National Institute on Alcohol
Abuse and Alcoholism No.
55 January 2002
Alcohol and
Minorities: An Update
Patterns of alcohol use and its consequences
vary widely among minority groups. Although more research is needed,
evidence suggests that prevention and treatment efforts may be more
effective when based on an understanding of the ethnic context of drinking
behaviors and their development (1,2). This Alcohol Alert summarizes
research on differences in alcohol use and problems, selected determinants
of drinking, and the development of targeted prevention and treatment
programs with respect to the four main minority groups in the United
States: African Americans; Hispanics; Asian Americans and Pacific Islanders
(AAPIs); and American Indians/Alaska Natives (AI/ANs). It is important
to note that these categories include hundreds of distinct ethnic or
racial populations which differ markedly in cultural characteristics
and drinking behavior. Consequently, research does not support broad
generalizations about specific subpopulations, many of which have not
been studied individually (3).
Ethnic Differences in Drinking Patterns
Data from nationwide surveys of adults
show that both current drinking (defined as consumption of 12 or more
drinks in the past year) and heavy drinking1 are most prevalent
among AI/ANs (4) and Native Hawaiians (5) and lowest among AAPIs (4).
Alcohol use is increasing significantly among Asian Americans, who constitute
one of the fastest growing U.S. minority populations (6). Among adolescent
minorities studied nationwide, African Americans show the lowest prevalence
of lifetime, annual, monthly, daily, and heavy drinking, as well as
the lowest frequency of being drunk (7). Hispanic adolescents have the
highest annual prevalence of heavy drinking, followed by Whites (7).
Among all age and ethnic groups, men are more likely to drink than are
women, and to consume large quantities in a single sitting (7,4).
1 Heavy drinking
is defined as five drinks on a single day at least once a month for
adults (4) and five drinks in a row at least once during the previous
two weeks for adolescents (7).
Ethnicity and Alcohol Problems
Medical Consequences. Research on alcohol's health effects on minority groups
has concentrated largely on cirrhosis, a progressive and often fatal
liver disease usually attributable to long-term heavy drinking. Analysis
shows a strong correlation between death rates from liver cirrhosis,
regardless of cause, and drinking levels nationwide (8). Consistent
with this association, deaths from chronic liver disease and cirrhosis
are about 4 times more prevalent among AI/ANs than among the general
US population (3). However Hispanics are approximately twice as likely
as Whites to die from cirrhosis (8), despite a lower prevalence of drinking
and heavy drinking (9). The reason for this discrepancy is unclear.
Evidence exists that Hispanics tend to consume alcohol in higher quantities
per drinking occasion than do Whites, resulting in a higher cumulative
dose of alcohol (9). In addition, Hispanics have a higher prevalence
than do Whites of hepatitis C, a serious infectious liver disease that
greatly increases the risk for liver damage in heavy drinkers (10).
Social Consequences. According to data from a nationwide survey, the prevalences
of drinking and driving in the past year were 19 percent among AI/ANs,
11 percent for both Whites and Hispanics, 7 percent for African Americans,
and less than 6 percent for AAPIs (4). Alcohol-related fatal crashes
are 3 times more prevalent among AI/ANs than among the general population
(3), constituting 1 of the 10 leading causes of death among AI/ANs,
along with alcohol-related suicide, homicide, and cirrhosis (11).
Contributors to Ethnic Differences
Social Factors. The availability of alcohol, as measured in terms of the
geographic density of alcohol sales outlets, has been linked to patterns
of alcohol-related traffic crashes in communities (12). Studies have
shown that greater densities of liquor stores are found in segregated
minority neighborhoods (13). However, the apparent association between
minority status and alcohol problems in some areas may reflect the disproportionate
concentration of alcohol outlets in low-income communities (12) rather
than ethnicity per se.
Another factor contributing to minority
drinking patterns is acculturation, the partial or complete adoption
of the beliefs and values of the prevailing social system. Through acculturation,
the original drinking pattern of an ethnic group tends to change to
resemble more closely that of the overall population. However, acculturation
also is influenced by gender, religious beliefs, family traditions,
personal expectations, and country of origin (14). Some researchers
have advanced the concept of "acculturation stress," whereby drinking
increases in response to the conflict between traditional values and
beliefs and those of the mainstream culture. Conversely, others have
pointed out that many people, especially youth, learn to draw on support
and resources from both cultures for protection against alcohol problems
(5).
Biological Factors. People vary in their vulnerability to the effects of alcohol.
Some of these differences result from genetically determined variations
in the body's ability to break down (i.e., metabolize) and eliminate
alcohol (15). For example, after drinking, many Asian subpopulations
experience flushing of the skin, nausea, headache, and other uncomfortable
symptoms. Those symptoms result primarily from inactivity of aldehyde
dehydrogenase-2 (ALDH2), an enzyme involved in a key step of alcohol
metabolism (16). A study of Asian males born in Canada and the United
States found that those who had inherited the gene for the less active
form of this enzyme drank two-thirds less alcohol, had one-third the
rate of binge drinking (i.e., consumption of more than 5 drinks per
day), and were three times more likely to be abstainers than a group
of Asian males who possessed the more active enzyme (17). However, some
people develop alcohol problems despite possessing the inactive form
of ALDH2, demonstrating the importance of additional factors in the
development of drinking patterns and consequences (17).
