciprocal influence models. COAs report more alcohol and other drug
problems, stronger alcohol expectancies, higher levels of behavioral
undercontrol and neuroticism and more psychiatric distress than nonCOAs.
In another study, adult children of alcoholics (ACOAs) reported higher
levels of depression and lower levels of self-esteem than non-ACOAs.
However, although ACOAs reported greater distress and lower levels of
marital cohesion and satisfaction, they were still functioning in the
non-pathological range on all measures. Data from this study have also
supported the idea that children with problem-drinking parents are at
risk for alcohol and other drug use as well as for psychological problems,
but that protective factors, such as relatively stable patterns of family
behavior around meals and holidays, can help offset the negative effects
of parental drinking.
Comorbidity. Adult female children of alcoholics were found
to be as likely as adult male children of alcoholics to have had one
or more lifetime diagnoses of psychiatric disorder. Lifetime prevalence
of affective disorders was the same in male and female siblings. Greater
risk of alcohol abuse/dependence and other drug abuse/dependence was
noted for daughters of alcoholic mothers compared to a group of women
who reported no history of parental alcoholism.
Methods. The SMAST was found to be potentially useful in
identifying problem drinkers and non-problem drinkers in the general
population. In another study, adult offspring of alcoholic women were
evaluated as family informants. A history of alcohol-related medical
problems in the mother was associated with reporting maternal alcoholism.
Being Black, having a history of suicide attempts in the mother, and
having a good maternal post-treatment outcome were associated with false-negative
reports. Female alcoholic offspring tended to underreport maternal alcoholism.
Gaps
The DBE portfolio on youth and family is large and diverse. Much methodological
advancement has been made and basic information collected. Alcohol and
adolescence is now an NIAAA-wide area of high priority for additional
research. Enhanced longitudinal studies that identify causal factors
and relationships would be a valuable contribution.
EPIDEMIOLOGY OF ALCOHOL AND THE ELDERLY
State of Knowledge (Karen M. Jennison, Ph.D.)
An age-related, alcohol-reduction pattern appears to be most descriptive
of aging populations, including retirement communities (Adams and Cox,
1997), and has been broadly confirmed in cross-sectional
as well as in a limited number of longitudinal studies (Adams et al.,
1990). National surveys show the percentage of abstainers
among the elderly to be 52% of men and 68% of women; however, the percentage
of users of alcohol in the older group will increase as younger cohorts
pass into old age. In nonalcoholic elderly, low-dose
alcohol consumption has been found to promote better health by stimulating
appetite, improving regular bowel function, and improving mood by lessening
inhibitions, stress, tension, and depression (Dufour et al., 1992).
Alcohol use and misuse are significant health issues for the elderly
because they cannot consume large quantities of alcohol without adverse
effects (Dufour and Fuller, 1995). Up to 70% of all elderly hospitalizations
are alcohol-related, and the cost of alcohol-related hospital care for
the elderly in 1990 was estimated to be as high as $60 million (Select
Committee on Aging 92). Age-specific mortality rates with explicit mention
of alcohol increase with age until they peak from age 55 to 65 and then
drop consistently for each older age group. This age-incremental mortality
trend reverses itself because of the lower levels of alcohol consumption
in the oldest age groups and because those with the largest alcohol
consumption die before they reach the oldest age groups (Stinson et
al., 1993).
Of approximately ten million alcoholics in the U.S. today, about three
million are over the age of 60 (Gupta, 1993), and coincident with the
aging of the population, the amount of alcohol-related problems among
older persons is rising (Adams and Cox, 1997).
Although the precise prevalence of alcoholism among the general elderly
population is unknown, estimates range from 2 - 10% with estimated prevalence
being considerably higher (18 - 40%) for elderly individuals who are
institutionalized patients in hospitals, nursing homes, general medical
wards, and in psychiatric hospitals (Egbert, 1993).
Stresses that may trigger late-onset alcoholism include depression,
bereavement, retirement, marital stress, economic changes, and physical
health problems (Jennison, 1992). Women are more likely than men to
be identified as late onset (Gomberg, 1997). Late-onset drinkers are
more likely to be minorities, less likely to have a family history of
alcoholism, have a better prognosis for remission, and are more tied
into family and friendship social networks (Mulford and Fitzgerald,
1992).
Women drink less than men at every age, with a significant risk factor
being a spouse or lover who is a problem drinker (Gomberg, 1995). Men
of all racial and ethnic groups have a higher alcohol-related mortality
rate than do women (Bertolucci et al., 1985). African Americans 60 years
or older report more alcohol-related problems than do Caucasians (Gomberg
and Nelson, 1995). Nearly two-thirds of older African American women
are abstainers compared to about one-half of Caucasian women. Latino
men and women are more likely to increase levels of drinking between
ages 40 and 59 than are Caucasians or African Americans (Gilbert and
Collins, 1997).
There are two specific recommendations: (1) Develop models of alcohol
use across the lifespan, including the elderly. (2) Appropriate questions
concerning patterns of alcohol consumption should be included in surveys
that involve large numbers of older people.
NIAAA PORTFOLIO ON ALCOHOL AND THE ELDERLY
(Mary Dufour, M.D., M.P.H.)
ELDERLY
The topic of the alcohol abuse among the elderly is a much-needed area
of research. DBE is currently supporting one study in this area and
several others that are described in the summary of grants focused on
women.
PAST GRANTS
Richard H. Blake (R01AA07683), " Older Persons Problem
Drinking Identification Screen", proposed to
identify the mechanisms involved in falling in the aged under both
normal conditions and when postural stability and gait were degraded
by alcohol.
Robin Room (R01AA06580), "Alcohol and Aging: A 20-Year
Follow-up Study" studied alcohol use and alcohol problems
in relation to disease, decreased functioning, and mortality in
the elderly.
Current Grants
Frank Sloan (R01AA12162), "Determinants and Cost of
Alcohol Abuse Among the Elderly and Near Elderly"
will use two panel data bases, the Health and Retirement Study and
the Asset and Health Dynamics of the Oldest Old, to examine relationships
between life experiences and drinking behavior. These data will
be supplemented by data from the National Long-Term Care Survey,
which has been linked to Medicare claims data to assess mortality
and some dimensions of morbidity as well as the impact of excessive
alcohol use on Medicare expenditures.
Gaps
Older individuals comprise the fastest growing segment of the population
of the U.S. and yet this represents the most underfunded area in the
DBE portfolio. Branch staff are especially interested in expanding this
segment of epidemiology research.
EPIDEMIOLOGY OF ALCOHOL AND WOMEN
State of Knowledge (Richard W. Wilsnack, Ph.D.)
Recent epidemiological research on women's drinking has identified
many gender-specific patterns that are not well understood. Women consume
less alcohol and have fewer alcohol-related behavior problems than men,
a nearly universal but variable pattern that remains difficult to explain
(Wilsnack et al., in press). Women's drinking is associated with risks
of breast cancer (Smith-Warner et al., 1998) and higher risks than men
of liver damage (Becker et al., 1996), and it may have curvilinear relationships
with general mortality, cardiovascular morbidity, and osteoporosis,
but the sizes and reasons for these associations have not been adequately
specified.
Women's drinking is also associated with higher probabilities of risky
sexual activity (Caetano and Hines, 1995), sexual assault (Greene and
Navarro, 1998), and domestic violence, but the complex reasons for these
associations (including timing of alcohol consumption and drinking behavior
of partners) have not yet been sorted out. Family histories of alcohol
disorders (Grant, 1998), childhood sexual abuse, and early onset of
drinking may all increase women's risks of alcohol-related problems,
but effect sizes are uncertain.
