Epidemiology of drinking, alcohol use disorders, and related problems in US ethnic minority groups

Handbook of Clinical Neurology, Vol. 125 (3rd series) Alcohol and the Nervous System E.V. Sullivan and A. Pfefferbaum, Editors © 2014 Elsevier B.V. All rights reserved

Chapter 37

Epidemiology of drinking, alcohol use disorders, and related problems in US ethnic minority groups RAUL CAETANO*, PATRICE A.C. VAETH, KAREN G. CHARTIER, AND BRITAIN A. MILLS School of Public Health, Dallas Regional Campus, University of Texas Health Science Center at Houston, Dallas, TX, USA

INTRODUCTION This chapter describes the epidemiology of drinking, alcohol use disorders, including abuse and dependence, and other alcohol-related problems (e.g., legal, interpersonal, job-related) among US ethnic minorities. The groups that have been traditionally included in these studies are Whites, Blacks, Hispanics, Asian Americans, American Indians, and Alaska Natives. To some extent, this grouping follows US census classifications of race and ethnicity, but there are also relevant differences. For instance, the US Census Bureau has treated Hispanics (or Latinos) as an ethnic group and not as a racial group, such as Whites or Blacks. The Bureau correctly argues that Hispanics can be of any race, and indeed they are. Yet, all studies in alcohol epidemiology treat Hispanics as a racially uniform group, without differentiating between, for instance, White Hispanics, Black Hispanics, and Asian Hispanics. Also, studies often treat ethnic minority groups as if they were culturally homogeneous, as if they all had come from the same (for example) European, Asian, or Latin American country. In reality, immigrant groups come to the United States from a variety of countries with different drinking traditions. Life in the United States can lead to some uniformity in drinking through acculturation, a process by which immigrant groups adopt drinking norms and drinking patterns dominant in US society. But this process never totally erases national or ethnic-specific drinking patterns and norms. Consequently, there is considerable heterogeneity in drinking across the three larger Hispanic national groups in the United States: Mexican Americans, Puerto Ricans, and Cuban Americans (Caetano et al., 2008; Mills and Caetano, 2010; Ramisetty-Mikler et al., 2010; Vaeth et al., 2012).

Most of the studies reviewed in this chapter analyze data collected from random samples of the adult household population (18 years of age and older) in particular ethnic groups. Because of this random selection, these studies provide results that are representative of drinking and its associated problems in the general population. An exception to the focus on adult drinking is the National Survey on Drug Use and Health, which is conducted by the Research Triangle Institute under contract with the Office of Applied Studies of the Substance Abuse and Mental Health Administration (SAMHSA, 2011). This yearly survey interviews over 70 000 people 12 years of age and older to capture drinking and drug use among the adolescent and adult household population. These alcohol epidemiologic studies show a number of health disparities across US ethnic groups. Besides well-known genetic differences in response to drinking, such as the flushing reaction to alcohol among Asian groups (Crabb et al., 1989; Kimura and Higuchi, 2011), many researchers have explained these health disparities in terms of the cumulative social disadvantages that characteristically affect ethnic minority groups in the United States.

BRIEF HISTORIC OVERVIEW Alcohol research with ethnic minorities in the United States began approximately 50 years ago in the mid 20th century with studies of drinking by Italian, Jewish, and Irish Americans (e.g., Bales, 1946; Lolli et al., 1958; Snyder, 1958). In general, these studies did not analyze representative samples of these groups but described indepth analysis of drinking patterns, norms regulating the use of alcohol, and cultural traditions associated with drinking in these groups. During the 1960s, epidemiologic

*Correspondence to: Raul Caetano, University of Texas School of Public Health, Dallas Regional Campus, 5323 Harry Hines Blvd, V8.112, Dallas, TX 75390-9128, USA. Tel: +1-214-648-1080, E-mail: [email protected]

