## June 2000

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health National Institute on Alcohol Abuse and Alcoholism 

### From the Secretary of Health and Human Services 

# HIGHLIGHTS FROM CURRENT RESEARCH 

# 10th 

# Alcohol and Health Special Report to the U.S. Congress oni 

# Table of Contents

Foreword

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### Preface

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### Introduction

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### Acknowledgments

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### Chapter 1: Drinking Over the Life Span: Issues of Biology, Behavior, and Risk

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Measuring the Health Risks and Benefits of Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Risks and Benefits of Alcohol Consumption: Physical Health . . . . . . . . . . . . . . .4 Psychosocial Consequences and Cognitive Effects . . . . . . . . . . . . . . . . . . . . . . .11 Effects on Society of Alcohol Use: Injuries and Violence . . . . . . . . . . . . . . . . . .12 Assessing Risks and Benefits: Mortality, Morbidity, and Disability . . . . . . . . . . .13 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Alcohol Involvement Over the Life Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Understanding the Age Progression of Alcohol Involvement in Childhood and Later Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Developmental Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Social Contexts and Drinking Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Changes in Patterns of Drinking Behavior as a Function of Social Change . . . . .40 Development and Drinking Behavior: Dynamic Models of Stability and Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

Alcohol and Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Individual-Level Studies: Drinking by Offenders . . . . . . . . . . . . . . . . . . . . . . .55 Individual-Level Studies: Drinking by Victims . . . . . . . . . . . . . . . . . . . . . . . . .58 Environmental Influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 Theoretical Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63ii Tenth Special Report to Congress on Alcohol and Health 

### Chapter 2: Alcohol and the Brain: Neuroscience and Neurobehavior

. . . . . . . . . . . . . . . . . . 67 Setting the Stage: The Structure and Function of Neurons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .69 Structure and Function of Neurons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 Communication Within and Between Neurons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 Neurotransmitters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77

From Cell Membrane to Nucleus: The Effects of Alcohol on Brain Neurons . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .78 Alcohol’s Effect on Synaptic Transmission During Acute Exposure . . . . . . . . . . . . . . . . . . . . . . . . . .78 Alcohol’s Effects on Protein Phosphorylation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 9 Long-Term Exposure to Alcohol: Gene Expression, Protein Phosphorylation, and Protein Localization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85

Acute Actions of Alcohol on the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .89 Measuring Alcohol’s Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89 Alcohol and Ion Channels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Alcohol and Neurotransmitter Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101 Neurobiological and Neurobehavioral Mechanisms of Chronic Alcohol Drinking . . . . . . . . . . . . . . . . . . . . . . . . .107 Reinforcement and Reward in Chronic Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107 Insights Into Features of Alcoholism From Animal Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108 Alcoholism and the Neural Structures of Reward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 Neurochemical and Molecular Adaptations to Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115 Alcoholism: Lasting Changes in the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 9 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123 The Neurotoxicity of Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134 Neuropathologic Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134 Morphological Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135 Functional Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138 Mechanisms of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142

Genetic Studies of Alcohol’s Actions on the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .147 Development of Animal Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .147 Investigation of Candidate Genes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149 Immediate Early Genes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155Table of Contents

iii 

### Chapter 3: Genetic and Psychosocial Influences

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Animal Genetic Studies on Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .160 Quantitative Trait Loci . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .160 Creating Rodent Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .161 Quantitative Trait Loci Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .165 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166 Recent Progress in the Genetics of Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .169 Findings From Twin/Family Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Findings From Genetic Linkage Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 3 Findings From Genetic Association Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 5 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177
Psychosocial Factors in Alcohol Use and Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181 Family History of Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181 Developmental Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186 Motivation To Drink . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187 The Role of Cognition: Beliefs About Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .190 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191


### Chapter 4: Medical Consequences

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Alcohol-Induced Liver Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198 Alcoholic Liver Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198 Preventing Liver Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .202 Nutritional Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .202 Other Liver Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .204 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207
Alcohol and the Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .214 Alcohol and Diseases Related to the Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .214 Diseases Related to Immunodeficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .214 Diseases Related to Autoimmunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215 The Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .216 Changes in the Immune System of Alcoholics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217 Experimental Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .219 Current Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .222 Therapeutic Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .226iv Tenth Special Report to Congress on Alcohol and Health

Alcohol’s Effects on the Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240 The Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .240 The Vascular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .244 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248

