Alcohol as evil – Temperance and policy
Addiction Research and Theory, August 2010; 18(4): 374–382.
Beverage alcohol has developed indelibly different footprints in different cultures. Research shows, indeed, that how a culture views and appreciates alcohol impacts people’s very likelihood of being addicted to it. In this context, the US and other Protestant English-speaking nations, and particularly Nordic ones, are characterized by intense binge drinking – amidst overall low consumption – leading to both social and health problems (including higher levels of alcohol-related mortality). At the same time, these are the very nations that propose alcohol control policies worldwide, which they support with advanced epidemiologic research. Ironically, this same research has shown how peculiar Temperance cultures’ drinking patterns are, particularly in contrast with those in Southern Europe. Yet superior-drinking cultures are ignored – even belittled – in formulating governmental alcohol policies. This paradox is explored and laid at the feet of ingrained anti-alcohol feelings that pervade Temperance cultures. One resulting subplot is the effort by leading Temperance journals and researchers to discourage alcohol producers and sellers from having any role in policy, and to punish and to ban researchers and social scientists in any way associated with producers and sellers.
Keywords: Alcohol policy, alcoholism, conflict of interest, controlled drinking, drinking problems, Mediterranean drinking, natural recovery, Nordic drinking, Temperance
Introduction – Temperance alcohol cultures
Colonial Americans viewed alcohol as a benign social lubricant, since ‘‘most colonial drinking was family and community oriented’’ (Lender and Martin 1982, p. 15). This view changed gradually, alongside social changes in America. By 1830, a massive Temperance movement had formed in the US, and in the following years, alcohol morphed from the ‘‘Good Creature of God’’ into ‘‘Demon Rum.’’ The Temperance ideology was that alcohol was inherently evil. Temperance beliefs waxed and waned until, from 1920 to 1933, national Prohibition was enacted in the US. But, even after Prohibition was repealed, strong Temperance elements remain in the collective American psyche.
Unlike an idealized view of science as a research-determined, results-oriented Olympiad endeavor, the see-sawing of positions and policies on alcoholism and alcohol use embodies political and economic forces, and – especially – cultural and historical attitudes toward alcohol. Chief among these, in the US, are Temperance views. To this day, Temperance attitudes pervade American beliefs about alcoholism, where they constantly struggle with scientific data. This struggle is reflected worldwide.
One template for discussing the role of Temperance in the US and international approaches to alcohol is the debate over corporate funding for alcohol research. Twice around the turn of the first decade of the twenty-first century, the pre-eminent journal, Addiction, presented strong editorial positions against such funding. Equally strong positions opposing the editorial views in Addiction were expressed in replies by other public health researchers – including editors of the current journal (disclosure: I was an editor of AR&T until last year, and am now on its editorial board).
Warring attitudes toward alcohol and alcohol policies internationally are unavoidable because attitudes – experiences – with alcohol vary radically from culture to culture. Alcohol is a universal intoxicant that appeared simultaneously in every cradle of civilization (McGovern 2009). As a result, there are as many, powerfully different ways of drinking and of experiencing alcohol as there are cultural settings. How fundamental are these differences was apparent in a study conducted by WHO/NIH to assess the cross-cultural applicability of DSM-IV diagnostic criteria for alcohol dependence. The conclusion: ‘‘While descriptions of dependence symptoms were quite similar among key informants from sites that share norms around drinking and drunkenness, they varied significantly in comparisons between sites with markedly different drinking cultures.’’ The investigators – no strangers to cultural variations – were nonetheless stunned by the depth of these differences: ‘‘Contrary to expectation, descriptions of physical dependence criteria appeared to vary across sites as much as the more subjective symptoms of psychological dependence’’ (Schmidt and Room 1999, p. 448).
Following are the three major areas – conceptions of alcoholism and its treatment, alcohol policy, and alcohol research funding – that have provoked intense conflict as we turned into the year 2010. All of these areas implicate deep-seated Temperance attitudes.
The disease of alcoholism and its treatment
Temperance views were channeled into the disease concept that came to dominate twentieth century conceptions of alcoholism in America. Jellinek’s disease formulation that alcoholics ‘‘could not stop because of a loss of control over drinking’’ was not a new scientific perspective, as claimed, but rather ‘‘the old Temperance movement had previously advanced the same view’’ (Lender and Martin 1982, p. 187). In this view, alcohol is an overwhelming force that corrupts and controls people’s lives. Researchers who have challenged disease conceptions have been severely attacked, particularly for the ideas that alcoholics can outgrow a drinking problem and that they can moderate their drinking.
