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Alcoholism is a type of substance addiction characterized by a preoccupation with alcohol and impaired control over alcohol consumption. Alcoholism is similar to illicit drug addiction in its association with physical and psychological dependence. However, as alcohol consumption is legal and socially accepted, problematic use often goes unrecognized and lacks the same social stigma as illicit drug use. Alcoholism falls into two separate but overlapping categories: dependence and abuse.

Alcohol abuse is more prevalent among youth and young adults and is characterized by binge drinking, often resulting in legal problems such as drunk driving arrests or interpersonal problems such as failure to fulfill employment responsibilities. In this entry the chronic and degenerative form of alcoholism--dependence--is the primary focus. Characterizing alcohol dependence is long-term abuse and the degradation of health caused by sustained long-term use. Onset of dependence can be slow, often taking years. The major criteria for diagnosis are increasing tolerance to the effects of use, loss of control over consumption, unsuccessful attempts to control use, continued drinking despite negative consequences stemming from use, the experience of withdrawal symptoms (the shakes, nausea) when consumption ceases, and drinking alcohol to relieve such symptoms.

The alcohol temperance and prohibition movements of the late 19th and early 20th centuries had some moderate success in framing alcoholism as a moral and social problem. Shortly after the repeal of prohibition, the foundation of Alcoholics Anonymous and the Yale Research Center played a key role in changing the definition of alcoholism from that of a personal defect and moral weakness to one based on the "disease model" that is dominant today. The American Medical Association (AMA) officially recognized alcoholism as a non-psychiatric disease in 1956. This acknowledgment was an important step in reducing the social stigma previously associated with alcoholism. The creation of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in 1971 and the passing of the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act in 1970 were instrumental in the increased proliferation of treatment and counseling services that began in the 1970s, as well as further reducing social stigma by protecting alcoholics from job discrimination.

Whereas the adoption of a disease model of alcoholism is generally viewed as a progressive development in medical science, it should also be viewed as a significant social and political accomplishment. By increasing the scope of institutions such as the AMA and giving rise to new government bureaucracies such as the NIAAA, the disease model laid the foundation for the birth of a multimillion-dollar "alcoholism industry" devoted to the scientific study and treatment of alcohol use.

Among the U.S. working-age population, an estimated 24.5 million meet the criteria for alcohol dependence, and lifetime prevalence rates among adults are between 14 percent and 24 percent. Generally speaking, rates of alcoholism decline as age increases. With respect to sex, alcoholism is at least twice as prevalent in males as females. Alcoholism is somewhat more prevalent among those of lower socioeconomic status groups and those with lower levels of educational attainment. That is, as income and education level increase, the likelihood of alcoholism decreases. Finally, with regard to race, research consistently finds higher levels of alcoholism in whites than in blacks. Prevalence among Asians and Hispanics is generally lower than in whites, whereas Native Americans generally display higher levels of both dependency and general use than other racial or ethnic groups.

Reliably identifying the causes of alcoholism is challenging. Twin and adoption studies found evidence of a hereditary predisposition, but a genetic basis for alcoholism has not been consistently established. Other research suggests that a family history of alcoholism is largely dependent on race and ethnicity. For example, alcoholism among Native American families is twice as common as among white, black, and Hispanic families. However, such research is socially controversial and widely criticized. In addition to research elucidating genetic and biological correlations, numerous social variables are also linked to alcoholism. Factors such as family structure, peer networks and the reinforcement of alcohol use, and alcohol availability are key contributors. Additionally, cognitive factors such as increased stress or strain, combined with an inadequate ability to effectively cope with emotional distress and other problems, can play a role.

The physical health risks resulting from alcoholism are numerous. Such risks include death from alcohol poisoning, heart disease, brain damage, nerve damage leading to impaired mobility, various types of liver problems, poor nutrition, severe and prolonged depression, insomnia, and sexual dysfunction. Withdrawal from sustained alcohol dependence is similar to withdrawal from heroin and is occasionally fatal. Symptoms can include nausea, severe headaches, seizures, the shakes, and hallucinations.

In terms of social health, alcohol is a major contributor to motor vehicle accidents, violence, and assaults, as well as such problems as drunk driving and public disorder. Alcoholism also correlates highly with homelessness, and research indicates that over half of the homeless population in the United States meets the criteria for alcoholism. With respect to violent crime, research consistently notes that the psychopharmacological effects of alcohol significantly increase the propensity toward aggressiveness and violent behavior, particularly among males. Research indicates that a substantial number of homicide and assault offenders are drunk at the time of their crimes. With respect to domestic violence and abuse, roughly two thirds of those who experienced violence by a partner reported that alcohol was a contributing factor. Among victims of spousal abuse specifically, roughly 75 percent of incidents involve an offender who had been drinking. Excessive alcohol use among offenders is also common in various acts of sexual assault, including rape.

Other research specifies a negative association between alcoholism and employment opportunities and wages for both males and females. Alcohol dependence also decreases the likelihood of full-time work and educational attainment. The broader social and economic costs of alcohol dependence are also substantial. The NIAAA estimates that the annual economic cost of alcoholism in the United States is approximately $150 billion. The cost includes health care for physical and mental problems related to alcoholism, abuse and addiction treatment services, and lost work potential and productivity.

Economists and other researchers strongly criticize the NIAAA cost estimates in the areas of medical care, social services, and lost productivity, asserting that estimates in the hundreds of billions of dollars are grossly overstated. Still, even using conservative estimates, alcoholism is one of the most widespread and costly substance abuse problems in the United States. With the exception of nicotine addiction, alcoholism is more costly to the United States than all drug problems combined.

Bibliography:

1) Heien, David. 1996. "The External Costs of Alcohol Abuse." Journal of Studies on Alcohol 57:336-42.

2) National Institute on Alcohol Abuse and Alcoholism. 1998. "Drinking in the United States: Main Findings from the 1992 National Longitudinal Alcohol Epidemiologic Survey." Rockville, MD: NIAAA.

3) National Institute on Drug Abuse. 1997. "The Economic Costs of Alcohol and Drug Abuse in the United States, 1992." Rockville, MD: NIDA.

4) Schneider, Joseph W. 1978. "Deviant Drinking as a Disease: Alcoholism as a Social Accomplishment." Social Problems 25:361-72.

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