Alcohol and Women: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .253 Health Consequences of Alcohol for Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .253 Physiologic Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .254 Liver Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .255 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .256 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .256 Alcohol and the Skeletal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .258 Research Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .258 Alcohol-Induced Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .259 Alcohol-Induced Osteopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .260 Bone Histomorphometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .261 Potential Mechanisms of Alcohol-Induced Bone Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .262 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .266 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .266

Alcohol and Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273 Age, Genetics, and Other Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 Menopausal Status and Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 74 Mechanisms of Alcohol-Related Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .275 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .278


### Chapter 5: Prenatal Exposure to Alcohol

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 Prenatal Alcohol Exposure: Effects on Brain Structure and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .285 Diagnosing the Effects of Prenatal Alcohol Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .285 Neuroimaging: Precise Pictures of Structural Damage to the Brain . . . . . . . . . . . . . . . . . . . . . . . .287 Physical Measures of Altered Brain Function: Cry Patterns and EEG’s . . . . . . . . . . . . . . . . . . . . . .289 Effects on Cognitive and Motor Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .290 Effects on Mental Health and Psychosocial Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .294 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .295 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .296Table of Contents

v Underlying Mechanisms of Alcohol-Induced Damage to the Fetus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .300 Challenges to FAS Research: Multiple Mechanisms, Sites of Action, and Risk Factors . . . . . . . . . .301 Candidate Mechanisms for Central Nervous System Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . .302 Candidate Mechanisms for Craniofacial Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .309 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .310 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .310 Issues in Fetal Alcohol Syndrome Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .323 Reviews of Prevention Programs and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .323 Methodological and Evaluation Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .325 Reaching to All, Regardless of Risk: Universal Prevention Approaches . . . . . . . . . . . . . . . . . . . . . .326 Targeting Those at Increased Risk: Selective Prevention Approaches . . . . . . . . . . . . . . . . . . . . . . .327 Helping Those at Highest Risk: Indicated Prevention Approaches . . . . . . . . . . . . . . . . . . . . . . . . .329 International Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .331 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .332 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .332



### Chapter 6: Economic and Health Services Perspectives

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Effects of Changes in Alcohol Prices and Taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .341 Public Policies and Alcohol Prices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .341 Alcohol Prices, Taxes, and Consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 2 Alcohol Taxes and Traffic Fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .346 Alcohol Demand and Marijuana Demand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .348 Benefits and Costs of Taxation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .349 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .351 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .352

Cost Research on Alcoholism Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .355 Past Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .355 Recent Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .356 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .361 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .361vi Tenth Special Report to Congress on Alcohol and Health

The Economic Costs of Alcohol Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .364 Distribution of the Burden of Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..365 Components of the Costs of Alcohol Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .366 Limitations and Caveats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .369 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .370



### Chapter 7: Prevention Research

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373 Reducing Alcohol-Impaired Driving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .375 Recent Trends in Alcohol-Related Traffic Fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 7 Legislative Efforts To Reduce Alcohol-Impaired Driving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .378 Enforcement of Impaired-Driving Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .386 Comprehensive Community Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .386 Alcohol Control Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .387 Individual Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .389 Safety Belt Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .390 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .391 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .391
Community-Based Prevention Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .397 Community Prevention for Heart Disease and Health Promotion: A Precedent . . . . . . . . . . . . . . .397 Methodological Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .398 Recent Research Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .399 Commentary and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .405 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .408 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .408
Alcohol Advertising: What Are the Effects? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .412 Background: The Frequency and Content of Advertising Messages . . . . . . . . . . . . . . . . . . . . . . . .413 Does Alcohol Advertising Affect Drinking or Drinking Problems? . . . . . . . . . . . . . . . . . . . . . . . . .414 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .422 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .423Table of Contents

vii 

### Chapter 8: Treatment Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427 Screening and Brief Intervention for Alcohol Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .429 Screening for Alcohol Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .429 Brief Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .432 Areas for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .437 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .439 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .439 Treatment of Alcohol Dependence With Psychological Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .444 Client-Treatment Matching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .444 Professional Treatment Modeled on the 12 Steps of Alcoholics Anonymous . . . . . . . . . . . . . . . . . .445 Supportive Ancillary Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .446 Intensity of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .448 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .448 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .449
Treatment of Alcohol Dependence With Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .451 Medications for Alcohol Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 52 Medications for Patients With Both Alcoholism and Depression . . . . . . . . . . . . . . . . . . . . . . . . . .457 In Closing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .458 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .458



### Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463ix 

# Foreword

I am pleased to present the Tenth Special Report on Alcohol and Health to the U.S. Congress, and through them to the American people. Alcohol problems, both those of individuals and those that affect society at large, continue to impose a staggering burden on our Nation. Domestic violence, child abuse, fires and other accidents, falls, rape, and other crimes against individuals such as robbery and assault—all are linked to alcohol misuse. Alcohol misuse also is implicated in diseases such as cancer, liver disease, and heart disease. Although often not aware of it, everyone shares a portion of this burden. For example, an estimated 20 to 40 percent of patients in large urban hospitals are there because of illnesses that have been caused or made worse by their drinking. This means that out of every 100 patients in such hospitals, almost half may be there because of their alcohol use. Each of us shares the price of these illnesses through rising health care costs. Because one in four children under the age of 18 lives in a household with one or more family members who are alcohol dependent or who abuse alcohol, our Nation will continue to be robbed of its future. As these children grow up, they too will be at risk for continuing the cycle of alcohol abuse and dependence that has plagued too many of our citizens for too long. As overwhelming as these facts are, the real tragedy is that many people do not yet understand that alcohol problems can yield to scientific investigation and medical intervention in the same way as other health conditions, and in many cases more successfully. The research findings presented in the Tenth Special Report to the U.S. Congress on Alcohol and Health clearly demonstrate that continued support for alcohol research, and the use of findings from research in prevention and clinical applications, offer the best hope for reducing the costs we all pay for alcohol problems. I commend it to your attention.

Donna E. Shalala Secretary U.S. Department of Health and Human Servicesxi 

# Preface

During the latter half of the twentieth century, we witnessed an unparalleled era of progress in medical science. Among other important scientific advances, we discovered the genetic code and are well on our way toward mapping the entire human genome, we began to explore how our brains work in concert with other body systems to promote or to impede health, and we developed increasingly sophisticated medical devices and technologies that allow us to look at the actual functioning of the myriad systems that make up human beings.

The Tenth Special Report to the U.S. Congress on Alcohol and Health presents significant new scientific findings about alcohol abuse and alcoholism since the last Special Report, issued in 1997. These findings clearly demonstrate that alcohol investigatorsworking in fields as diverse as epidemiology, genetics, neuroscience, toxicology, prevention, and treatment are using the very latest tools and techniques of science to expand our knowledge of how to prevent, reduce, and treat alcohol problems. Because alcohol use problems exact such a personal, social, and economic toll on the American people—an estimated 100,000 lives and $184.6 billion annually—the scientific progress described in the Tenth Special Report is heartening. As important as this progress is for those whose lives have been affected by alcohol use, I believe that the Tenth Special Report serves a greater purpose. Science does not happen in a vacuum. Rather, it is a cumulative process that builds upon theknowledge developed by many scientists working in many different areas of investigation. Therefore, what is discovered about one disease or health condition may very well provide important clues about other diseases and conditions, clues that will help in the development of medications, treatments, and preventive approaches that can be widely applied. Because alcohol affects virtually all body systems and because alcohol use problems affect all levels of human interaction, the alcohol research field represents, in many respects, a microcosm of science in its entirety. Thus, the findings described in the Tenth Special Report about genetics, neural circuitry, the effect of the environment on gene expression, fetal development, cognition, psychological therapies, prevention and education, and treatment contribute significantly to the knowledge we need to solve not only the problems associated with alcohol abuse and alcoholism, but also the problems of human biology and behavior in general. I would like to commend the scientists who participated in the development of the Tenth Special Report and the staff of the National Institute on Alcohol Abuse and Alcoholism for their efforts to bring this important information to the attention of the U.S. Congress and the American people.
Ruth Kirschstein, M.D. Acting Director National Institutes of Healthxiii 

