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in the United States. Drinking habits associated with acculturation changed more quickly for men than for women. Despite the fact that their alcohol consumption increased, MexicanAmerican men reported fewer alcohol-related problems than Mexican men. Among both male and female Mexican Americans, acculturation was associated with a more permissive attitude toward alcohol consumption and a more neutral view of alcohol, with less support both for positive and negative aspects of alcohol use. Finally, only a small percentage of individuals surveyed believed that heavy drinking by Hispanic men in the United States is related to the need to demonstrate male prowess, or "machismo," defined in this study as the idea that “a real man can hold his liquor."

Representing nearly 3 percent of the U.S. population in 1990, Asian Americans constitute a rapidly growing segment of the country. When considered together, all subgroups of Asian Americans have lower prevalences of alcohol abuse, alcoholism, and adverse consequences of drinking than other racial and ethnic groups in the United States (Sue 1987). However, grouping Asian Americans is inadequate to define their true heterogeneity. Chinese Americans are the largest of the Asian-American minorities, accounting for approximately 24 percent of the AsianAmerican population; Filipinos represent about 20 percent; Japanese, Asian Indians, and Koreans each account for about 12 percent; and Vietnamese represent about 9 percent (U.S. Bureau of the Census 1991).

Racial differences in alcohol sensitivity between Oriental and Caucasian populations have been well documented (Chan 1986). The primary manifestation is a highly visible facial flushing accompanied by other symptoms of discomfort; these symptoms occur in approximately 47 to 85 percent of Orientals, compared with 3 to 29 percent of Caucasians (see Chapter 7, Biochemical Effects of Alcohol Metabolism). It has been hypothesized that Orientals limit their alcohol use to avoid the discomfort associated with the flushing response (Chan 1986); however, evidence indicates that flushing is only marginally related to reduced alcohol use (Johnson 1989).

Thus, sociocultural and environmental factors influence drinking patterns among Asian Americans more than has been appreciated. As might be expected given the cultural diversity noted above, drinking patterns among the various Asian-American subgroups also vary significantly. Studies in Hawaii indicated that alcohol

use by Caucasians and Native Hawaiians was comparable, but that both of these groups drank more heavily than the Japanese, Chinese, and Filipinos (Ahern 1989; Le Marchand et al. 1989; Murakami 1989). Chinese and Filipinos ranked lower than Japanese in most drinking prevalence and alcohol abuse estimates (Ahern 1989). These studies also showed that females drank far less alcohol than males and that these sex differences held true across the various ethnic groups.

In studies of drinking among Asian Americans in Los Angeles, Japanese and Filipino men were found to have the highest prevalence of heavier drinking, 29 percent compared with 26 percent among Korean men and 14 percent among Chinese men.

In studies of drinking among Asian Americans in Los Angeles, Japanese and Filipino men were found to have the highest prevalence of heavier drinking, 29 percent compared with 26 percent among Korean men and 14 percent among Chinese men (Chi et al. 1989; Kitano and Chi 1989). Kitano and Chi (1989) found that approximately 12 percent of Japanese women were heavier drinkers, 4 percent of Filipino women, fewer than 1 percent of Korean women, and no Chinese women. Those most likely to drink were men under the age of 45 and college graduates in professional or white-collar occupations living in large cities. Among this group, personal attitudes toward drinking were permissive, and friends were tolerant of drinking.

Traditionally, the Chinese approve of drinking in such defined situations as certain religious ceremonies and on festive occasions (Yu et al. 1989). Alcohol consumption is also condoned for medicinal purposes, and the Chinese have a tendency to increase this medicinal use of alcohol with age. However, excessive use is strongly condemned. Although alcoholism was practically unknown in the intact Chinese culture, Chin et al. (1991) identified it among older male Chinese immigrants in New York City, many of whom were restaurant workers. Their pathological drinking patterns developed in response to occupational pressures and easy access to alcohol on and off the job, social isolation, and family problems. Physical consequences of alcoholism in this group may be exacerbated