Women's problem drinking may have two-way relationships with other
mental health problems (depression, anxiety, bulimia), smoking, obesity,
and homelessness, but the time sequences have not been unraveled. Effects
of women's drinking on fertility and on the brain, interactions of alcohol
with women's use of prescription drugs, and ways that women's drinking
is influenced by role demands and by the drinking behavior of partners
need more investigation. However, the greatest limitations to be overcome
in research on women's drinking are more methodological than substantive:
the needs for greater attention to timing, processes, social contexts,
and effect sizes.
There are two specific recommendations: (1) It is important to improve
data collection on patterns of alcohol consumption in regard to timing,
social contexts, and processes, especially in women. (2) Improve data
analyses in terms of curvilinear relations, two-way relations, and effect
sizes.
NIAAA PORTFOLIO ON ALCOHOL AND WOMEN
(Mary Dufour, M.D., M.P.H.)
During the past 10 years, efforts to develop data on drinking patterns
and their correlates in women through longitudinal national surveys
continued, a study involving rural women began, and a study on family
history of alcoholism in women was undertaken. Current work focuses
on special topics and subpopulations of women, including older women,
bone mineral density, hormone replacement therapy, and the effects of
moderate drinking. Other special populations of women under current
investigation include lesbians and poor, rural women. Other areas, such
as genetic risk factors for alcoholism among women are included in the
DBE portfolio as well as among grants in the genetics portfolios elsewhere
in NIAAA.
Past Grants
Three grants have been completed in the past 10 years:
Jean Golding (R01AA09342), "Effects of Drinking and
Nursing--An Epidemiological Study" evaluated
the hypothesis that drinking during lactation is associated with
alterations in infant cognitive, motor, or somatic growth with data
from an ongoing longitudinal prospective study of 15,000 pregnancies,
examining infants at 3 years of age.
Barbara W. Lex (R01AA06794), "Alcoholism and Family
History in Women" evaluated the contribution of family
history of alcoholism as a possible antecedent risk factor for alcohol
problems in women by comparing young (aged 21-25), moderate-drinking,
family history positive (FHP) women with family history negative
(FHN) women matched on age, socioeconomic status, education, height-weight
ratio, and drinking patterns. Groups were compared on standardized
subjective, behavioral, and psychomotor tests before and after alcohol/placebo
administration. Subjects were also compared with alcoholic and nonalcoholic
FHP and FHN women and men.
Sue A. Russell (F31AA05277), "Sexual Abuse & Dysfunction
& Alcohol Abuse in Women" examined the roles
of sexual abuse and subsequent sexual dysfunction on alcohol use
and abuse patterns.
Current Grants
Sharon C. Wilsnack (R37AA04610), "Problem Drinking
in Women--A National Longitudinal Study" is continuing
longitudinal national survey work on drinking among U.S. women.
This program of research begun in 1981 is unique in the NIAAA grant
portfolio and has produced much important information about trends
in women's drinking, relationships between women's drinking and
work patterns and sexual experiences, and factors that predict onset
and chronicity of problem drinking in women. In the current period
of support, a national survey of 1,550 women will be conducted in
the year 2001 to increase knowledge about longitudinal patterns
of drinking. While most of the women will have participated in previous
waves of the survey, a new sample will also be included in the 2001
survey. Aims are to evaluate 20-year trends; predictors of 5-, 10-
and 20-year age-specific changes; correlates and predictors of heavier
drinking among older women and those of childbearing age; and links
with eating disorders and use of prescribed psychoactive drugs.
Using data from an international project, cross-national variations
in women's drinking behavior and its antecedents and consequences
are also being evaluated.
Two new studies focus on rural women and lesbians, respectively:
Mary R. Boyd (R15AA11903), "Substance Abuse among Rural
Women of South Carolina" is conducting a descriptive
study of risk factors for alcohol and other drug abuse among low-income
rural women. Comparisons are being made between alcohol and other
drug abusing women and non-abusing women on risk factors that include
sociodemographics, family history, victimization, daily hassles,
alcohol expectations, coping, and self-esteem.
Tonda L. Hughes (K01AA00266), "Sexual Identity and Drinking:
Risk and Protective Factors" is investigating
putative risk and protective factors for heavy drinking and alcohol-related
problems in lesbians and heterosexual women. The study also plans
to evaluate conceptual and methodological problems that limit research
on lesbians' use of alcohol. Analyses are planned to elucidate theoretical
implications regarding the influence of gender and adherence to
traditional female gender-role expectations on women's use of alcohol.
Three new studies focus on older women:
Judith S. Gavaler (R01AA11184), "Alcohol and Estrogen
Replacement Therapy Interaction" is studying factors
that modulate estrogen levels in postmenopausal (PMP) women, the
role of established and potential estrogen level determinants in
PMP women who are not receiving Estrogen Replacement Therapy, and
the response in levels of various hormones to the chronic use of
ERT. The interaction of ERT and moderate alcohol consumption is
also being examined. Data on self-reported sociodemographic information,
diet, medical history, medication use, alcohol consumption, and
family history are being gathered from 1250 ethnically diverse postmenopausal
women. Biologic data include blood hormonal analysis and measurements
of waist, height, weight and blood pressure.
M. Kathleen Clark (R29AA10197), "Women's Alcohol Dependency
and Recovery Bone Mass Impact" is investigating
the effect of alcohol dependence and recovery on bone mineral density
and bone turnover in premenopausal women aged 20-40. Bone mineral
density of the femoral neck and lumbar spine is being measured,
and data are being gathered on reproductive characteristics, nutritional
status, alcohol use, liver function, and lifestyle. Black and White
women will also be compared.
Heidi B. Nelson (R29AA11187), "Moderate Alcohol, Function,
and Health of Older Women" is evaluating associations
between moderate alcohol use, smoking, and tests of neuromuscular
and physical function among women aged 65 and older using data collected
prospectively (1986-1994) from nearly 10,000 women participating
in the Study of Osteoporotic Fractures. The research is also assessing
the impact of alcohol use on specific morbidities, mortality, and
institutionalization. In addition, a subsample of about 1,250 women
is being examined in terms of patterns, context, and attitudes relative
to alcohol use among older women. Results to date indicate that
women who use moderate amounts of alcohol continuously perform better
on tests of neuromuscular and physical function compared to former
and intermittent drinkers and lifetime abstainers.
Selected Findings
Drinking Patterns and Problems. Longitudinal follow-up
from 1981 to 1991 indicated a decline in women's drinking since 1980.
However, adverse drinking consequences and episodes of extreme drinking
were most common among women aged 21 to 34; unmarried, divorced, separated,
or cohabiting women; and women with spouses or companions who are frequent
drinkers. Women aged 35 to 49 showed the highest rates of chronic alcohol
problems, including alcohol dependence, withdrawal symptoms, and loss
of control over drinking. For women under age 65, risks of problem drinking
rose with patterns of role deprivation: lack or loss of marital, job,
and child-rearing roles. However, the demands of multiple roles were
not a significant cause of problem drinking. Cross-sectional analyses
of women drinkers showed that heavy and problem drinking was associated
with unwanted marital, employment, and parenthood statuses. The most
consistent predictor of persistent (chronic) problem drinking was sexual
dysfunction. Women's experience of childhood sexual abuse was associated
with recent alcohol use and drinking-related problems; history of sexual
abuse also predicted the onset of problem drinking over a 5-year follow-up
period. Associations were found between increasing levels of drinking
and reproductive dysfunction in which dysmenorrhea, heavy menstrual
flow, and premenstrual discomfort increased as drinking level increased.
Heavy-drinking women (six or more drinks a day at least five times a
week) also had elevated rates of gynecologic surgery other than hysterectomy.