Contemporary organizations and government agencies have been a part of spreading and maintaining disease conceptions.
None of these post-repeal efforts – Alcoholics Anonymous, the Yale (Rutgers) Center [of Alcohol Studies], or the National Council on Alcoholism – would consider itself a Temperance organization . . . . Those in what has become known as the ‘alcoholism movement’ certainly are not prohibitionists, but in a sense they are Temperance workers . . . . [T]he National Institute on Alcohol Abuse and Alcoholism (NIAAA) took on many of the old Temperance movement functions . . . . [M]any of the goals of modern organizations are similar to those of the earlier dry crusade. Like Temperance advocates, post-repeal activists have tried to spread their views of alcohol problems as widely as possible. (Lender and Martin 1982, pp. 188–189)
Thus, it marked quite a change when the NIAAA Spectrum (2009) published a brief reprise with the provocative – as well as definitive – title, Alcoholism Isn’t What It Used To Be. This piece was picked up by the Los Angeles Times (Roan 2009) in an article called, ‘‘You Can Cut Back’’ – meaning people may moderate alcoholic drinking. This is a forbidden – a ridiculed and despised – idea in the Temperance view. But, in the Spectrum, Mark Willenbring, director of NIAAA’s Division of Treatment and Recovery Research, asserted that new research ‘‘findings turn on its head much of what we thought we knew about alcoholism.’’
This article began: ‘‘The realization dawned gradually as researchers analyzed data from NIAAA’s 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).’’ NESARC is a national population survey of over 43,000 Americans in regard to their current use of alcohol and their drinking histories. It discovered that only a small minority of alcoholics display the progressive ‘‘disease’’ portrayed as typical in Alcoholics Anonymous. Instead, the NIAAA investigators noted that ‘‘about three-fourths of individuals are in full recovery; more than half of those who have fully recovered drink at low-risk levels . . . about 75% of persons who recover from alcohol dependence do so without seeking any kind of help . . . .’’
But it is disingenuous to say that NESARC has just made NIAAA investigators aware of all this. Ten years before, the same NIAAA team conducted the National Longitudinal Alcohol Epidemiologic Survey (NLAES) that showed the same things. As I wrote (Peele 1998) based on NLAES: ‘‘Not only do most alcoholics improve significantly without treatment, but they typically do so without quitting drinking.’’ It is more accurate to say that for political and historical reasons, NIAAA investigators in 2009 felt that they could challenge historical Temperance notions, whereas earlier they feared career-endangering negative reactions if they did.
The shift in the view of alcoholism carries with it a shift in approaches to treating it. Previously, attacks from disease treatment advocates caused the biggest brouhahas around findings similar to NESARC. In 1980, for instance, Rand Corporation researchers published a 4-year follow-up study of alcoholics treated at NIAAA-funded centers. The director and associate director of the NIAAA immediately and publicly questioned the study’s findings of substantial controlled drinking among alcoholics (Brody 1980). This response was a part of a powerful reaction in the alcoholism treatment community against the Rand study and its results.
There was a different climate in 2009, however, when Willenbring (in the LA Times article) announced, ‘‘People with mild to moderate alcohol disorders can be treated with medications or behavioral therapy with a primary care doctor . . . . But many people can do this on their own without having a professional. The idea is teaching people how to reevaluate their drinking.’’ ‘‘Reevaluating’’ indicates recalibrating, or moderating, problematic drinking – which the majority of recovered alcohol-dependent subjects in NLAES and NESARC did (Dawson 1996; Dawson et al. 2005).
Nonetheless, saying these former problem drinkers had really been alcoholics is still likely to raise hackles – a legacy from Temperance. As a result, Willenbring and the NIAAA are wary in wording their recommendations for reevaluating drinking. Nonetheless, the fact that those objections were muted in 2009 to the NIAAA Spectrum announcement shows that the US cultural environment for alcoholism has changed. This actually proves the truism that political and cultural developments precede scientific ones. At the same time, almost paradoxically, the gingerliness with which these ideas are dealt demonstrates that residual Temperance views persist in American culture.