by the Chinese belief that alcohol has medicinal value. Entry into alcoholism treatment is delayed by the Chinese tradition of seeking help within the family, and it may be that alcoholism in the community is more prevalent than indicated by the numbers seeking treatment (Chin et al. 1991). Shared concern about the increasing use of alcohol was the basis for a joint United StatesJapan Alcohol Epidemiological Project (Clark and Hesselbrock 1988; National Institute on Alcohol Abuse and Alcoholism/National Institute on Alcoholism-Japan 1991). The purpose of the project was to compare drinking patterns and alcohol-related problems among Japanese, Japanese Americans living in Hawaii, Japanese Americans living in California, and Caucasian Americans living in California. Over the past three decades in Japan, alcohol-use patterns have changed (Clark and Hesselbrock 1988). Per capita alcohol consumption and the incidence of alcoholic liver disease have both increased. Like many other countries, Japan has experienced an increase in alcohol consumption among youth and women, population groups that did not traditionally drink alcohol. In traditional Japanese society, alcohol served an integrative function among males; this function has been extended to the business sector, where it is viewed as necessary behavior for success and essential for maintaining good human relations within a company. Drinking also has a tradition within the family. The goal of "banshaku," in which the male head of a household drinks through dinner after returning home from work, is relaxation and rest. Recently, more Japanese wives are participating with their husbands in banshaku.

Frequency of drinking among current drinkers was highest among Japanese men living in Japan, followed by Caucasians; it was lowest among Japanese American men (NIAAA/NIA-Japan 1991). Heavier drinking was most prevalent and abstinence was least prevalent among Japanese men living in Japan; Japanese men in Hawaii and Caucasian men in California reported similar alcohol intake; and Japanese men in California were least likely to drink heavily. In contrast, Caucasian women, followed by Japanese women living in Japan, made up the highest percentage of female frequent drinkers. The proportion of frequent drinkers was the same among JapaneseAmerican women in California and in Hawaii, and lower than that for Caucasian and Japanese women (Clark and Hesselbrock 1988). Japanese women living in Japan were most likely to abstain, and heavier drinking was rare among

women in all the groups. Kitano et al. (1992) found that drinking norms held by the study populations, even after controlling for age, education, and religion, were consistent with the patterns of drinking identified by Clark and Hesselbrock.

Perhaps even more than with other minorities, it is inappropriate to generalize about alcohol abuse and adverse consequences of drinking among American Indians and Alaska Natives. Although they make up less than 1 percent of the total population, the Federal Government recognizes over 300 different tribes (May 1989). Tribal social, economic, and educational customs and conditions vary tremendously, even in tribes residing in geographic proximity; these differences extend to drinking patterns, attitudes toward alcohol use, and the prevalence of alcohol-related problems. Accordingly, there are tribes that drink moderately with few problems, as well as tribes with high rates of heavy drinking and highly visible alcohol-related problems. The latter account for the fact that Indians are considered, as a group, to be problem drinkers (May 1989).

The age-adjusted alcoholism death rate for American Indians and Alaska Natives has decreased by 63 percent since its peak in 1973 of 66.1 deaths per 100,000 (Indian Health Service 1992). However, after reaching a low of 24.6 in 1986, the rate increased to 33.9 per 100,000 in 1988, which is 5.4 times higher than the U.S. alcoholism death rate for all races. Compared with Indian females, Indian males had higher alcoholrelated death rates at every age except for the 15 through 24 age group. Death rates from alcoholism peaked for the 45 through 54 age group and then decreased; alcohol-related mortality rates of 65.5 to 96.8 deaths per 100,000 have been reported for Indian males ages 35 through 74 (Indian Health Service 1992).