Lifetime rates of miscarriage, stillbirth, prematurity, infertility,
and birth defects were significantly elevated among those at upper levels
of drinking. Findings of another study indicated that family history
positive (FHP) women had lower subjective responses to alcohol and lower
blood alcohol levels than family history negative (FHN) women, but their
subjective responses were more strongly correlated with blood alcohol
levels. Findings for women confirmed the lower magnitude of subjective responses
of FHP compared to FHN men following comparable doses of alcohol.
Gaps
Aspects of research on alcohol and women have been touched in reviewing
every other area of the portfolio; however, gaps clearly remain. The
epidemiology of gender differences in risks and benefits of moderate
drinking needs clarification, as does that of specific alcohol-related
medical consequences. Clarification of the role of alcohol in the development
and course of breast cancer is critical. Additional research on subpopulations
of women is also needed.
ALCOHOL USE AMONG MEMBERS OF AMERICAN ETHNIC-RACIAL
MINORITY GROUPS
State of Knowledge (Steven C. Schinke, Ph.D.)
Persons who identify themselves as Asian drink much less than their
Caucasian counterparts, and they report fewer alcohol-related problems
(SAMSA, 1998). Asian men drink more alcohol than women, older Asian
Americans are more likely than younger ones to abstain, and younger
people are more likely to be heavy or problem drinkers (Higuchi et al.,
1994). Rates of heavy drinking are highest among the Japanese (25%),
followed by the Filipinos (20%), Koreans (15%), and Chinese (1%). Research
suggests that as acculturation occurs, Asian American drinking rates
conform to those in the general population (Johnson and Nagoshi, 1990).
Among many Asian groups, the absence of certain metabolic enzymes results
in an unpleasant flushing of the skin after drinking alcohol, and such
individuals consume less alcohol than do those with no or slow flushing
responses (Nakawatase et al., 1993).
Among Mexican-Americans, Puerto Ricans, and Cuban-Americans, men are
more likely than women to drink and to drink heavily (Caetano, 1998).
Although Mexican-Americans have the highest abstention rates (men 27%,
women 46%), they are also the most likely to be the heaviest drinkers
(men 44%, women 7%). Data from the Hispanic Health and Nutrition Examination
Survey show that patterns of alcohol use and abuse differ significantly
among Hispanic subgroups. Younger age is the major predictor of drinking
versus abstaining and of heavy drinking (Caetano, 1988). Protective
factors in Hispanic men include being older, employed, and in highest
income category (Caetano and Clark, 1998). For Mexican-American women,
being divorced or single is the only predictor of heavy drinking and
drinking-related problems (Caetano, 1988). Higher levels of acculturation
leads to more drinking among Mexican-American men and women (Caetano,
1988).
Although tremendous variation exists in drinking prevalence from one
tribe of Native Americans to the next, men drink much more than women.
Urban Indian populations generally drink more than reservation populations.
There is a very high percentage of heavy drinkers in the American Indian
population, particularly heavy binge drinking of more than 5 - 7 drinks
per episode; many problem or heavy drinkers quit drinking in early or
late middle age (May, 1996). American Indians are especially at risk
for alcohol-related consequences. Indian youth have consistently higher
rates of alcohol use compared to non-Indian peers (Beauvais, 1996) and
drink earlier, in greater amounts, and have a higher level of drinking-related
consequences.
Drinking patterns for African American and Caucasian men are more similar
than different (Herd, 1994). However, young African American men are
less likely to be frequent heavy drinkers than young Caucasian men.
Greater income predicts more drinking for Caucasians but not African
Americans. Rates of heavy drinking and alcohol-related problems among
African Americans are highest in the urban Northeast and lowest in the
South (Herd, 1989). In contrast to the similarities in drinking patterns,
African American men report significantly greater numbers of drinking
consequences than Caucasian men, even after adjusting for income, education,
occupation, and employment status (Herd, 1994).
There are two specific recommendations: (1) Epidemiological studies
are needed that assess the pattern of alcohol consumption in ethnic/racial
populations, disaggregating influences of socioeconomic status (SES;
education, income, age, gender, and region).
(2) Identify positive/protective influences for each culture, with
particular emphasis on African Americans, Hispanics, and Native Americans.
NIAAA PORTFOLIO ON RACE/ETHNICITY
(Captain Darryl Bertolucci)
During the past 10 years, DBE has supported several grants investigating
alcohol use among American Indian populations, with a particular emphasis
on Indian youth. Several studies have also focused attention on persons
of Hispanic origin, including Mexican-Americans, Cuban Americans, and
Puerto Ricans. In addition, studies involving comparisons of two or
three ethnic groups, including Hispanics, Blacks, and American Indians
have been supported. Currently, the portfolio includes a continuing
biethnic study and a new study of Mexican-American youth.
Past Grants
Fred Beauvais (R01AA08302), "Alcohol Use, Dropouts, and
Indian Youth" studied the relationship between dropping
out of school and alcohol use among American Indian youth living on
reservations.
Mary A. Burnam (R01AA07741), "Patterns of Alcohol Involvement
Among Mexican Americans" studied patterns of alcohol
use and alcohol disorder among Mexican Americans as a function of
ethnicity (i.e., Mexican Americans versus non-Hispanic whites), and
among Mexican Americans in terms of country of origin, acculturation,
urbanicity, and region.
Glorisa Canino (R01AA09990), "Development and Testing of
the Spanish Alcohol Use Disorder and Associated Disabilities
Interview Schedule [AUDADIS] directed a project that translated,
adapted, and tested the reliability and validity of the AUDADIS in
a community of Spanish speaking respondents.
Gerald Gurin (R01AA07142), "Drinking Behavior, Norms and
Problems in Puerto Rican Adults" sought to develop
basic epidemiology data on the distribution of drinking behavior patterns
and alcohol-related problems, attitudes and norms about drinking to
explore the relationships between negative affect, alcohol expectancies
and drinking problems.
Patrick B. Johnson (R01AA08008), "Comparison of Puerto
Rican and Irish American Drinking" directed a
large-scale study of the drinking behavior and alcohol-related problems
of Puerto Rican and Irish American men and women in which interviews
with representative probability samples in the New York metropolitan
area were conducted. Differences in drinking patterns based on ethnicity,
educational attainment, acculturation, and alcohol expectancies were
explored.
Stephen J. Kunitz (R01AA08153), "A Follow-up Study of
Alcohol Abuse" conducted a retrospective cohort study
of three groups of Navajo Indian adults first interviewed in 1966-1967
to assess the association between alcohol consumption patterns and
problems at baseline and outcomes such as mortality, health status,
health care utilization and level of psychosocial functioning.
Spero M. Manson (R01AA08474), "Alcohol Use/Abuse among
Indian Boarding School Students" conducted a longitudinal
survey of American Indian students (grades 9-12) which examined the
latent structure of adolescent alcohol use.
Kyriakos S. Markides (R03AA08522), "Alcohol Consumption
Patterns in Mexican Americans" used data from
the Southwestern Sample of the Hispanic Health and Nutrition Examination
Survey (HHANES) to investigate alcohol consumption patterns among
Mexican Americans by age and gender. Data from the HHANES were also
used to determine life-course patterns of alcohol consumption among
Mexican Americans, Cuban Americans and Puerto Ricans residing in the
mainland United States.
Kathleen R. Merikangas (R01AA09978), "Minority Children
at High Risk for Alcohol-Related Problems" studied Black
children aged 8-17 who were at high and low risks for alcohol-related
problems based on paternal alcoholism history.
James A. Neff (R01AA06723), "Drinking Patterns and Consequences:
A Tri-Ethnic Study" conducted a prospective study
to examine typical drinking patterns, motives, and contexts for drinking
in relation to subsequent alcohol use and alcohol-related problems
in Blacks, Whites, and Mexican Americans.
Marcia T. Russell (R01AA05702), "Stress, Race, and Alcohol
Use in a Household Population" conducted a household
population survey of drinking patterns, alcohol-related problems,
stress factors, blood pressure and sociodemographic characteristics
in a representative sample of Black and White adults.