Alcohol control policy
Just as the disease vision of alcoholism as an expression of Temperance attitudes has been the dominant model for treatment in the US, a similarly negative Temperance view of alcohol and its effects has become prominent in public health policy, particularly in Nordic and other Temperance countries. Epidemiologists in these nations – which we will see have low alcohol consumption, high binge rates, and more social and health problems due to drinking – are the progenitors of alcohol policies aimed at discouraging drinking worldwide. Just as alcoholics were leaders of the American alcoholism movement, the countries with the worst drinking habits became leaders in the alcohol policy world. Their favored policies involve higher pricing (through taxation) of alcohol so as to lower consumption, as well as restricting access – for example, in Scandinavia, limiting the amount of alcohol individuals are allowed to import from the continent, where alcohol is less heavily taxed and controlled. These policies are proposed to reduce drinking problems.
Room et al. (2009a) uncovered the discouraging finding that, in the Nordic countries, lowering taxes and easing restrictions on personal importation did not increase consumption, as the authors anticipated: ‘‘That a relatively large change in alcohol prices did not seem to produce a change in consumption is not something which the literature would have predicted.’’ Holder (2009), in a comment on the article, worried that such a finding indicated (in Room et al.’s words, 2009b) that ‘‘calling a halt to implementing policies to reduce alcohol harm is a ‘major unsupported assumption’ of our article’’ (p. 590). The authors reassured him ‘‘that developing models and testing them is not an excuse to put off policymaking,’’ even as this study in the center of the control policy world had disconfirmed that model for modern Scandinavia. That such policies are vouchsafed was made evident when, shortly after the publication of Room et al. (2009a), a US task force recommended alcohol tax rises as an important public health measure to curb excessive alcohol use and related harms, based on a literature review by Elder et al. (2010).
These policy discussions take place in an international Temperance cultural context. In a classic treatise, Levine (1992, p. 3) defined Temperance countries as those that ‘‘developed large, ongoing, extremely popular temperance movements in the nineteenth century and the first third or so of the twentieth century.’’ There were nine countries: Five Protestant English-speaking and four Nordic. Policy ideas created both by, and about, Temperance cultures were tested through the European Comparative Alcohol Study (ECAS). ECAS – whose core researchers were all from Nordic nations – published the first systematic European comparison of drinking problems, Alcohol in Postwar Europe (Norström 2002).
The results of ECAS were stunning. While some empiricists had expressed skepticism about the great differences in styles of drinking that are often noted between, say, Oslo and Florence, London and Athens, Alcohol in Postwar Europethoroughly supported with data that alcohol-related problems were lowest in Southern Europe and highest in the North, despite the much greater controls the latter imposed and the lower drinking ages and far greater consumption in the former. Even more surprising was that alcohol-related mortality was also much higher in the North, due principally to the tendency in Temperance cultures to drink in heavy bursts, rather than regularly, but moderately. This leads to more accidents, violence, and suicide, and perhaps even to cirrhosis in Finland, Norway, Sweden – which consume the least alcohol – than in France, Italy Portugal, Spain, Greece – that consume the most. ECAS found alcohol-related mortality was substantially higher in Northern than Southern Europe: 18 versus 3 such deaths per 100,000 for men, 3 versus 0.5 for women (Table 6.6). There was an inverserelationship between alcohol consumption and alcohol-related mortality.
The ECAS research team remedied this seemingly serious disconfirmation of both the Temperance and the modern policy belief that higher consumption meant more alcoholrelated social problems and mortality by proposing that it was increases in consumption within a given society that were harmful – although this was most notably evident, once again, in the Nordic countries, where ‘‘the association between alcohol consumption and experiencing an alcohol-related problem was stronger in Sweden and Finland than in other countries.’’ This included ‘‘that all forms of mortality analyzed (except IHD) respond more strongly – whether measured in relative or absolute terms – to changes in overall consumption in Northern Europe than in other country groups’’(p. 168).
So, control policies proposed in Temperance cultures are actually more true in these cultures. This led to the seeming need for a counterpoint summary from a Southern European, which was provided in the ECAS volume by Allamani (2002). Allamani described differences in the way alcohol was consumed across Europe: ‘‘In the Northern countries, alcohol is described as a psychotropic agent. . .. It has to do with the issue of control and with its opposite – ‘discontrol’ or transgression. In the Southern countries, alcoholic beverages – mainly wine – are drunk for their taste and smell, and are perceived as intimately related to food, thus as an integral part of meals and family life. . .[so that drinking] is not connected to the topic of control’’ (p. 197).