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surveys of drinking patterns with local or national representative samples of the household population were developed and analyzed (Knupfer and Room, 1967; Cahalan et al., 1969). These surveys had broad descriptive goals and their attention to ethnic differences in drinking was limited. However, in the late 1970s a new era in alcohol research with ethnic groups began. The National Institute on Mental Health funded the Epidemiology Catchment Area (ECA) study, which examined the prevalence and correlates of psychiatric disorders in five metropolitan areas of the country: Los Angeles, Saint Louis, Baltimore, Durham, and New Haven. Considerable attention was given to the epidemiology of alcohol abuse and dependence in these surveys, with special attention paid to Blacks and Hispanics (see, for instance, Helzer and Canino, 1992). The ECA sample interviewed in Los Angeles was designed to examine psychiatric disorders among Mexican Americans and the sample in Saint Louis had a strong focus on Blacks (Burnam et al., 1987a, b; Burnam, 1989). In 1984, the then Berkeley-based Alcohol Research Group conducted the first national survey of drinking with oversamples of Blacks and Hispanics (Caetano, 1989; Herd, 1990). Respondents were a representative sample of the US household population of adults, and several papers analyzing this survey appeared in the literature with indepth analysis of drinking among Blacks and Hispanics. Also in the 1980s, the 1985 National Household Survey on Drug Abuse (NHSDA), which interviewed a nationally representative sample of the US household population, oversampled Blacks and Hispanics, providing detailed national-level data on drinking and alcohol use disorders in these two groups (CarsonDeWitt, 2001). In 2003, the NHSDA became the National Survey on Drug Use and Health (NSDUH), which does not oversample ethnic minorities, but because it interviews a large number of respondents annually (around 70 000), it can provide detailed information on drinking (past 30 days) and alcohol use disorders (past year) among ethnic minorities. Other national surveys of relevance to the study of the association between drinking and ethnicity are the 1995 National Alcohol Survey (NAS), which oversampled Blacks and Hispanics nationally, the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES), which oversampled Blacks, and the 2002 National Epidemiologic Survey of Alcohol Related Conditions (NESARC), which oversampled Blacks and Hispanics. The NAS was conducted by the Alcohol Research Group, then at Berkeley, now in Emeryville, California. The second and third surveys, NLAES and NESARC, were conducted by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). In addition to the 1995 NAS, the Alcohol Research Group has conducted national telephone surveys in 2000, 2005, and 2010.

All these telephone surveys are large enough and have oversamples of Blacks and Hispanics that enable comparative analyses of drinking among Whites, Blacks, and Hispanics in the United States.

WHAT THE CHAPTER WILL COVER This chapter is organized as follows: first, drinking among Whites, Blacks, and Hispanics is described. The focus is on these three groups because these are the ethnic groups most frequently studied in alcohol epidemiology and because these are the three largest ethnic groups represented in the US population. This is followed by a discussion of alcohol use disorders (alcohol abuse and dependence), as defined in the fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV: American Psychiatric Association, 1994), among Whites, Blacks, and Hispanics. Next, the chapter addresses drinking and alcohol use disorders among subgroups of Hispanics, defined by national origin: Mexican Americans, Puerto Ricans, Cuban Americans, and South/Central Americans. The same structure is applied to the examination of drinking and alcohol use disorders among Asian American subgroups. Presently, there is more information at the national-group level for Hispanics and Asian Americans than other groups. This is followed by a review of alcohol studies with Native Americans (i.e., American Indians and Alaska Natives), focusing on both drinking and associated problems in this group. Finally, theories proposed to explain health disparities in the alcohol field are reviewed and application to the neurology clinic considered.