# Introduction

The first Special Report on Alcohol and Health was presented to the U.S. Congress in 1971. In that report, and in each subsequent one, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) summarized for the Congress—and the American people—the cumulative body of alcohol research findings in each area of investigation. For this, our 10th edition of the Special Report, we found ourselves in a pleasant, if somewhat daunting, position. The breadth and scope of alcohol research has grown so tremendously that summarizing the total body of alcohol research in one document is no longer manageable; so we have chosen to present the findings from alcohol research in a new way—to summarize what is known in a particular area and to describe in greater detail significant research findings that have been reported since the Ninth Special Report . And, in the best tradition of the Special Reports on Alcohol and Health
, this 10th edition continues to provide both extensive information on alcohol use problems and ample cause for hope that we are well on the way to preventing and effectively treating them. Alcohol is widely used in our society. Most individuals who use alcohol drink in ways that do not increase risk for alcohol use problems. Some, however, drink in ways or at times during their life course that increase risk to themselves or others. Still others who use alcohol may derive a health benefit from its use. Defining precisely who is at risk for alcohol use problems and assessing the risks versus benefits of alcohol use are the first steps toward providing accurate public health information and designing effective interventions to reduce alcohol use problems. The Tenth Special Report presents important new findings about biological and behavioral factors that affect the risks and benefits of drinking over the life span. Perhaps the single greatest influence on the scope and direction of alcohol research has been the finding that a portion of the vulnerability to alcoholism is genetic. This finding, more than any other, helped to establish the biological basis of alcoholism. It also provided the basis—and justification—for much of the progress in genetics, neuroscience, and neurobehavior described in the Tenth Special Report . Today we know that approximately 50 to 60 percent of the risk for developing alcoholism is genetic. Genes direct the synthesis of proteins, and it is the proteins that drive and regulate critical chemical reactions throughout the human body. Genetics, therefore, affects virtually every facet of alcohol research, from neuroscience to Fetal Alcohol Syndrome. It is clear from the findings presented in the Tenth Special Report thatalthough much remains to be discovered, progress has been made toward understanding how genes are involved in the etiology of alcohol use problems, including how genes interact with other genes and with the environment to produce disease. The progress made in the neurosciences over the last two decades has been spectacular.Alcohol investigators have taken full advantage of this progress by applying neuroscience techniques to the study of alcohol use problems. As a result, our understanding of the neural processes that underlie alcohol-seeking behavior and of how alcohol’s actions in the brain are related to the phenomenon of addiction has grown dramatically. Recent progress in neuroscience research described in the Tenth Specialxiv Tenth Special Report to Congress on Alcohol and Health
Report has yielded information critical to characterizing some of the cellular and molecular processes involved in alcohol use and has helped associate these processes with the behavioral and physiologic manifestations of alcohol use and abuse. One important tool used in both genetics and neurobehavioral research is the animal model. Alcohol scientists have applied molecular biology techniques to develop a number of important animal models that allow the study of the genes associated with traits that might influence alcohol-related behaviors. Findings from studies using both vertebrate and nonvertebrate animal models and other study results concerning the etiology of alcohol use problems are discussed in the Tenth Special Report

. Although the toxicology of alcohol—how alcohol damages the body—was one of the first areas in alcohol research to be studied, the acceptance of the biological foundations of alcoholism and the subsequent increase in alcohol-related biological research helped to focus scientific attention on the mechanisms by which this damage occurs. As described in several chapters of the Tenth Special Report , alcohol research scientists have uncovered new information about the kinds of damage that alcohol exposure can cause to the brain, both during prenatal development and later in life,and to other major body organs. More important, there is a very good accounting of the progress that alcohol scientists have made toward understanding how this damage occurs. It is knowing the “how” that has the potential to produce therapeutic interventions to limit or ameliorate many of the alcohol-related health consequences. Limited in the past, research on prevention is coming into its own. The findings from prevention research applied to various public policies already have been shown to save lives. New approaches to school-based and community prevention are demonstrating that well-planned prevention programs based on rigorously studied and validated models can reduce the magnitudeand extent of our Nation’s alcohol-related problems. Prevention research is also examining the role that advertising plays with respect to alcohol use and abuse. The main goal of alcoholism treatment is to help alcoholics maintain sobriety. The Tenth Special Report highlights the progress that has been made toward developing both behavioral strategies and medications to help achieve this goal. Some of the most compelling questions about treatmenthave to do with factors that help to make treatment services effective. Some studies haveshown significant reductions in drinking following treatment with extensively tested and refined behavioral therapies. Other strategies, involving brief interventions in primary care settings, haveproved to be effective in reducing alcohol consumption in persons drinking at levels associated with negative health consequences. Because many individuals continue to experience problems with alcohol after treatment, there is a need to further improve treatment efficacy. One of the principal payoffs of biological research in genetics and neuroscience is the potential for developing medications to treat a variety of alcohol use problems. Neuroscience research already has provided the groundwork for new medications for treating alcoholism. Researchers now are looking for new medications that target the mechanisms of the addiction itself, such as drugs that interfere with the reward properties of alcohol or craving, which are thought to be major factors in relapse. It is likely that no one medication will be effective for everyone nor that there will be the proverbial “silver bullet” of pharmacotherapies for alcoholism. Just as there are different types of medications with different mechanisms of action to treat complex diseases like diabetes, it is likely that there will be a range of medications, coupled with verbal therapies, available to clinicians. Last, like everyone else during this ending of one century and beginning of a new century, I would like to share my thoughts on where we are heading in alcohol research. Finding the genesfor alcoholism is probably one of the most important goals in alcohol research. However, it is theIntroduction