Merrill C. Singer (R01AA07161), "Natural History of Drinking
among Puerto Rican Men" studied the natural history
of drinking among Puerto Rican men in relation to a set of explanatory
variables.
Julian F. Thayer (R29AA07352), "Distress and Alcohol Use
in Ethnic Minorities" conducted an exploratory investigation
of the interrelationship between psychological distress and alcohol
and other drug use across Black, White, and American Indian ethnic
groups.
Current Grants
Karen Trocki (R01AA10013), "Drinking and Problem Epidemiology
in Blacks and Hispanics" is continuing Raul
Caetano's analysis of national surveys of drinking patterns among
Blacks and Hispanics. The grant is in its 6th year. Current analyses
are describing and testing the factor structure of alcohol expectancy,
attitudes toward drinking and reasons for drinking; assessing the
relationship between drinking potential and expectancies, attitudes
and reasons for drinking; and finding support for alcohol control
policies and factors that underlie them.
In a new project, Randall C. Swaim (R01AA09895), "Alcohol
Use and Related Problems - Mexican-American Youth"
is conducting a survey in five southwestern states of alcohol
use and alcohol-related problems among Mexican-American 8th and 12th
grade students and among White non-Hispanic youth from the same regions.
Dropouts from the 12th grade age cohort will also be studied. Comparisons
will be made by grade, gender, dropout status, and ethnicity with
frequency and intensity of alcohol use, age first drunk, reasons for
drinking, and perceived harm from drinking. Emotional and behavioral
problems resulting from alcohol use, including drinking and driving,
will also be assessed.
Selected Findings
Youth. American Indian youth in grades 7-12 showed high
rates of alcohol and other drug use (20% were heavily involved); when
school dropout was taken into account, estimates for the entire age
cohort increased. However, since trends for Indian youth were similar
to trends for non-Indian youth, prevention strategies effective with
other groups could also be effective with this population. In another
study, a three-dimensional latent structure of American Indian adolescent
alcohol use was identified involving quantity and frequency, negative
consequences, and serious problem drinking. Quantity and frequency significantly
predicted psychological adjustment (depressive symptoms, antisocial
behavior) and three measures of others' perceptions of a Indian youth
drinking; negative consequences contributed significantly to prediction
of these variables above the prediction offered by drinking quantity
and frequency. Serious problem drinking was a significant predictor
only for antisocial behavior in American Indian boys and for others'
thinking that girls had a problem with drinking.
Drinking Patterns and Problems. A study of American Indian
adults found that young men at high risk for alcoholism often stopped
or moderated their drinking as they aged. Analysis of drinking histories
revealed that, compared to those who have survived, the persons who
had died were likely to have been solitary drinkers. This research also
developed data for the entire Navajo population on changing mortality
from alcohol-related causes since the 1960's.
In a study of Mexican-Americans, Cuban-Americans and Puerto Ricans
living in the U.S., age differences in patterns of consumption among
Mexican American and Puerto Rican males reflected aging effects. Acculturation
was positively related to frequency of consumption and probability of
being a drinker in all three Hispanic groups. In women, a positive relationship
between acculturation and total drinks consumed was seen among Cuban-Americans;
in Mexican-Americans, a positive association with acculturation was
seen for both volume (drinks per occasion) and total drinks consumed.
Acculturation was not related to alcohol consumption in Mexican American
men. Acculturation was positively related to consumption in younger
Mexican American women but not middle-aged women; however, evidence
suggested that middle-aged women might be turning to alcohol in response
to marital disruption and poverty. In addition, middle-aged women who
were not employed were less frequent drinkers, but unemployed women
who did drink were heavier drinkers than employed women. In another
study, analyses provided little evidence to support an acculturation-stress
model of alcohol use in which stresses of acculturation produce higher
levels of alcohol consumption among moderate or high acculturation groups.
Generally, quantity and frequency of alcohol consumption were somewhat
higher among the least acculturated males and moderately acculturated
females.
In a national survey of Whites, Blacks, and Hispanics, alcohol problems
were found to be stable over time among White and Black men and increasing
among Hispanic men. Dependence-related problems were more stable among
Black than among White men. Among women, the incidence of dependence-related
problems and social consequences from drinking was higher among Blacks
than Whites. Hispanic women had a higher incidence of social consequences
from drinking than White women. In general, Hispanics and Blacks were
more at risk than Whites for developing a number of alcohol-related
problems. Risk curves indicated that drinking pattern (including frequency
of drunkenness or maximum daily consumption) rather than volume alone
played an incremental role in predicting risks of engaging in criminal
behavior or being victimized. Results also indicated that even at lower
average levels of drinking, there was considerable risk for drunk driving.
In a study of Black and White adults, stressors were highly predictive
of alcohol use and drinking problems among men who relied upon avoidant
coping strategies or who held strong positive expectancies about effects.
Results also indicated that stressful life events were more strongly
related to alcohol use among men, whereas stressful events were more
strongly related to psychotherapeutic drug use among women. Drinking
to cope mediated the relationship between depression and alcohol use/abuse.
A positive relationship between work-family conflict and alcohol abuse
was seen almost exclusively in those who believed that alcohol promotes
relaxation and reduces tension. When the relationship between drinking
patterns and blood pressure was examined, a positive relationship was
found between average drinks per day and systolic and diastolic blood
pressure. Drinking frequency had a positive effect on both diastolic
and systolic blood pressure, whereas drinking quantity did not affect
either. Relative odds ratios indicated that the risk of alcohol abuse/dependence
associated with a positive family history increased with increasing
age among whites whereas it decreased with increasing age among blacks.
Among whites, the relative odds ratio for the effect of family history
was higher for females than males; however, among blacks it was higher
for males than females.
Alcohol consumption rates were generally higher in Irish Americans,
who were also less likely than Puerto Ricans to be either lifetime or
current abstainers. Irish Americans reported more frequent drinking
and more instances of intoxication in the past year, as well as earlier
age of initiation to drinking than Puerto Ricans. Overall analyses comparing
the relationship between alcohol effect expectancies and reaction expectancies
and to male and female college students' drinking behavior found that
different types and patterns of expectancies were related to the drinking
behaviors of male and female college students, but frequency and quantity
were jointly determined by effect and reaction expectancies.
Comorbidity. An analysis of Puerto Rican adults showed that
the co-occurrence of depressed mood and drinking problems was strongly
moderated by alcohol expectancies. More specifically, co-occurrence
was strongest among those Puerto Ricans who most expected alcohol to
elevate their mood. In a study of Mexican-American and non-Hispanic
whites, findings indicated that using large quantities of alcohol and
male daily drinking were associated with depressed mood. Associations
of quantity and frequency with depression were independent of each other.
Among women, the cultural and demographic characteristics of high-quantity
drinkers and abstainers (both of whom tended to be Mexican Americans)
accounted for the association of alcohol use with depression. Alcohol
use disorders were more likely to precede major depression than follow
it. Mexican Americans in particular showed a pattern characterized by
primary alcoholism. Female gender, low acculturation and low income
were associated with secondary depression among alcoholics. Overall,
results revealed that lifetime risks of major depression were roughly
double for men with lifetime alcohol use disorders compared to men without
alcohol use disorders. The absolute risk for depression was higher for
women with alcohol use disorders. Among men, there was some suggestion
that unemployment and unmarried status mediated the association of alcohol
consumption with depression.
Methods. The translation and adaptation of the AUDADIS
instrument for use in Hispanic populations provided researchers with
an invaluable tool for the measurement of alcoholism and its associated
disabilities among Hispanics in the U.S. and Puerto Rico.