Allamani’s (2002) views are not prominent in the Alcohol in Postwar Europe volume, where the ECAS research team determined, ‘‘Despite all cultural variation in alcohol consumption and drinking patterns, alcoholic beverages are commodities that contain special risks everywhere. The research evidence on the positive and negative health effects of drinking will probably always remain controversial.’’ Nonetheless, these Nordic nationals assert, it is safe to say that less drinking is better for people (pp. 224–225).
For his part, Allamani notes, ‘‘Many European policies have been based on the brilliant and extensive studies carried out in Northern Europe and in North America. They put great emphasis on control and restriction measures. . .. As a consequence, alcohol studies and experiences are strongly influenced by both the Nordic and English-speaking countries. International agencies, and WHO itself have possibly been influenced by this situation.’’
We can readily verify Allamani’s assertions. Taking two key publications advocating control policies, Alcohol Policy and the Public Good (Edwards et al. 1994) andAlcohol: No Ordinary Commodity (Babor et al. 2003), the former lists 17 participants – 16 are from Levine’s nine Temperance countries (the other is from the Netherlands). Among 15 listed for Commodity, 14 are from Temperance nations (the other from Germany). None of the authors of either volume is from South, Central or Eastern Europe, Asia, Latin America, etc. Those not included represent major, active drinking cultures, such as China, Belgium, Switzerland, Hungary, Austria, Japan, Argentina, Poland, Brazil, Ireland, Israel, Spain, France, Italy, Greece, and on and on – all of which have recognizably different drinking cultures from Temperance societies.
Alcohol funding ethics
Advocates of the Temperance ideology have moved on from arguments concerning research and public policy and are devoting substantial energy to suppressing alternative views according to their funding source. When Babor et al. say that alcohol is no ordinary commodity, they mean – in a word – that it is bad, or that it has overwhelming propensity for badness. The first authors of the two books above have both been editors-in-chief of the journal Addiction. This journal has been a leader in proclaiming the need to eradicate alcohol industry funding in the field – and for punishing those who accept such money. Yet, of course, alcohol producers and sellers are the main counterpoising force to their Temperance views. And, thus, Temperance researchers see these as evil forces which all should eschew.
Heim (2006, p. 98), in the current journal, editorialized about ‘‘the lengths to which some ‘gatekeepers’ are prepared to go to discredit research that may not be compatible with their own worldview. There are signs that substance use and addictions research is becoming more and more likely to be judged on whether it was funded by ‘good’ or ‘bad’ sources as opposed to its scientific merit.’’ A similar tempest had previously occurred in relation to the Farmington Consensus among substance and addiction journal editors, an alliance spearheaded by the Addictiongroup. When Griffith Edwards, then editor-in-chief of Addiction, rescinded publication of an earlier article written by authors who did not disclose industry funding, and then wrote with others (Edwards et al. 2002) an editorial attacking a book (Frenk and Dar 2000) that questioned the concept of nicotine addiction, AR&T editors Davies et al. (2002) reacted, ‘‘So the purpose of the Farmington Consensus is, bluntly, to separate the good guys from the bad guys.’’
They went on to write of the Addiction editorial on Frenk and Dar’s book:
[T]he authors found themselves on the receiving end of what can only be called a self-righteous crusade, damning their book because some of the initial source material was commissioned by a firm of solicitors with tobacco connections. We are invited to reject the content in its entirety on that basis. In our view this amounts to nothing less than an attempt to suppress a coherently argued position and thus to suppress an ensuing open debate which in our view is the very stuff of scientific discourse . . . .
We now see that Farmington can be used to disqualify entire bodies of argument and criticism with which certain people do not agree, on grounds that have nothing to do with the scientific merit of the work; and to launch retrospective witch-hunts whereby previously published work can also be disqualified. In our view, this is morally indefensible.