DRINKING AMONG WHITES, BLACKS, AND HISPANICS Most of the recent cross-sectional analyses that describe drinking among Whites, Blacks, and Hispanics have been based on data from the NESARC (e.g., Grant et al., 2007; Hasin et al., 2008; Keyes et al., 2009) or the NSDUH. There have also been trend analyses based on NLAES and NESARC data (e.g., Caetano et al., 2010, 2011; Chartier and Caetano, 2011). Caetano et al. (2010) described trends in the mean number of drinks consumed per month among Whites, Blacks, and Hispanics using NLAES and NESARC data. Table 37.1 shows these data, indicating that, among both men and women, there were no statistically significant differences for any of the three ethnic groups between 1992 and 2002. Within-year analyses showed that, for 2002, the mean number of drinks for White men was significantly higher than the mean for Black and Hispanic men. Among women, analysis of data for 1992 and 2002 showed statistically significant differences in the mean number of

EPIDEMIOLOGY OF DRINKING, ALCOHOL USE DISORDERS, AND RELATED PROBLEMS

631

Table 37.1 Mean number of drinks consumed per month by Whites, Blacks, and Hispanics: Trends between survey years (NLAES ¼ 1992; NESARC ¼ 2002) White

Males* Females{{

Black

Hispanic

1992

2002

1992

2002

1992

2002

21.3 6.2

22.3 6.2

19.8 4.9

18.9 5.2

18.5 3.3

17.8 3.9

NESARC, National Epidemiologic Study on Alcohol and Related Conditions; NLAES, National Longitudinal Alcohol Epidemiology Study. *t-tests significant between White and Black men (P < 0.01), and White and Hispanic men (P < 0.001) in 2002. { t-tests significant between Hispanic and Black women (P < 0.01), and Hispanic and White women (P < 0.001) in 1992. { t-tests significant between Hispanic and White women (P < 0.001), and Black and White women (P < 0.05) in 2002.

drinks between Hispanic and Black women and between Hispanic and White women. Caetano et al. (2010) also described trends in the proportion of drinkers, showing a statistically significant increase in the proportion of current drinkers for all three ethnic groups between 1992 and 2002. Table 37.2 from that work shows that the increase in percentage points was similar in the three ethnic groups: five points among Whites, six among Blacks, and seven among Hispanics. As a result, White and Hispanic men have similar rates of current drinking in 2002 that are higher than that of Blacks. Among men, there are statistically significant differences in the frequency of drinking five or more drinks in a day for all three ethnic groups between 1992 and 2002. This is best seen in Table 37.2 by examining the proportion of men reporting this behavior once a week or more in 2002 compared to 1992. At the same time, there was also an increase in the proportion of drinkers who did not report drinking five or more in a day from 1992 to 2002. This increase was larger for Whites and Blacks (10 and 13 percentage points, respectively) than for Hispanics (nine percentage points). There also were significant trends between 1992 and 2002 in drinking to intoxication less than once per month or more frequently. However, in contrast to data on drinking five or more drinks, the proportion in each frequency category of intoxication was more stable. The overall proportion of men reporting intoxication was the same in 1992 and 2002 for Whites (29% and 30%), Blacks (21% and 22%), and Hispanics (26% and 25%). Data for women in Table 37.2 show that there also was a statistically significant increase in the proportion of current drinkers in all three ethnic groups. About a third of Black and Hispanic women were drinkers in 2002, compared to almost half of White women. Variations in the frequency of drinking five or more drinks per day between 1992 and 2002 were also significant for all three ethnic groups. There also were differences in the

proportion of White, Black, and Hispanic women who drank but did not report consuming five or more drinks in a day, which increased in all three groups. The overall proportion of drinkers reporting drinking five or more drinks among women declined among Whites (16% to 12%) and Blacks (8% to 6%), but was relatively stable among Hispanics (10% to 9%). In all three ethnic groups, variations in the frequency of drinking to intoxication in each specific frequency category from 1992 to 2002 were relatively small. Data from the NLAES and NESARC cover alcohol consumption in the 12 months prior to the survey interview. Data for the NSDUH cover the past 30 days. This narrower window may miss drinkers with an infrequent pattern of drinking or binge drinking but is less susceptible to recall biases than 12-month data (SAMHSA, 2012b). Data from the 2011 NSDUH show that any alcohol use in adults (i.e., ages 18 or older) is most prevalent for Whites (60.5%) and similar for Hispanics (47.2%) and Blacks (46.2%). Binge drinking and heavy drinking are high-risk consumption patterns that contribute to a variety of alcohol-related social and health problems (Naimi et al., 2003; Rehm et al., 2003). In 2011, Whites reported the highest prevalence of heavy drinking (7.6%), followed by Hispanics (5.7%), and Blacks (4.4%). Rates of binge drinking were 25.3% for Whites and 26.0% for Hispanics, with a lower percentage for Blacks (4.4%; NIAAA, 2004; Chen et al., 2010). The data discussed so far clearly show that men drink more than women, a trend common among all ethnic groups in the US population. Age is also an significant predictor of drinking and binge drinking. Epidemiologic research in the United States has repeatedly shown a traditional pattern of drinking by age, indicating that those who are younger drink more than those who are older (Cahalan et al., 1969; Clark and Midanik, 1982). These cross-sectional data for the US general population show an increase in drinking during the 20s followed by an