Gaps
Race/ethnicity is a crosscutting issue. Further research on the impact
of race/ethnic differences in all of the portfolio areas is important--injury,
morbidity and mortality, women, youth, family, etc. Since doing large-scale
national surveys with adequate representation of many rare/ethnic groups
such as Asian American, American Indians, Native Hawaiians, etc. is
logistically difficult and prohibitively expensive, development of alternate
methodologies for gaining information in these subpopulations would
be a valuable contribution.
NIAAA EPIDEMIOLOGY PORTFOLIO IN WORKPLACE
AND OTHER AREAS
WORKPLACE
Grants in NIAAA's portfolio of research on the workplace explore the
relationships between alcohol consumption, alcohol abuse, and alcohol
dependence and labor market outcomes such as participation in the labor
force, number of hours worked, and earnings. They also address the impact
of job characteristics, professional training, and experiences in the
workplace on alcohol-related outcomes. During the past 10 years, three
of the four grants funded have employed longitudinal designs. Currently,
DBE's portfolio in this area consists of a study of alcohol-related
consequences of harassment in the workplace.
Past Grants
Richard R. Bryant (R01AA08477), "Impact of Substance
Abuse on Labor Supply and Wages" described and analyzed
the impact of alcohol and other drug use and abuse on the labor
market experience of young adults. Data from the National Longitudinal
Survey of Youth (NLSY) were used to estimate wages and hours worked
for users and nonusers of alcohol and/or other drugs, taking into
account possible self-selection bias.
David C. Dooley (R01AA08379), "Relationship of Economic
Conditions and Alcohol Use" explored the relationships
between job loss and alcohol use and dependence in labor markets
and industrial sectors with different levels of demand for labor.
These analyses were conducted with panel data from the Epidemiologic
Catchment Area (ECA) Project.
J. Paul Leigh (R01AA08610), "Occupational Hazards, Job
Characteristics, and Alcohol Use" examined the association
between heavy alcohol use and job hazards, using data from the second
National Health and Nutrition Examination Survey (NHANES), the Quality
of Employment Study, and the California Occupational Mortality Study.
Judith A. Richman (R29AA07311), "Drinking Patterns of
Male and Female Future MDs"; and (R01AA07311),
"Problem Drinking over Time by Future MDs"
studied the relative influence of variables including personality
characteristics, childhood experiences, social support, reasons
for drinking, and stressors related to medical school training on
the development and course of drinking patterns and alcohol-related
problems among a cohort of medical school students over a five-year
period. Data were analyzed from developmental, occupational stress,
and gender role perspectives.
Current Grants
This study is being conducted by Judith A. Richman (R01AA09989),
"Harassment, Gender and Drinking -- An Epidemiology
Study" in a large sample of university employees. The
work setting is racially and ethnically diverse and the sample includes
four occupational groups. Participants were surveyed at two points
in time. Data are being gathered on childhood experiences of abuse,
cognitive style, coping repertoire, social support, occupational
drinking norms, alcohol consumption, motivations for drinking, alcohol-related
problems, and perceived experiences of harassment (both sexual and
non-sexual). Multivariate statistical techniques are being used
to describe pathways through which work-based harassment predicts
alcohol-related outcomes for both men and women.
Selected Findings
These studies found a variety of positive relationships between measures
of alcohol use and abuse and employment-related variables. These relationships
include a greater incidence of clinically significant alcohol abuse
among persons who were laid off from work than among those who were
not (over a one-year interval) and a strong positive correlation between
heavy use of beer and fatality rates within industries and occupations
(while noting that blue-collar jobs are more hazardous than others and
that persons in blue-collar jobs were more likely to drink beer). Among
medical students followed through their clinical training, drinking
outcomes were explained by abusive experiences in the workplace interacting
with personal vulnerabilities.
Gaps
Many research opportunities remain in the area of alcohol and the workplace.
Longitudinal research which provides information on time sequence and
causal linkages between individual factors, alcohol use/abuse and selection
and impact of occupation would be valuable for identifying individual
and occupational use and protective factors.
OTHER
A number of grants supported by DBE have investigated the psychosocial
and environmental contexts within which people drink and how those contexts
serve to motivate a person to initiate drinking, to continue to drink,
to abstain from drinking or to stop drinking. The consumption of alcohol
occurs against the backdrop of a person's intersecting social, psychological
and environmental experience. Environmental experience also includes
the role of laws and taxes as they affect the economic and physical
availability of alcoholic beverages. In addition, while the study of
alcohol use and abuse is relevant to the population at large, there
is sometimes heightened interest in the role of alcohol in special groups.
Such groups include veterans, the homeless, persons with certain comorbid
conditions, the young, and college students, to name a few. NIAAA has
supported a number of grants that investigated the role of alcohol in
these groups. Finally, a number of historical grants have been awarded;
these awards were motivated by the assumption that an enhanced understanding
of the history of alcohol use in the United States and other nations
will inform present research and augment our understanding of current
alcohol use within our country. NIAAA is currently supporting a grant
studying the relationship of between gambling and alcohol and other
drug abuse.
PSYCHOSOCIAL/ENVIRONMENTAL FACTORS AND DRINKING
Past Grants
Antonia Abbey (R01AA07316), "Psychosocial Factors Affecting
Alcohol Consumption" investigated the relationship
between psychological and social factors and decisions about when
to purchase and consume alcohol. More specifically, this study examined
the relationship between subjective and social availability and
alcohol consumption.
Nan Lin (R01AA07600) "Life Events, Social Support, and
Drinking" examined life events, especially undesirable
life events, as triggering factors for changes in drinking practices.
The effects of social support, social endorsement of drinking and
psychological resources on drinking generally and on the relationship
between triggering events and drinking was studied.
Harold A. Mulford (R01AA07798) "Alcohol Availability,
Consumption and Problems" looked at the effects
of a substantial increase in the availability of alcohol on levels
of alcohol consumption and problem drinking. The study was carried
out in Iowa where a change in the Alcoholic Beverage Control Laws
privatized outlets, making alcohol more readily available. The investigators
also looked at how the interrelationship of alcohol availability,
consumption and problems may be affected by sociodemographic variables,
drinking contexts and drinking patterns.
Mark V. Pauly (R01AA08345) "Economic Causes and Effects
of State Alcoholism Spending" developed a simultaneous
equation model of spending levels for alcoholism treatment that
examined the effects of treatment on health outcomes. In this model,
citizen preferences, economic influences, and political structure
simultaneously determined alcohol tax levels and treatment spending
levels. The influence of state income levels, federal grants, the
pressure of state mandates, the state's budgetary obligations for
other public spending and voter characteristics were also part of
the explanatory model.
Current Grants
John W. Welte (R01AA11402) "Co-Occurrence of Gambling
and Substance Use in the U.S." is investigating the relationship
of gambling and pathological gambling and alcohol and other drug
use, and abuse. The study is collecting assessments of alcohol and
other drug use patterns and gambling behavior using a nationally
representative telephone survey. Data to be collected includes demographic
information and gambling and alcohol and other drug use behavior.
Goals of this research include an enhanced understanding of the
correlation of gambling and alcohol and other drug abuse, an examination
of the common predictors of gambling behavior and other alcohol
and drug abuse and the determination of the prevalence of pathological
gambling and gambling behaviors among various demographic groups.
Selected Findings
Despite substantial increases in the number of off-premise outlets
for bottled wine and spirits, following their privatization there was
little or no change in the frequency of drinking in several different
contexts or in the specific kinds of drinking-related problems studied.
In addition, there was little, if any, change in the self-reported amount
of liquor purchased outside the state of Iowa, in spite of the fact
that privatization resulted in a 6.1 percent increase in retail liquor
prices.