xv beginning of the story rather than the end. For this information to be of practical use, we must understand how biology and behavior interact to produce disease. There is a welcome trend in the alcohol field toward reciprocal work between the biological and behavioral sciences. The potential success of this type of collaboration has been well demonstrated by major research efforts such as the Collaborative Study on the Genetics of Alcoholism, which involved both biological and behavioral science and scientific principles. Other examples of this type of work can be found in research on the effects of alcohol on the fetus, where there are excellent behavioral studies of children with Fetal Alcohol Syndrome and other alcohol-related birth defects as well as detailed information from imaging studies about the tremendous structural changes in the brains of children exposed to alcohol in the womb. We also are learning about the proper connectivity among neurons. In this work it appears that alcohol actually prevents the appropriate expression of certain genes. The trend toward studying the whole human animal, not just its genetic or neural parts, will continue to be advanced, I believe, by a rejection of the “reductionist” view, which seeks to define humankind in terms of its genes, and acceptance of the tenet that genes are not (or even mostly) destiny, just as humankind is not just the sum of its neurons and circuits. That we are continuing to expand our knowledge of alcohol use problems is clear from the material presented in this Special Report. The scientists,and the NIAAA staff who have worked so diligently to present the Tenth Special Report to the Congress, have my thanks for their efforts. The task now for each of us who is concerned about the impact of alcohol abuse and alcoholism on our society is to accelerate the pace of research that has enabled us to come this far to ensure that the new millennium brings new successes.
Enoch Gordis, M.D. Director National Institute on Alcohol Abuse and Alcoholismxvii 

# Acknowledgments

Mary Jane Ashley, M.D. Department of Public Health Sciences Faculty of Medicine University of Toronto Addiction Research Foundation Mental Health Services Corporation

of Ontario Toronto, Ontario, Canada Gregory Bloss, M.A. Division of Biometry and Epidemiology National Institute on Alcohol Abuse

and Alcoholism Bethesda, Maryland Susan J. Bondy, Ph.D. Department of Public Health Sciences Faculty of Medicine University of Toronto Addiction Research Foundation Mental Health Services Corporation

of Ontario Toronto, Ontario, Canada
Laurie A. Chassin, Ph.D. Department of Psychology Arizona State University Tempe, Arizona
Robert T. Cook, M.D., Ph.D. Pathology and Laboratory Medicine VA Medical Center and University

of Iowa Iowa City, Iowa
John Crabbe, Ph.D. Portland Alcohol Research Center Department of Behavioral Neuroscience Oregon Health Sciences University Portland, Oregon
Fulton T. Crews, Ph.D. Center for Alcohol Studies University of North Carolina School

of Medicine Chapel Hill, North Carolina Vincent M. Figueredo, M.D. Division of Cardiology Lovelace Medical Center Albuquerque, New Mexico Michael F. Fleming, M.D., M.P.H. Center for Addiction Research

and Education University of Wisconsin Madison, Wisconsin
Michael T. French, Ph.D. Health Services Research Center and

Department of Economics University of Miami Miami, Florida
Charles R. Goodlett, Ph.D. Department of Psychology Indiana University-Purdue University

at Indianapolis Indianapolis, Indiana
Joel W. Grube, Ph.D. Prevention Research Center Berkeley, California
Henrick J. Harwood The Lewin Group Falls Church, Virginia
Brenda Hewitt Office of the Director National Institute on Alcohol Abuse

and Alcoholism Bethesda, Maryland
Michael E. Hilton, Ph.D. Health Services Research Program Division of Clinical and Prevention

