Challenging Dogma - Fall 2008

Sunday, December 14, 2008

One Finger Points, Three Point Back- Sarah M. Ragsdale

An estimated 6-percent of middle-aged men abuse alcohol – nearly four times greater than women and twice the rates of just one decade prior (37, 38). Due to the social, economic and physical effects of alcohol abuse, the public health community must improve its strategies to reduce the prevalence of alcohol abuse among all populations. Specifically, many criticisms of the public health community’s strategies to reduce alcohol consumption among middle-aged men are presented. The public health community has failed to adequately measure the problem, study the populations at-risk and intervene effectively. Population stigmatization and confusion result from the individualistic approaches to interventions among middle-aged men.

Failure to Measure

The first major limitation of the public health community’s approach to address the problem of alcohol abuse exists in the existing definitive measures of the problem. The problem of alcohol abuse is largely defined in terms of overall consumption and other quantitative measures. Healthy People 2010 “set the national objective for reducing per capita alcohol consumption to no more than 1.96 gallons ethanol, … a decrease of 12.5 percent, or about 3 percent per year from 2006 through 2010” (1). It is problematic to measure alcohol abuse by per-capita consumption or overall deaths by alcohol-related diseases because population-level measures do not allow for the detections of “subtle and complicated relationships,” which can lead to underreporting (2 p. 163); therefore, requiring flawed individual assessments.

Addressing the first point, when alcohol epidemiologists measure alcohol in the aggregate of per-capita consumption or deaths by cirrhosis of the liver, only correlation, not causality, can be inferred. Relying on the “three primary sources” of alcohol data (death certificate data, the Fatal Accident Reporting System, and the National Hospital Discharge Survey) limits understanding of the problem (3). Although defined as objective, data from death certificates present inherent flaws as “sympathetic certifiers” of the cause of death may enter non-alcohol-related codes to protect the individual’s reputation (3). This often leads to underestimates of the problem’s true prevalence in all populations.

Due to the limitations of data collected in terms of overall consumption or deaths, additional individual-level data must be collected to understand possible relationships. Of six national surveillance studies sponsored by the Centers for Disease Control (CDC), all assess only volume consumed in a given time frame (5). This is problematic because, again, alcohol consumption measurements are often in terms difficult for all consumers to relate and self-quantify. Using a graduated frequency scale of mean consumption per day, week or month proves to be less effective than other approaches, which impacts accuracy of reports (6). The primary method for data collection is what the National Institute of Alcohol Abuse and Alcoholism (NIAAA) sadly describes as the “newer and improved” approach of self-reported questionnaires. These flawed assessments further contribute to the failure to definitively measure alcohol abuse. Surveys, in their effort to quantify the problem, are often skewed by limited sample sizes, increased margins of error, failures to properly sample minority populations, underestimate consumption and under-sample heavy drinkers (3). Marks discusses the problem of “inappropriateness in framing the questions” (4, p. 15) as yet another threat to the study of this public health problem.

Failure to Study the Population

Not only has the public health community failed to develop definitive measures of the problem of alcohol abuse, it has failed to study the root causes of the problem among populations, including middle-aged men. This failure results from the reliance on quantitative and biomedical models to study treatment and prevention, virtually ignoring possible qualitative and social science approaches.

According to the NIAAA’s suggestions for improving treatment and prevention in the middle-aged population, new research opportunities should focus on developing new medications for craving control and organ injury prevention (8). They note most research on the topic has “focused on how alcohol damages body tissues,” and they secondarily note “research shows that a variety of factors—both biological and social— influence an individual’s response to therapy” (8). Focusing greater attention on biologic factors over social factors in research presents the missed opportunity to employ the social sciences (8).

The NIAAA discusses the overlook of social science methods in its strategic plan by outlining the need to “identify biological factors and contextual social factors that contribute to the decisional process to change drinking behavior as part of the transitional process from alcohol dependence to recovery” and “increase understanding of the role of social context in promoting positive change in drinking behavior” (9). Although this suggestion is slightly better, it still does not address primary prevention as it incorporates social science techniques in response to relapse alone. The NIAAA also notes “naturalistic, qualitative and longitudinal studies can identify factors influencing natural history and disease course, in order to inform more explanatory studies” (9). The idea of contextualizing risk factors is supported by Link, et al when they advocate for a shift in the assessment of public health problems as “social factors have received far less attention” and suggest “fundamental causes” and “social patterning” of disease (10, p. 80).