A common stereotype suggests that "Indians cannot hold their liquor" (May 1989). According to this stereotype, Indians are perceived as craving liquor and as being overtaken by "horrendous changes-for-the-worse" when they drink (MacAndrew and Edgerton 1969). It has been demonstrated that, unlike Orientals, Indians have no innate physiological deficits or vulnerabilities that would account for a differential, adverse reaction to alcohol (May 1989; Rex et al. 1985). Therefore, researchers have focused on social, cultural, and psychological factors to explain the disproportionately high rates of alcoholism and alcohol-related problems among Indians. Poverty and racial discrimination may be cited as causes

of Indian drinking: An ecological study was conducted in which alcohol sales data from 48 counties in Ontario were correlated with the proportion of the county population that was Indian (Adrian et al. 1991). When all counties were compared, per capita alcohol consumption was 1.11 liters higher in counties with Indian reserves than in counties without reserves; further, per capita consumption increased as the proportion of Indian reserve population increased. A multiple regression analysis including the proportion of Indian reserve population and other county characteristics such as income, employment, household crowding, type of industrial activity, northern isolation, and tourism accounted for over 60 percent of the variation in alcohol consumption between Ontario counties. The authors noted that every $1,000 increase in income was associated with a 0.297-liter reduction in per capita alcohol consumption. It was therefore suggested that establishing policies to improve the economic status of Canadian Indians would lead to a marked decrease in alcohol intake and its attendant problems in this population.

In 1986, the Indian Health Service (IHS) began to increase its efforts in the area of alcoholism prevention, and by 1988 about 300 alcohol and substance abuse treatment programs served American Indians (Rhoades et al. 1988). Several of the prevention programs developed by IHS emphasize improved self-image, value and attitude clarification, decisionmaking, and the physical and emotional effects of alcohol and other drug abuse. In an effort to reach young children and continue to provide a support system as they grow up, many prevention programs are established as Head Start programs and extend into adulthood.

The Anti-Drug Abuse Act, passed in 1986, made resources available for adolescent treatment centers and community-based pre- and postresidential care. At the same time, several tribes began actively addressing the problem of alcoholism (Rhoades et al. 1988). Thus, the development of antialcohol movements in response to high rates of alcohol problems has been taking place among Indian tribes and at the national level. The potential strength of antialcohol movements among Indians was dramatically illustrated by the experience of the Alkali Lake Band in Canada; this community recognized alcoholism as a major social, economic, and health problem and has made concerted efforts to reduce the group's high rate of alcoholism (Rhoades et al. 1988). The recent emphasis

on prevention has included providing treatment for increasing numbers of youth in the United States (Indian Health Service 1992). Outreach work was increased in 1986, and as a result the proportions of new cases in treatment increased from 22 percent in 1985 to 38 percent in 1988.

Summary

The slow decline in apparent per capita alcohol consumption that began in 1981 has continued and shows no signs of leveling off. However, current per capita consumption is still substantially higher than the relatively stable levels that prevailed during the 1950s. Adjusted per capita consumption, estimated for drinkers only, reveals that States with high abstention rates have higher per capita alcohol consumption than indicated by their unadjusted per capita consumption rates. Significant increases in abstention and decreases in heavier drinking between 1983 and 1988 were observed across a broad range of age, sex, and sociodemographic groups.

Little change in alcohol-related morbidity among patients discharged from short-stay community hospitals was noted from 1979 through 1989; however, in 1988, mortality rates from liver cirrhosis fell to their lowest level since 1951, continuing a decline that began in 1973. The proportion of fatal traffic crashes in which alcohol was involved declined from 1982 to 1990, most dramatically among drivers between 16 and 20 years old. Analyses summarizing deaths across various diseases and injuries that can be attributed to alcohol also documented downward trends in alcohol-related mortality rates from 1979 to 1988 among whites and nonwhites of both sexes.

Despite these declines, alcohol was a contributing factor in half of all fatal traffic crashes in 1990; further, alcohol-related mortality accounted for about 5 percent of all deaths in the United States in 1988. Alcohol use is associated not only with excess mortality, but also with premature mortality. Heavier drinkers die at younger ages, and estimates of years of potential life lost per individual from alcohol-related conditions such as alcoholic liver disease and fatal traffic crashes are substantially higher than those associated with conditions such as cancer and heart disease. Although no significant changes in the prevalence of alcohol-related social and other consequences from 1979 were observed in the 1984 National Alcohol Survey, attitudes toward

the acceptability of alcohol became less permissive, especially among young people.