Research National Institute on Alcohol Abuse

and Alcoholism Bethesda, Maryland Ralph Hingson, Sc.D. Social and Behavioral Sciences

Department Boston University School of Public Health Boston, Massachusetts Constance Horgan, Ph.D. Institute for Health Policy Heller School Brandeis University Waltham, Massachusetts 

# Contributorsxviii Tenth Special Report to Congress on Alcohol and Health

Jan M. Howard, Ph.D. Prevention Research Branch Division of Clinical and Prevention Research National Institute on Alcohol Abuse and Alcoholism Bethesda, Maryland
Thomas E. Johnson, Ph.D. Institute for Behavioral Genetics University of Colorado at Boulder Boulder, Colorado Robert W. Karp, Ph.D. Genetics, Neuroscience, and Behavior

Research Branch Division of Basic Research National Institute on Alcohol Abuse and Alcoholism Bethesda, Maryland
Donald S. Kenkel, Ph.D. Department of Policy Analysis and Management Cornell University Ithaca, New York
Robert F. Klein, M.D. Endocrinology and Metabolism Section VA Medical Center Portland, Oregon George Koob, Ph.D. Department of Neuropharmacology The Scripps Research Institute La Jolla, California Mary Jo Larson, Ph.D. New England Research Institutes, Inc. Watertown, Massachusetts David M. Lovinger, Ph.D. Departments of Molecular Physiology and

Biophysics and of Pharmacology Vanderbilt University School of Medicine Nashville, Tennessee
Susan E. Martin, Ph.D. Violence, Trauma, and Unintentional Injury

Prevention Research Branch Division of Clinical and Prevention Research National Institute on Alcohol Abuse and Alcoholism Bethesda, Maryland
Barbara J. Mason, Ph.D. Department of Psychiatry and Behavioral Sciences University of Miami School of Medicine Miami, Florida Sarah N. Mattson, Ph.D. Center for Behavioral Teratology San Diego State University San Diego, California Philip A. May, Ph.D. Center on Alcoholism, Substance Abuse

and Addictions University of New Mexico Albuquerque, New Mexico Craig J. McClain, M.D. Clinical Research Center Division of Digestive Diseases and Nutrition University of Kentucky Medical Center and

Lexington VA Medical Center Lexington, Kentucky Esteban Mezey, M.D. Division of Gastroenterology Department of Medicine The Johns Hopkins University Baltimore, Maryland
Robert Nash Parker, Ph.D. Robert Presley Center for Crime and Justice Studies Department of Sociology University of California Riverside, California Jurgen T. Rehm, Ph.D. Fachhochschule Hamburg Hamburg, Germany Addiction Research Foundation Mental Health Services Corporation of Ontario Toronto, Ontario, Canada Robert G. Rychtarik, Ph.D. Research Institute on Addictions Buffalo, New York
Robert F. Saltz, Ph.D. Prevention Research Center Berkeley, California Keith W. Singletary, Ph.D. Department of Food Science and Human Nutrition University of Illinois, Urbana-Champaign Urbana, Illinois
Barbara Smothers, Ph.D. Epidemiology Branch Division of Biometry and Epidemiology National Institute on Alcohol Abuse and Alcoholism Bethesda, MarylandAcknowledgments