According to Marks, “health is a “multivariate construct that lends itself to interdisciplinary approach” (4, p. 10) therefore, understanding alcohol abuse from a social perspective, allows for more effective study of target populations particularly. The NIAAA “recognizes the need to support research that focuses on client populations as well as research on the aggregate population” (11). Doing so, according to the NIAAA, “could provide meaningful insight to guide the development of more effective strategies to change individual behavior to improve health” (11). However, when studying specific populations, alcohol researchers have focused much effort on underage drinking and college student drinking patterns, making the middle-aged population much less of a priority (34). The reasons for this are complex. It appears the public health community views alcohol abuse as a socially and environmentally modifiable “risky behavior” during youth (9); however, when the population ages, it is seen as chronic or genetic - only modifiable by drug treatment and therapy (12). With such frame, focus naturally gravitates toward the development of treatments as opposed to interventions. If alcohol abuse is viewed in the same context as HIV, it is clear that “there is an epidemic beneath the epidemic we know about” (13, p. 69) as the public health community has failed to understand the root social causes of alcohol abuse among middle-aged men.

Failure to Intervene

The public health community’s individualist approach to alcohol abuse among middle-aged men is reflected in the measurement and study of the problem as well as the approaches to intervene. Since “the goal of public health research is to provide a scientific basis for the development of effective strategies to improve health status” (7, p. 1175), it is not surprising public health has over looked alcohol abuse at the social-level resulting in population confusion and stigmatization.

Social-level interventions

The NIAAA discusses in its strategic plan many methods to reduce alcohol abuse among middle-aged men, focusing on drug treatment and individual behavior change (9). The NIAAA advocates for various models including the Transtheoretical Model (Stages of Change), Cognitive-Behavioral Therapy, and Motivational Enhancement (9), but makes no mention of various social theories and approaches. Although many structural-level policies exist to combat underage and college student drinking, few exist that specifically target middle-aged or male populations (34). The same can be said for community-level social interventions. Of the six “effective” prevention programs the NIAAA lists, zero target adult populations (34).


Public health professionals have historically plagued the community with mixed messages on many primary prevention fronts resulting in public confusion. Don’t have sex before marriage, but if you do, use a condom. Don’t use drugs, but if you do, recycle your needles. Don’t drink underage, but once you are of age, go for it. Don’t drink and drive, but if you don’t drive, then drink. Alcohol is bad for you, but alcohol is good for you. How is the public to synthesize this information? The CDC defines heavy drinkers as consuming one or more drinks daily (14), while Men’s Health Magazine reports alcohol to be “fine in moderation” (15) and “the recommended safe intake for men is around three units of alcohol a day. That is 21 units per week.” (16). Although Men’s Health is not a peer-review scientific magazine, it is accessible and accepted by many adult men who may internalize it guidelines over the CDC fact sheets. The popular media messages and some scientific data are clearly counter to the messages from public health organizations which often declare alcohol as unsafe in any quantity or frequency.

Public health organizations have received criticism for exaggerations of risks associated with alcohol abuse, leading some to be classified as neo-prohibitionist. The Center on Addiction and Substance Abuse (CASA) was sharply criticized by representatives from the American Beverage Licensees and the Chronicle of Higher Education by its efforts to “paint the most alarming picture possible" (17) resulting in “denounce(ing of) responsible consumption (of alcohol) with half-baked advocacy disguised as real research." (18). The Washington Times criticized Mothers Against Drunk Drivers (MADD) in much of the same way by declaring that MADD's "ongoing push to compel states to adopt ever-lower standards for being legally drunk‚ is becoming a prohibitionist jihad driven by hysteria, not medical reality" (19). Even the American Medical Association (AMA) is not free of criticism as many question the rationale for never rejecting their resolution in support of prohibition in the 1920s (17).


Stigmatization is a side effect of the public health community’s alarming alcohol messages as well as the individualistic frame of alcohol abuse. Alcohol abusers were “viewed more harshly” by peers than even the heavily stigmatized mentally ill according to one study’s findings (20). Stigmatization is further illustrated by the skewing of death records by “sympathetic certifiers” as mentioned previously. The same study noted that if the individual is viewed as responsible for their alcohol abuse problem, their peers tended to place blame and viewed them as “dangerous” and “feared and avoided them” (20).