Among some African Americans, genetically
determined variability in another alcohol-metabolizing enzyme, alcohol
dehydrogenase-2, appears to affect the degree of vulnerability to alcoholic
cirrhosis and alcohol-related fetal damage (15).
Prevention
Some alcohol prevention programs that have
demonstrated success in the general population have been modified to
be more culturally relevant for specific ethnic groups. The following
two programs have been scientifically evaluated to compare the effectiveness
of the culturally sensitive version with that of the generalized version
for the populations in question.
School-Based Prevention. The school-based Life Skills Training (LST) program was
designed to help adolescents cope with social influences that encourage
use of alcohol and other drugs (AODs). Researchers compared the standard
LST program with a modified version based on both the traditional and
current cultural heritages of African American and Hispanic inner-city
youth (1). Data collected two years after program initiation indicated
that participation in either program produced significant decreases
in measures of alcohol consumption. However, the culturally focused
approach produced significantly greater improvement than did the generalized
LST approach (1).
Family Based Prevention. Since its inception as a generic program for White and
multiethnic children of alcohol- or other drug-abusing parents, the
Strengthening Families Program (SFP) has been modified for use with
specific ethnic populations. The modified program generally has been
found effective in reducing family problems and alcohol use among rural
and urban African Americans and to a lesser extent with urban Hispanics
(2). Among Native Hawaiians, however, comparison of the generic SFP
with a culturally modified format produced inconclusive results (2).
Alcohol Availability. The high density of alcohol outlets in minority neighborhoods
is noted above. However, the effect of limiting alcohol availability
to reduce drinking problems among specific minority groups is not known.
An exception to this situation is found among Alaska Natives, where
geographic isolation and diversity of local alcohol control policies
have combined to enable controlled research on naturally occurring experiments.
Studies of local alcohol control laws in
remote Alaska Native communities have shown that prohibiting the sale,
importation, and possession of alcohol by adults as well as by adolescents
(i.e., dry communities) is associated with total (18) and alcohol-involved
(19) injury-related death rates and alcohol-related outpatient visits
(20). In contrast, a study of American Indian reservations in the northwestern
United States suggests that alcohol-related deaths may be reduced more
effectively by restricting the sale and use of alcoholic beverages rather
than by prohibiting them (19). This conclusion is supported by results
of a study that mapped the locations of alcohol-related deaths in a
"dry" Navajo reservation in New Mexico. Most such deaths occurred among
intoxicated pedestrians along roads leading to border towns, suggesting
that those residents were returning from places outside the reservation
where they had gone to obtain alcohol (21).
Treatment
The Community Reinforcement Approach is
a highly flexible treatment intervention that can be adapted to ethnic
or cultural minorities through cooperation with family and community
networks. The program has experienced some initial success in treating
alcoholic members of a Navajo subpopulation in New Mexico who had not
responded to previous alcoholism treatment approaches. An integral part
of the program was the inclusion of American Indian spiritual traditions
to encourage abstinence (22). However, no randomized, controlled studies
have been performed to prove that incorporating traditional cultural
and spiritual beliefs and practices would enhance treatment in other
AI/AN cultures (3). In particular, the growing urban AI/AN population
tends to be highly acculturated with little or no knowledge of reservation
or native village cultural traditions (23).
Alcohol and Minorities-
A Commentary by NIAAA Director Enoch Gordis, M.D.
In the previous Alert on this topic,
I noted that the increasing number of studies of alcohol problems among
minorities had produced important findings and important new questions
to answer. This continues to be the case. For example, we know that
Hispanic males have the highest rates of cirrhosis mortality among all
groups, but we do not know why. We have begun to identify biological
mechanisms that may increase vulnerability to alcohol-related fetal
damage in some African Americans. More complete knowledge of these mechanisms
brings new hope for pharmacotherapy to aid the already indispensable
prevention methods in reducing risk. Finally, although we have begun
to look at the effects of society and culture on alcohol problems among
US minority groups, the heterogeneity of such groups presents a future
research challenge and opportunity.
A Personal Note
As many readers know, I retired as Director
of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as
of December 31, 2001. I would like to take this opportunity to thank
the scientists and NIAAA staff who have worked on putting together the
Alcohol Alert since its inception in 1988 and the many counselors,
policymakers, and interested members of the public who read and use
the information in the Alerts.
As a personal observation, the alcohol
field has changed tremendously since I entered it in the 1960s. My predecessors
as NIAAA Director and I have been gratified to see the field's growth
over the years into the well-respected, science-based field of medicine
that it is today. We have made much progress, but as long as alcohol
remains the number one drug of abuse in our Nation with such heavy personal,
social, and economic costs, we have much to do. I believe we are up
to the challenge, and I wish each and every one of you success in the
coming years.
References
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