xix Bryon H. Adinoff, M.D. VA Medical Center Dallas, Texas
Efrain Azmitia, Ph.D. Biology Department New York University New York, New York Thomas Babor, Ph.D. Department of Psychiatry University of Connecticut Health Center Farmington, Connecticut
Monte Bissell, M.D. Division of Gastroenterology University of California at San Francisco San Francisco, California James D. Beard, Ph.D. Department of Physiology College of Medicine The University of Tennessee-Memphis Memphis, Tennessee
Howard T. Blane, Ph.D. Research Institute on Addictions Buffalo, New York Gregory Bloss, M.A. Division of Biometry and Epidemiology National Institute on Alcohol Abuse and Alcoholism Bethesda, Maryland Ann May Diehl, M.D. School of Medicine Johns Hopkins University Baltimore, Maryland
Bruce C. Dudek, Ph.D. Department of Psychology University of Albany, State University of New York Albany, New York Constance Horgan, Ph.D. Institute for Health Policy Heller School Brandeis University Waltham, Massachusetts Stephanie S. O’Malley, Ph.D. Department of Psychiatry Substance Abuse Treatment Unit Yale University School of Medicine New Haven, Connecticut Edward P. Riley, Ph.D. Center for Behavioral Teratology Department of Psychology San Diego State University San Diego, California
Kenneth J. Sher, Ph.D. Department of Psychology University of Missouri Columbia, Missouri
Boris Tabakoff, Ph.D. Department of Pharmacology University of Colorado School of Medicine Denver, Colorado
Sharon C. Wilsnack, Ph.D. Department of Neuroscience University of North Dakota Grand Forks, North Dakota Ellen Stewart, B.A. New England Research Institutes, Inc. Watertown, Massachusetts
John J. Woodward, Ph.D. Department of Pharmacology and Toxicology Medical College of Virginia Campus Virginia Commonwealth University Richmond, Virginia Robert A. Zucker, Ph.D. Department of Psychiatry and Psychology Alcohol Research Center and Substance

Abuse Division University of Michigan Ann Arbor, Michigan



# Editorial Advisory Board

Peer Reviewersxx Tenth Special Report to Congress on Alcohol and Health

Raul Caetano, M.D., Ph.D. Alcohol Research Group Berkeley, California Frank J. Chaloupka, Ph.D. Department of Economics University of Illinois at Chicago Chicago, Illinois
Michael C. Costanza, Ph.D. Medical Biostatistics University of Vermont Burlington, Vermont Nancy L. Day, Ph.D. Western Psychiatric Institute and Clinic Pittsburgh, Pennsylvania
Robert Foss, Ph.D. Highway Safety Research Center University of North Carolina Chapel Hill, North Carolina Susan Gapstur, Ph.D Department of Preventive Medicine Northwestern University Medical School Chicago, Illinois
Louis Gliksman, Ph.D. Addiction Research Foundation Toronto, Ontario, Canada
Rueben A. Gonzales, Ph.D. Division of Pharmacology College of Pharmacy University of Texas Austin, Texas Stanley S. Greenberg, Ph.D. Section of Cardiopulmonary Research Louisiana State University Medical Center New Orleans, Louisiana
Janet R. Hankin, Ph.D. Department of Sociology Wayne State University Detroit, Michigan
R. Adron Harris, Ph.D. Department of Pharmacology University of Colorado Health Sciences Center Denver, Colorado
Andrew C. Heath, D.Phil. Department of Psychiatry Washington University School of Medicine St. Louis, Missouri Robert J. Hitzemann, Ph.D. Department of Psychiatry State University of New York at Stony Brook Stony Brook, New York
Harold D. Holder, Ph.D. Prevention Research Center Berkeley, California Yedy Israel, Ph.D. Department of Pathology Jefferson Medical College Philadelphia, Pennsylvania Joseph L. Jacobson, Ph.D. Department of Psychology Wayne State University Detroit, Michigan
Glenda Kaufman Kantor, Ph.D. Family Research Laboratory University of New Hampshire Durham, New Hampshire
Lee Ann Kaskutas, Dr.P.H. Alcohol Research Group Berkeley, California Karen Kopera-Frye, Ph.D. Department of Psychology University of Akron Canton, Ohio George Kunos, M.D., Ph.D. Department of Pharmacology and Toxicology Medical College of Virginia Virginia Commonwealth University Richmond, Virginia
Francine E. Lancaster, Ph.D. Biology Department Texas Woman’s University Denton, Texas Richard Longabaugh, Ed.D. Center for Alcohol and Addiction Studies Brown University Providence, Rhode Island Bryan Luce, Ph.D., M.B.A. MEDTAP International, Inc. Bethesda, Maryland
David MacKinnon, Ph.D. Department of Psychology Arizona State University Tempe, ArizonaAcknowledgments