This is even more problematic when alcohol abuse is considered with mental illness. The mentally ill are already marginalized, which compounds barriers to treatment of mentally ill alcohol abusers. As noted in tobacco research which concludes “these people are already stigmatized by their underlying psychiatric condition - Adding the further burden of the stigma associated with smoking makes it even harder for them to achieve the wellness that they and their families seek” (21 p. 2286). One study concluded that “those in treatment for alcohol or drug problems are frequently and disproportionately marginalized” (25). Just as was shown in smoking research the “risk of the marginalization of smoking is that it further isolates the group of people with the highest rates of smoking – persons with mental illness, problems with substance abuse, or both” (21). Cohen, et al describe social isolation as a health risk “comparable to the risks associated with cigarette smoking, high blood pressure and obesity and is robust even after controlling for these and other traditional risk factors” (40). Hence, it is no surprise as result that 42-percent of alcohol addicts had “bad opinion of health services” (25) resulting in missed treatment and intervention opportunities.


Public health practitioners can be our own worst enemy when it comes to assessing and preventing public health problems. In the case of alcohol abuse, the public health community has failed to adequately measure and the problem through failed epidemiologic measures and assessment methods. The public health community’s failed intervention and communication strategies have further confused, stigmatized and negatively impacted the screening and treating of alcohol abuse among middle-aged men.

Silver Lining:
Public Health Solutions to a Public Health Failure

In light of the many existing criticisms of the public health community’s strategies to reduce alcohol abuse among middle-aged men, several solutions are possible. In order to address the epidemiological problem of flawed definitive measures of alcohol consumption and abuse, improvements to data collection measures are necessary. Next, techniques from social epidemiology are necessary to address the failure to study the underlying reasons for alcohol abuse. Finally, the failure to develop successful interventions is addressed through approaches from Social Network Theory and Social Marketing Theory, which address the individual-level bias and stigma associated with alcohol abuse in this population.

Failure to Measure - Solutions

In order to address the failure to definitively measure alcohol abuse, the very epidemiologic approaches of assessment require improvement. The first proposal is to improve the way consumption data is collected on individuals. The second is to look at the overall social effects of alcohol abuse.

Since population-level data can lead to the underreporting of alcohol abuse, individual-level assessments are necessary to understand and define the scope of the problem. Strunin addresses many of the problems associated with the public health community’s methods to collect data on alcohol abuse when noting “valid reports of drinking has been controversial in alcohol studies” (30). She points out that many estimates of alcohol abuse “rely on accuracy of self-report data” that can “deny or deliberately deceive reports of behavior” (30); however, much can be done to improve instruments of measurement.

One improvement is to use improved questionnaires to fill in the knowledge gaps of consumption data. Some suggested improvements to questionnaires from the literature range from using diary methods and improving survey questions and their ordering (27, 28, 29). Another improvement that Strunin and others note is the use of beverage-specific measures (6, 30). The most compelling improvement from her work is the use of “multidisciplinary approaches” and “ethnographic interviewing and other qualitative methods in assessing alcohol use” (30). This approach is particularly useful to measure specific populations such as middle-aged men.

By focusing on measures such as volume of ethanol consumed and death by cirrhosis of the liver, the public health community misses other big picture strategies to measure the problem of alcohol abuse. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) lists “social problems resulting from alcohol abuse” as an “area of interest” but underscores that researchers rely on “more objective sources” (3). However, many quantifiable social problems result from alcohol abuse in the middle-aged population including failure of work obligations, legal problems, divorce, marital violence, child abuse and other crimes (26). Although it is difficult to develop measures of association, the failure to examine social effects to measure alcohol abuse among populations is clearly a missed opportunity to assess population-specific alcohol consumption.

Failure to Study - Solutions

With solutions to correct the public health community’s failure to develop definitive measures to effectively assess alcohol abuse, it is important to improve the strategies in studying the root causes of alcohol abuse among middle-aged men. The present methods in studying the individual risk factors for alcohol abuse can be improved by the conceptualization of risk factors in the social epidemiologic approach.