Gender friends, alcohol consumption, coping, and social motives for
drinking were significant predictors of alcohol consumption. Significant
interaction was observed between drinking to cope with stress and perceived
stress, and between drinking for social reasons and friends' alcohol
consumption. Four distinct "reasons for drinking alcohol"
scales were established through factor analysis: drink to cope, drink
to be sociable, drink to enhance social confidence, and drink for enjoyment.
Physical availability, in contrast to subjective and social availability,
was not a significant multivariate predictor of alcohol consumption.
SPECIAL POPULATIONS
Past Grants
Howard Blane (R01AA07076), "Drinking and Alcoholism
in Young Men: A National Study", studied the
psychosocial pathogenesis of alcohol use disorders and prevalence
rates for alcohol disorders in young men.
Jack Goldberg (R03AA07773) "Alcohol Consumption in
Veterans and Non-Veterans" assessed the association
between alcohol consumption and problem drinking in veterans as
compared to non-veterans in order to evaluate whether the stereotype
of the "alcohol-abusing veteran" is based on a real phenomenon
or a myth.
Elizabeth M. Smith (R01AA07549) "Patterns of Alcoholism
in Subsamples of Homeless Men" involved a systematic
controlled study of alcoholism and other psychiatric disorders among
the St. Louis homeless population. The study examined the temporal
relationships between onset of mental illness and homelessness in
a cross-sectional study of 900 homeless men and women.
Selected Findings
Draft eligibility status from 1970, 1971 and 1972 was unrelated to
alcohol consumption, despite the facts that eligibility for the draft
significantly increased the likelihood of military service and that
veterans are more likely to report increased alcohol consumption than
non-veterans. In a direct comparison of veterans and non-veterans, a
greater proportion of Vietnam-era veterans were current heavy drinkers
and a smaller proportion were abstainers than non-veterans (controlling
for age, region of the US, urbanization, ethnicity, marital status,
education and income). Similar patterns were observed for lifetime prevalence
of alcoholism (veterans have nearly two and a half times the lifetime
prevalence of non-veterans), cirrhosis of the liver, and unspecified
alcohol-related problems.
In the majority of persons, psychiatric disorder preceded homelessness,
and earlier onset of homelessness was associated with several diagnoses:
schizophrenia, major depression, generalized anxiety disorder, alcohol
and drug use disorders and antisocial personality. Alcohol use disorders
affected older homeless persons in greater numbers while drug use disorders
were seen more frequently among younger homeless people. Among homeless
women, it was found that although major mental illness is over-represented;
the majority does not suffer from major mental illness.
HISTORY OF ALCOHOL USE
Past Grants
Gregory A. Austin conducted two investigations: Grant
(R01AA07202) entitled "History of Alcohol in Britain"
provided a chronological history of alcohol use in England and Great
Britain from the Middle Ages to 1985; grant (R01AA04570) entitled
"Historical Review of Alcohol Abuse and Control"
provided a complete, up-to-date account of the role of alcohol throughout
US history from colonial times through the 1980's with particular
attention to the role of alcohol policies and changes in consumption
levels, patterns and trends.
Ron P. Roizen (R01AA09623) "Per Capita Alcohol Consumption,
1790-1950" conducted a time-series analysis of US per
capita consumption of alcohol for the period 1790-1950 examining consumption
across various beverage classes by age and gender for five-year intervals.
Back to Top
REFERENCES
Abel E, Zeidenberg P, Regan S et al.: Alcohol and violent death, Erie
County, New York, 1973-1983. MMWR 1994;33: 226-227.
Adams WL, Cox NS: Epidemiology of problem drinking among elderly people.
In: Gurnack AM (ed) Older Adults' Misuse of Alcohol, Medicines, and
Other Drugs. New York, Springer Publ. Co., pp 1-23, 1997.
Adams WL, Garry P, Rhyne R et al.: Alcohol intake in the healthy elderly:
Changes with age in a cross-sectional and longitudinal study. J Amer
Geriatrics 1990;38: 211-216.
Allen JP, Litten RZ, Fertig JB et al.: A review of research on the
alcohol use disorders identification test (AUDIT). Alcohol: Clin Exp
Res 1997;21: 613-619.
Anthony JC, Eaton WW, Henderson AS: Looking to the future in psychiatric
epidemiology. Epidemiol Rev 1995;17: 240-242.
Arbuckle JL. Amos User's Guide. Chicago, Small Waters, 1995.
Babor T: Substance abuse disorders and persons with physical disabilities:
Nature, diagnosis and physical subtypes. In: Heinemann A (ed) Substance
Abuse and Physical Disability. New York, Haworth Press, pp: 43-57, 1993.
Baboriak JJ, Anderson AJ, Hoffmann RG: Interrelationship between coronary
artery occlusion, high-density lipoprotein cholesterol, and alcohol
intake. J Lab Clin Med 1979;94: 348-353.
Bailey SL, Camlin CS, Ennett ST: Substance use and risky sexual behavior
among homeless and runaway youth. J Adolescent Health 1998;23.
Beauvais F: Trends in drug use among American Indian students, 1975-1994.
Amer J Pub Health 1996;86: 1594-1598
Becker U, Deis A, Sorensen TI et al.: Prediction of risk of liver disease
by alcohol intake, sex and age: A prospective study. Hepatology 1996;23:
1025-1029.
Berglund M: Suicide in alcoholism: A prospective study of 88 suicides.
Arch Gen Psychiatry 1984;41: 881-891.
Biederman J, Wilens T, Mick E et al.: Psychoactive substance use disorders
in adults with ADHD: Effects of ADHD and psychiatric comorbidity. Am
J Psychiatry 1995;152: 1652-1658.
Blumentahl SJ: Suicide: A guide to risk factors, assessment, and treatment
of suicidal patients. Med Clin North Am 1988;72: 937-971.
Caetano R: Alcohol use among Mexican Americans and in the U.S. population.
In: Gilbert MJ (ed) Alcohol Consumption among Mexicans and Mexican Americans:
A Binational Perspective. Los Angeles, University of CA, pp 53-84, 1988.
Caetano R: The epidemiology of alcohol-related problems in the U.S.:
Concepts, patterns and opportunities for research. Drugs Soc 1997;11:
43-71.
Caetano R, Clark C: Trends in alcohol consumption patterns among Whites,
Blacks, and Hispanics: 1984 and 1995. J Stud Alcohol 1998: 659-668.
Caetano R, Hines AM: Alcohol, sexual practices, and risk of AIDS among
blacks, Hispanics, and whites. J Acquired Immune Deficiency Syndromes
Hum Retroviral 1995;10: 554-561.
Cottler LB, Grant BF, Blaine J et al.: Concordance of DSM IV alcohol
and drug use disorder criteria and diagnoses as measured by AUDADIS-ADR,
CIDI and SCAN. Drug Alcohol Dep 1997;47: 195-205.
Crockford DN, el-Guelbaly N: Psychiatric comorbidity in pathological
gambling. Can J Psychiatry 1988;43: 43-50.
Dufour M, Fuller RK: Alcohol in the elderly. Ann Rev Med 1995;46: 123-132.
Dufour MC, Archer L, Gordis E: Alcohol and the elderly. Clin Geriatric
Med 1992;8: 127-141.
Egbert AM: The older alcoholic: Recognizing the subtle clinical clues.
Geriatrics 1993;48: 63-69.
Ericksen KP, Trocki KF: Sex, alcohol and sexually transmitted diseases:
A national survey. Fam Plann Perspect 1994;26: 257-263.
Feinstein A: The pre-therapeutic classification of comorbidity in chronic
disease. J Chronic Dis 1970;23: 455-468.
Gilbert MJ, Collins RL: Ethnic variation in women's and men's drinking.
In: Wilsnack R, Wilsnack S (eds) Gender and Alcohol: Individual and
Social Perspectives. New Brunswick, NJ, Rutgers Center of Alcohol Studies,
pp 357-378, 1997.