A nationwide household interview survey indicated that in 1988 approximately 15.3 million individuals met DSM-III-R criteria for the diagnoses of alcohol abuse, or dependence, or both. Rates are higher among males than among females; they are highest in the younger age groups surveyed (18-29) and decrease with increasing age.

There has been little evidence of major changes during the past two decades in alcohol consumption or drinking problems among women in general, but changes may be occurring within certain subgroups of women.

There has been little evidence of major changes during the past two decades in alcohol consumption or drinking problems among women in general, but changes may be occurring within certain subgroups of women. For example, a recent analysis found that in younger age groups, rates for alcohol abuse or dependence in women more closely approximated those in men, with gender differences becoming increasingly pronounced with age. Reasons underlying these findings appear to be complex.

In a longitudinal study of women's drinking, factors predicting the onset of problem drinking were younger age, cohabitation, and a lifetime use of drugs other than alcohol. The most consistent predictor of persistent problem drinking was sexual dysfunction; other predictors included being employed part-time, remaining single, and experiencing recent depression. Thus, factors associated with onset of drinking problems appear to differ from factors associated with their continuation. Problem drinkers experienced lower levels of subsequent alcohol dependence after a divorce or separation, suggesting that marital difficulties may have contributed to their earlier problems.

Alcohol was the most frequently used drug among high school seniors in 1990. Despite the fact that it is illegal for most high school students to buy alcoholic beverages, almost 90 percent of high school seniors have tried them; 32 percent drank heavily (i.e., five or more drinks at a single sitting) in the 2 weeks prior to the interview; and 3.7 percent reported drinking daily. These

figures represent substantial decreases in consumption over the past decade. Considerable gender differences exist among high school seniors, college students, and young adults; in general, males consume larger amounts of alcohol and drink more frequently than females. Almost half of white, Native American, and MexicanAmerican males drank heavily in the 2 weeks prior to the interview. The prevalence of heavy drinking was significantly lower among Puerto Rican and other Latin American males and black and Asian-American males. Racial or ethnic differences among females generally paralleled those for males, but consumption rates were substantially lower.

Longitudinal studies of alcohol use investigating age-related changes have produced varying results. Taken together, however, these studies suggest that drinking patterns of middle age may be maintained into old age to a greater extent than previously appreciated and that some of the changes in drinking observed among the elderly may reflect changes taking place in society as a whole, rather than an age-specific effect. Nevertheless, late-onset alcohol abuse or dependence, which develops after years of nonproblem drinking, may be more common than previously believed. Age-related increased biological sensitivity to alcohol, late life stresses, increased discretionary time and money, and social pressure to increase alcohol consumption in some retirement settings all appear to be associated with late-onset alcohol abuse or dependence.

Increasingly, studies of alcohol use in minorities are focusing on factors that address the extent to which cultural and other factors may underlie drinking patterns and consequences of alcohol use. By identifying cultural and sociodemographic factors associated with low levels of problem drinking, research may lead to improved prevention and treatment of alcoholrelated problems among minorities. For example, research has identified distinct differences in drinking patterns of Mexican-American, CubanAmerican, Puerto Rican, and other Latin American individuals, as well as differences between foreign-born and first-generation U.S.-born persons of Hispanic heritage. Similarly, drinking patterns among subgroups of Asian Americans have been found to differ. Among American Indians, there are tribes that drink moderately with few problems as well as tribes with high rates of heavy drinking and visible alcohol-related problems. Among black women, sociodemographic correlates of abstention and heavy drinking have

been found, including age, marital status, parity, and church attendance. Surveys have identified higher abstention rates and lower rates of heavier drinking in blacks than in whites; however, higher rates of alcohol-related problems, particularly health problems, occurred among black males. Age-related differences in heavy drinking have also been identified; rates of heavy drinking peaked among younger whites and decreased with age, but in blacks heavy drinking peaked during middle age.

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