xxi Stephen A. Maisto, Ph.D. Department of Psychology Syracuse University Syracuse, New York
William J. McBride, Ph.D. Department of Psychiatry Indiana University School of Medicine Institute of Psychiatric Research Indianapolis, Indiana
Matthew McGue, Ph.D Department of Psychology University of Minnesota Minneapolis, Minnesota Gary G. Meadows, Ph.D. Department of Pharmaceutical Sciences College of Pharmacy Washington State University Pullman, Washington
Lorraine Midanik, Ph.D. School of Social Welfare University of California at Berkeley Berkeley, California
Brenda A. Miller, Ph.D. Research Institute on Addictions Buffalo, New York
Michael J. Moore, Ph.D. Fuqua School of Business Duke University Durham, North Carolina
A. Leslie Morrow, Ph.D. Department of Psychiatry University of North Carolina School of Medicine Chapel Hill, North Carolina
M. W. Perrine, Ph.D. Vermont Alcohol Research Center South Burlington, Vermont Horace Mitchell Perry III, M.D. Division of Geriatrics St. Louis University Health Sciences Center St. Louis, Missouri Tamara J. Phillips, Ph.D. Research Division VA Medical Center Portland, Oregon Christopher J. Ruhm, Ph.D. Department of Economics University of North Carolina at Greensboro Greensboro, North Carolina Marcia Russell, Ph.D. Research Institute on Addictions Buffalo, New York
Herman H. Samson, Ph.D. Department of Physiology and Pharmacology Bowman Gray School of Medicine Winston-Salem, North Carolina Michael A. Sayette, Ph.D. Department of Psychology University of Pittsburgh Pittsburgh, Pennsylvania
Edward M. Sellers, M.D., Ph.D. Pharmacology/Dependence Research Unit Women’s College Hospital Toronto, Ontario, Canada Don Shepard, Ph.D. Brandeis University Waltham, Massachusetts Jody L. Sindelar, Ph.D. Department of Epidemiology and Public Health Yale University New Haven, Connecticut
Michael D. Slater, Ph.D. Department of Technical Journalism Colorado State University Fort Collins, Colorado Alan W. Stacy, Ph.D. Institute for Prevention Research University of Southern California Los Angeles, California
Kathleen K. Sulik, Ph.D. Department of Cell Biology and Anatomy University of North Carolina Chapel Hill, North Carolina Gyongyi Szabo, M.D., Ph.D. Department of Medicine University of Massachusetts Medical Center Worcester, Massachusetts
Ronald G. Thurman, Ph.D. Laboratory of Hepatobiology and Toxicology Department of Pharmacology University of North Carolina School of Medicine Chapel Hill, North Carolina Maharaj K. Ticku, Ph.D. Department of Pharmacology University of Texas Health Sciences Center San Antonio, Texasxxii Tenth Special Report to Congress on Alcohol and Health

Steven N. Treistman, Ph.D. Department of Pharmacology University of Massachusetts Medical Center Worcester, Massachusetts
Russell T. Turner, Ph.D. Department of Orthopedics Mayo Foundation Rochester Rochester, Minnesota Carl Waltenbaugh, Ph.D. Department of Microbiology/Immunology Northwestern University Medical School Chicago, Illinois Friedbert Weiss, Ph.D. Department of Neuropharmacology Scripps Research Institute La Jolla, California
James R. West, Ph.D. Department of Anatomy and Neurobiology College of Medicine Texas A&M University Health Sciences Center

National Institute on Alcoholism and Alcohol Abuse Staff

Office of Scientific Affairs Charlotte Armstrong, Project Officer Maureen B. Gardner, Project Officer Michael Eckardt, Ph.D. Diane W. Miller, M.P.A. Kenneth R. Warren, Ph.D. Contractor Staff Palladian Partners Cate Timmerman Trudy Barnes Elizabeth Hess, E.L.S. Catherine Rankin Peter Taylor Market Experts Karen McGuinness Maureen Berg Kristen Dill 

# Editing, Production, and Project Management

Many NIAAA scientific staff members contributed their time and expertise to ensure the accuracy of this report. These include individuals who wrote sections of the report and are listed as contributors. In addition, the following NIAAA staff members are due particular thanks for the extent of the effort they devoted to reviewing manuscripts and providing guidance on the content: Mary Dufour, M.D., M.P.H., Kenneth R. Warren, Ph.D., Gregory Bloss, M.A., Susan Farrell, Ph.D., Laurie Foudin, Ph.D., Richard Fuller, M.D., Jan Howard, Ph.D., Robert Huebner, Ph.D., Antonio Noronha, Ph.D., Vishnudutt Purohit, Ph.D., Barbara Smothers, Ph.D., and Samir Zakhari, Ph.D.