Gilson SH, Chilcoat H, Stapleton J: Illicit drug use by persons with
disabilities: Insights from the National Household Survey on Drug Abuse.
Amer J Pub Health 1996;86: 1613-1615.
Goldman MS, Darkes J, DelBoca FK: Expectancy mediation of biopsychosocial
risk for alcohol use and alcoholism. In: Kirsch I (ed) How Expectancies
Shape Experience. Washington DC, American Psychological Association,
in press.
Gomberg ES, Nelson BW: Black and white older men: Alcohol use and abuse.
In: Beresford T, Gomberg ES (eds) Alcohol and Aging. New York, Oxford
University Press, pp 307-323, 1995.
Gomberg ES: Older women and alcohol use and abuse. In: Galanter M (ed)
Development in Alcoholism, Vol 12, Alcoholism and Women. New York, Plenum
Press, pp 61-79, 1995.
Gomberg ES: Alcohol abuse: Age and gender differences. In: Wilsnack
R, Wilsnack S (eds) Gender and Alcohol. New Brunswick NJ, Rutgers Center
of Alcohol Studies, pp 225-244, 1997.
Grant BF: The impact of a family history of alcoholism on the relationship
between age at onset of alcohol use and DSM-IV alcohol dependence: Results
from the National Longitudinal Alcohol Epidemiologic Survey. Alcohol
Health Res World 1998;22: 144-147.
Greene DM, Navarro RL: Situation-specific assertiveness in the epidemiology
of sexual victimization among university women: A prospective path analysis.
Psychol Women Quart 1998;22: 589-604.
Gruenewald PJ, Millar AB, Treno AJ: Alcohol availability and the ecology
of drinking behavior. Alcohol Health Res World 1993;17: 39-45.
Gupta K: Alcoholism in the elderly: Uncovering a hidden problem. Postgrad
Med 1993;93: 203-206.
Herd D: The epidemiology of drinking patterns and alcohol-related problems
among U.S. Blacks. In: Alcohol Use among U.S. Ethnic Minorities. Washington
DC, U.S. Govt Printing Office (ADM 89-1435), 1989.
Herd D: Predicting drinking problems among Black and White men: Results
from a national survey. J Stud Alcohol 1994;61-71.
Higuchi S, Parrish KM, Dufour M et al.: Relationship between age and
drinking patterns and drinking problems among Japanese, Japanese-Americans,
and Caucasians. Alcohol Clin Exp Res 1994;18: 305-310.
Hingson R, Howland J: Alcohol and non-traffic unintended injuries.
Addict 1993;88: 877-883.
Holdener F: Alcohol and civil aviation. Addict 1993:88: 953-958.
Hubbard J, Everett A, Khan M: Alcohol and drug abuse in patients with
physical disabilities. Amer J Drug Alcohol Abuse 1996;22: 215-231.
Jennison KM: The impact of stressful life events and social support
on drinking among older adults: A general population survey. Int J Aging
Hum Develop 1992;35: 99-123.
Johnson RC, Nagoshi CT: Asians, Asian Americans, and alcohol. J Psychoactive
Drugs 1990;22: 45-52.
Kandel DB, Chen K, Warner LA et al.: Prevalence and demographic correlates
of symptoms of last year dependence on alcohol, nicotine, marijuana,
and cocaine in the U.S. population. Drug Alcohol Dep 1997;44: 11-29.
Kessler RC, Crum R, Warner L et al: Lifetime co-occurrence of DSM-III-R
alcohol abuse and dependence with other psychiatric disorders in the
National Comorbidity Survey. Arch Gen Psychiatry 1997;54: 313-321.
Klatsky A, Friedman GD, Siegelaub AB: Alcohol consumption before myocardial
infarction. Results from the Kaiser-Permanente epidemiologic study of
myocardial infarction. Ann Intern Med 1974;81: 294-301.
Kreutzer J, Witol A, Marwitz J: Alcohol and drug use among young persons
with traumatic brain injury. J Learn Dis 1996;29: 644-650.
Leigh BC, Stall R: Substance use and risky sexual behavior for exposure
to HIV: Issues in methodology, interpretation, and prevention. Amer
Psychol 1993;48: 1035-1045.
Li G, Smith GS, Baker SP: Drinking behavior in relation to cause of
death among US adults. Am J Public Health 1994;84: 1402-1406.
Martin CS, Kaczynski NA, Maisto SA et al: Patterns of DSM IV alcohol
abuse and dependence symptoms in adolescent drinkers. J Stud Alcohol
1995;56: 672-680.
May PA: Overview of alcohol abuse epidemiology for American Indian
populations. In: Sandefur G, Rundfuss R, Cohen B (eds) Changing Numbers,
Changing Needs: American Indian Demography and Public Health. Washington
DC, National Academy Press, pp 235-261, 1996.
Mulford HA, Fitzgerald JL: Elderly versus younger problem drinker profiles:
Do they indicate a need for special programs for the elderly? J Stud
Alcohol 1992;53: 601-610.
Muthen B: Second-generation structural equation modeling with a combination
of categorical and continuous latent variables: New opportunities for
latent class/latent growth modeling. Washington DC, American Psychological
Association, in press.
Nakawatase TV, Yamamoto J, Toshiaki S: The association between fast-flushing
response and alcohol use among Japanese Americans. J Stud Alcohol 1993;54:
48-53.
Office of Inspector General: Youth and Alcohol: A National Survey.
Drinking Habits, Access, Attitudes, and Knowledge. Rockville MD, Dept
of Health Human Services, 1991.
O'Malley PM, Johnston LD, Bachman JG: Alcohol use among adolescents.
Alcohol Health Res World 1998;22: 85-93.
Rehm J: Measuring quantity, frequency, and volume of drinking. Alcohol:
Clin Exp Res 1998;22: 4s-14s.
Reiger DA, Farmer M, Rae DS et al.: Comorbidity of mental disorders
with alcohol and other drug abuse: Results from the Epdiemiologic Catchment
Area study. JAMA 1990;264: 2511-2518.
Roizen J: Epidemiological issues in alcohol-related
violence. In: Galanter M (ed) Recent Developments in Alcoholism, Vol
13: Alcoholism and Violence. New York, Plenum Press, pp 7-40, 1997.
SAMHSA: Prevalence of substance use among racial and
ethnic subgroups in the U.S. 1991-1993. Rockville, MD, 1998.
Searles JS, Helzer JE, Walter DE: Comparison of drinking
patterns measured by daily reports and timeline follow-back. Psychol
Addict Behav, in press.
Select Committee on Aging: Alcohol Abuse and Misuse
among the Elderly. Washington, DC, U.S. Government Printing Office.
Committee Pub 102-852, 1992.
Shillington AM, Cottler LB, Compton WM, Spitznagel
EL: Is there a relationship between heavy drinking and HIV risk behaviors
among general populations subjects? Int J Addict 1995;30: 1453-1478.
Smith GS, Branas CC, Miller TR: Fatal non-traffic injuries
involving alcohol: A meta-analysis. Annals Emergency Med, in press.
Smith-Warner SA, Spiegelman D, Yaun SS et al: Alcohol
and breast cancer in women: A pooled analysis of cohort studies. JAMA
1998;279: 535-540.
Stall R, Heurtin-Roberts S, McKusick L et al.: Sexual
risk for HIV transmission among singles-bar patrons in San Francisco.
Med Anthropology Quart 1990;4.
Swift R: Transdermal ethanol. Addict 1993;88: 1037-1039.
Turner CG, Ku L, Rogers SM et al.: Adolescent sexual
behavior, drug use, and violence: Increased reporting with computer
survey technology. Science 1998;280: 867-873.
Verheul R et al.: Prevalence of personality disorders
among alcoholics and drug addicts: An overview. Eur Addict Res 1995;1:
166-177.