The NIAAA reports many causes of alcohol abuse among middle aged men including a gene influencing consumption (31), depression (32) anxiety (33) and family history (34). These conclusions ignore many social factors, which is not surprising as they result from the heavy reliance on the biomedical model. They also possibly result from the Type III error of epidemiology by “providing the right answer to the wrong question” (7). This error results from the “discrepancy between the questions being asked and the methods used to address the question” (7, p. 1175). The “evident” failure of epidemiologists to recognize many social factors (35. p. 110) results from what Schwartz lists as “value-laden considerations” that “limit the realm of inquiry” (7, 1175). This error, however, can be minimized by replacing this individualistic risk factor epidemiology with social epidemiology.

To combat “biomedical individualism,” social epidemiology studies social determinants as root causes of disease (36, p. 22). Instead of adjusting for social factors in the analysis phase of study design as possible confounders, social factors are the “focus of analysis” (36 p. 22). In order to review possible social risk factors, cultural context would first need to be assessed through both anthropologic and epidemiologic approaches. Then, social networks would be reviewed to map relationships and normative behavior among alcohol abusive individuals to identify a possible “core group” (36). Next, neighborhood effects would be studied to view the interaction of social networks in their cultural and geographic context – paying attention to poverty, marginalization, social isolation, etc. Finally, social capital would be measured. After reviewing social factors, structural risk factors require analysis. Adequate structural analysis would review demographic changes, violence and discrimination, legal structures and policy enforcement (36).

Failure to Intervene – Solutions

Along with the failure to study and definitively measure alcohol abuse, the public health community has failed to develop social-level interventions for alcohol abuse among middle-aged men. Confusion and stigmatization of the population result from this failure. This can be corrected in two ways. The first is to employ social-level techniques including Social Network Theory. The second is to use Marketing Theory to disseminate accurate information to the public, reduce stigmatization of the population, and change social norms.

Social Network Theory

The goal of social epidemiology is to reveal the underlying social networks that influence behavior. Once these are revealed, the Social Network Theory can be applied to develop social-level interventions. The effects of social networks are illustrated in research on smoking cessation. In the predominantly middle-aged population studied, researchers found that smokers quit “in concert” (41). Isolated individuals did not influence decisions to quit smoking, but rather it was social ties to other smokers and non-smokers (41). If results translate to the same population of alcohol abusers then specific social networks can be studied and successfully intervened upon.

Marketing Theory

Ether defines social networks as predictors of the “formation of public opinions” (39); therefore, marketing to specific social networks effectively alters social norms and attitudes. This is important for alcohol abuse among middle-aged men because “social networks can be especially important in the construction of a person’s reputation” (39). As discussed previously, barriers to treatment result from the stigmatization and social isolation of the population so a shift in perception of reputation can reduce stigmatization.

Aside from reducing the stigmatizing effects of alcohol abuse among middle-aged men, marketing theory accomplishes health behavior change because media is “a major source of patterned social expectations about the social organization of specific groups in modern society.” (42). The basic idea is to make a promise to mass media consumers and support that promise with visual images and a consistent message. If applied correctly, this strategy will identify what the population aspires to be and will offer that to them.

Marketing theory views groups differently than a collection of individuals based on group dynamics. DeFleur and Ball-Rokeach note the individual-level treatment interventions such as those suggested by NIAAA offer a “very incomplete picture of the human condition” because human beings act in an “intensely social nature.” (42, p. 219). This allows for the idea that groups of middle-aged men can be affected at the same time through a mass media message. Due to the group focus, it recognizes the many layers of influence on the individual. This addresses the flaw of the NIAAA models as they “fail to account for real-world cognition” (4, p. 8) by falsely assuming an internal locus of control and free choice. They also assume that behavior is “not restrained by political or social factors” (4, p. 8) many of which are portrayed through mass media. People are powerfully influenced by “accumulated exposure to media content” as “indirect influences on culture and society” (42, p. 206).


The failures of the public health community to address alcohol abuse among middle-aged men are clear; however, the solutions are promising. This paper does not suggest tossing out the window current epidemiologic approaches to measuring and studying the problem in this population, but does present clear opportunities to incorporate the social sciences and qualitative approaches. Theories with roots at the social level offer promising solutions to the failed individualist intervention attempts.


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