That these opposing positions represent something more than arguments to be reasoned out is proven by their constant repetition. Thus, in 2009, Addictionpublished another call for discouraging alcohol funding (Goozner et al. 2009), to which AR&T editors Davies and Rotgers (2009) responded with a comment entitled, ‘‘Disclosure in the Best Interests of Science? Or Moral Crusade?’’ Not deterred by this discussion just a few months earlier, in the January 2010 issue of Addiction, Stenius and Babor (2010) recommended upping the ante in its anti-alcohol-industry-funding position, asserting ‘‘that the integrity of alcohol science is best served if all financial relationships with the alcoholic beverage industry are avoided,’’ that records of these should be kept permanently, and that people be obligated to disclose industry funding they received at any time, however dimly related – or not so – to the topic at hand.
Two invited responses in Addiction from public health researchers (with no association with AR&T) repeated familiar arguments, albeit with new twists. Gmel’s (2010) comment was titled ‘‘The Good, the Bad and the Ugly,’’ where the ‘‘good’’ and the ‘‘bad’’ – as regarded by Addiction, that is – are by now well-known (Gmel’s title is, of course, sardonic). The ‘‘ugly’’ in his comment refers to young researchers who are being told that they had better never dare to touch industry money, since ‘‘Now, in ethical statements, any life-time connection with tobacco, alcohol, pharmaceutical or gaming industry has to be declared . . . [t]ogether with a recommendation of building a register of ethical life-time statements this may blacklist anybody forever’’(p. 204).
Another commentator – Sulkunen (2010) – wondered what this meant for him, having worked for many years for the Finnish Alcohol Monopoly, the sole producer, importer, and seller of alcohol in that country. Gmel (2010) likewise asked why these ‘‘principles apply only to the industry? What about funding by alcohol monopolies that nowadays seek to increase revenues through increased availability, or by temperance organizations? The latter may also be ideologically partisan.’’ John Tierney (2010), science writer for the New York Times, added his voice to this debate by rejecting – mocking – the anti-industry position (not specifically connected to alcohol):
Conflict-of-interest accusations have become the simplest strategy for avoiding a substantive debate. The growing obsession with following the money too often leads to nothing, but cheap ad hominem attacks . . . . It is simpler to note a corporate connection than to analyze all the other factors that can bias researchers’ work: their background and ideology, their yearnings for publicity and prestige and power, the politics of their profession, the agendas of the public agencies and foundations and grant committees that finance so much scientific work.
Alcohol and alcoholism-related science and policy do not fit the mold that science progresses straightforwardly. Strong cultural values are attached to substances, most notably alcohol, as occurs in Temperance cultures. At the same time, alternative conceptions of alcohol and alcoholism ebb and flow and emerge as governing images for policy and treatment for a time. These conceptions are steeped in cultural differences, but also vary with historical epochs, including economic and political developments.
One immense social process influencing views of alcohol, addiction, and treatment is globalization. For example, the EU is heading toward standardization of alcohol taxation and control policies (although achieving such uniformity has a long way to go). These cross-European influences are evidenced by, on the one hand, the lowering of taxes and increase in personal allowances for importation, which represent a loosening of traditional Nordicnation restrictions, that Room et al. (2009a) studied. Allamani (2002) conversely noted that Nordic control policies are being imposed throughout Europe.
These developments are reflected in – and reflect – changing attitudes toward alcohol throughout Europe. It is possible to see trends toward the Temperancing of European attitudes (Central European countries appeared almost uniformly throughout the ECAS’s Alcohol in Postwar Europe as intermediate between North and South in drinking and policies). But, at the same time, Southern attitudes toward appreciation of wine and other alcohol as a part of the Mediterranean lifestyle are becoming a European ideal, especially among elites, including in Temperance cultures.
Finally, there is no conclusive science of alcohol’s effects, of the definition of alcoholism and how it is treated, or of policies and ethics in regard to alcohol and research about it. These are all in a shifting balance of competing ideas and forces that never cease to operate. This war is now most heated in the case of alcohol-industry funding.
I have received funding from alcohol producers, most notably to organize the conference, Alcohol and Pleasure, under the auspices of ICAP in 1998. I am funded primarily by my Life Process Program for addiction treatment at St. Gregory Retreat Center, and secondarily by forensic work – most often for clients fighting professional licensure actions or mandated treatment.
Declaration of interest: The views expressed in this article are those of the author and do not necessarily reflect those of the editors or editorial board members of Addiction Research and Theory.
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