Wilsnack RW, Vogeltanz ND, Wilsnack SC: Gender differences
in alcohol consumption and adverse drinking consequences: Cross-cultural
patterns. Addict, in press.
Back to Top
APPENDIX A
Subcommittee for Review of Epidemioloty Portfolio
Chair
Nancy L. Day, Ph.D.
Western Psychiatric Institute and Clinic
3811 O'Hara Street
Pittsburgh, PA 15213-2593
Experts in Alcohol-Related Areas
Mary Jane Ashley, M.D.
Department of Public Health Sciences
University of Toronto
McMurrich Building, Fourth Floor
12 Queens Park Crescent West
Toronto M5S 1A8
CANADA
Raul Caetano, M.D., Ph.D.
School of Public Health
University of Texas
5323 Harry Hines Blvd., Room V8-112
Dallas, TX 75235-9128
Mark S. Goldman, Ph.D.
Department of Psychology
University of South Florida
4200 East Fowler Avenue, BEH 339
Tampa, FL 33620-8200
Kenneth E. Leonard, Ph.D.
Research Institute on Addictions
1021 Main Street
Buffalo, NY 14203-1016
Experts in Non-Alcohol-Related Areas
Patricia R. Cohen, Ph.D.
Department of Epidemiology
School of Public Health
Columbia University
100 Haven Avenue, T2 16D
New York, NY 10032
William W. Eaton, Ph.D.
Department of Mental Hygiene
Johns Hopkins School of Public Health
624 N. Broadway, Room 880
Baltimore, MD 21205
Stanislav V. Kasl, Ph.D.
Department of Epidemiology and Public Health
Yale University School of Medicine
60 College Street, LEPH 406
P. O. Box 208034
New Haven, CT 06520-8034
Back to Top
APPENDIX B
Experts in Epidemiology
Linda B. Cottler, Ph.D.
Department of Psychiatry
Campus Box 8134
Washington University in St. Louis
St. Louis, MO 63130
John E. Donovan, Ph.D.
Pittsburgh Adolescent Alcohol Research Center
Department of Psychiatry
University of Pittsburgh School of Medicine
3811 O'Hara Street
Pittsburgh, PA 15213-2593
Thomas K. Greenfield, Ph.D.
Alcohol Research Group
2000 Hearst Avenue, Suite 300
Berkeley, CA 94709-2176
John E. Helzer, M.D.
Department of Psychiatry
428 MFU-Patrick
University of Vermont School of Medicine
Burlington, VT 05405
Karen M. Jennison, Ph.D.
Sociology Department
University of Northern Colorado
Greeley, CO 80639
Eric Rimm, Sc.D.
Department of Nutrition
Harvard School of Public Health
665 Huntington Avenue
Boston, MA 02115
Paul M. Roman, Ph.D.
Behavioral Health
Institute for Behavioral Research
102A Barrow Hall
University of Georgia
Athens, GA 30602
Steven Schinke, Ph.D.
30 Wall Street, 4th Floor
New York, NY 10005
Gordon S. Smith, Ch.B., M.P.H.
Johns Hopkins Center for Injury Research
and Policy
624 N. Broadway
Hampton House 593
Baltimore, MD 21205-1996
Karen Trocki, Ph.D.
Alcohol Research Group
2000 Hearst Ave., Suite 300
Berkeley, CA 94709-2176
Richard W. Wilsnack, Ph.D.
Department of Neuroscience
University of North Dakota School of
Medicine and Health Sciences
Grand Forks, ND 58202-9037
Back to Top
APPENDIX C
NIAAA Program Staff
Captain Darryl Bertolucci
Epidemiology Branch, NIAAA
Bethesda, MD 20892-7003
Mary Dufour, M.D., M.P.H.
Deputy Director, NIAAA
6000 Executive Blvd., Suite 400
Bethesda, MD 20892-7003
Vivian Faden, Ph.D.
Division of Biometry and
Epidemiology, NIAAA
6000 Executive Blvd., Suite 514
Bethesda, MD 20892-7003
Susan Farrell, Ph.D.
Division of Biometry and
Epidemiology, NIAAA
6000 Executive Blvd., Suite 505
Bethesda, MD 20892-7003
David Sanchez
Division of Biometry and
Epidemiology, NIAAA
6000 Executive Blvd., Suite 505
Bethesda, MD 20892-7003
Back to Top
APPENDIX D
NIAAA Staff, Representatives from other NIH Institutes, and Guests
Henri Begleiter, Ph.D., M.D.
Department of Psychiatry
Box 1203
State University of New York
Health Science Center at Brooklyn
450 Clarkson Avenue
Brooklyn, New York 11203
Ann Blanken
Division of Epidemiology and
Prevention Research, NIDA
6001 Executive Blvd., Room 5153
Mail Stop Code 9589
Bethesda, MD 20892
Susan Cahill
Planning and Financial Management
Branch, NIAAA
6000 Executive Blvd., Suite 412
Bethesda, MD 20892-7003
Faye Calhoun, D.P.A.
Office of Collaborative Research, NIAAA
6000 Executive Blvd., Suite 400
Bethesda, MD 20892-7003
Michael J. Eckardt, Ph.D.
Office of Scientific Affairs, NIAAA
6000 Executive Blvd., Suite 409
Bethesda, MD 20892-7003
Richard K. Fuller, M.D.
Division of Clinical and
Prevention Research, NIAAA
6000 Executive Blvd., Suite 505
Bethesda, MD 20892-7003
Enoch Gordis, M.D.
Director, NIAAA
6000 Executive Blvd., Suite 400
Bethesda, MD 20892-7003
Bridget Grant, Ph.D.
Biometry Branch, NIAAA
6000 Executive Blvd., Suite 514
Bethesda, MD 20892-7003
Harold D. Holder, Ph.D.
Prevention Research Center
Pacific Institute for Research and Evaluation
2150 Shattuck Avenue, Suite 900
Berkeley, California 94704
Nancy Hondros
Planning and Financial Management
Branch, NIAAA
6000 Executive Blvd., Suite 412
Bethesda, MD 20892-7003
William M. Lands, Ph.D.
Office of the Director, NIAAA
6000 Executive Blvd., Suite 400
Bethesda, MD 20892-7003
Ting-Kai Li, M.D.
Department of Medicine
Indiana University School of Medicine
Emerson Hall 421
545 Barnhill Drive
Indianapolis, IN 46202-5124
Steve Long
Office of Policy, Legislation,
and Public Liaison, NIAAA
6000 Executive Blvd., Suite 405
Bethesda, MD 20892-7003
Matt McGue, Ph.D.
Department of Psychology
Elliot Hall, Room N-218
75 East River Road
University of Minnesota
Minneapolis, MN 55455
Suzanne Medgyesi-Mitschang, Ph.D.
Office of the Director, NIAAA
6000 Executive Blvd., Suite 405
Bethesda, MD 20892-7003
Carrie L. Randall, Ph.D.
Department of Psychiatry and
Behavioral Science
Medical University of South Carolina
171 Ashley Avenue
Charleston, SC 29425
Fred Stinson, Ph.D.
CSR, Inc.
1400 Eye Street, N.W.
Suite 200
Washington, DC 20005
Ronald Suddendorf, Ph.D.
Office of Scientific Affairs, NIAAA
6000 Executive Blvd., Suite 409
Bethesda, MD 20892-7003
Kenneth Warren, Ph.D.
Office of Scientific Affairs, NIAAA
6000 Executive Blvd., Suite 409
Bethesda, MD 20892-7003
Ms. Migs Woodside
35436 Indian Camp Trail
Scottsdale, AZ 85262
Sam Zakhari, Ph.D.
Division of Basic Research, NIAAA
6000 Executive Blvd., Suite 402
Bethesda, MD 20892-7003