632

R. CAETANO ET AL.

Table 37.2 Current drinkers, frequency of drinking five or more drinks in a day, and frequency of intoxication among Whites, Blacks, and Hispanics by gender and survey year (NLAES ¼ 1992; NESARC ¼ 2002) White

Black

Hispanic

Males

1992

2002

1992

2002

1992

2002

Drinking status* Current drinkers (n) 5+ drinks in a day (n) Once a week or more 1–3 times a month < Once a month Drinker/No 5+ drinks Ex-drinkers/abstainers Drinking to intoxication (n) Once a week or more 1–3 times a month < Once a month Drinker/ no intoxication Ex-drinkers/abstainers

58.31 (7937) 13 538 9.2 9.2 18.7 30.0 41.9 13 555 2.7 5.4 21.0 29.1 41.8

63.52 (6885) 10 782{ 13.6 7.0 11.5 31.3 36.7 10 766{ 5.2 5.1 20.3 32.7 36.7

46.56 (967) 2091 9.6 6.8 11.5 18.3 53.7 2094 3.2 4.2 13.7 25.2 53.7

52.50 (1554) 3025{ 11.4 3.6 5.8 31.5 47.7 3023 { 4.4 4.9 12.7 30.3 47.7

52.95 (635) 1191 9.8 11.0 16.8 15.3 47.1 1192 2.8 5.2 18.6 26.3 47.1

60.28 (2281) 3700{ 14.1 9.3 11.9 24.6 40.2 3698 { 4.3 4.5 16.4 34.5 40.2

White

Black

Hispanic

Females

1992

2002

1992

2002

1992

2002

Drinking status* Current drinkers (n) 5+ drinks in a day (n) Once a week or more 1–3 times a month < Once a month Drinker/ not 5+ drinks Ex-drinkers/abstainers Drinking to intoxication (n) Once a week or more 1–3 times a month < Once a month Drinker/ no intoxication Ex-drinkers/abstainers

37.69 (6848) 18 295 2.2 3.4 10.5 21.5 62.4 18 303 0.8 1.9 12.9 22.0 62.4

46.98 (6321) 13 631{ 3.2 2.9 6.2 34.5 53.2 13 618{ 1.7 2.7 15.2 27.2 53.2

21.26 (871) 3850 2.4 2.4 3.5 12.8 78.9 3851 0.8 1.4 4.6 14.4 78.8

30.31 (1507) 5194{ 2.3 1.3 2.3 24.3 69.8 5192{ 1.6 2.1 6.7 19.9 69.8

23.78 (411) 1617 1.2 2.1 7.0 13.5 76.3 1618 0.4 1.3 8.1 14.0 76.3

31.67 (1473) 4576{ 2.6 2.2 4.2 22.6 68.5 4573{ 1.3 1.9 8.7 19.6 68.5

Proportions and means are weighted; numbers in parentheses reflect current drinker sample size. NESARC, National Epidemiologic Study on Alcohol and Related Conditions; NLAES, National Longitudinal Alcohol Epidemiology Study, *Significant between ethnic groups within survey years. { P < 0.001, { P < 0.01: indicates significant difference between survey years within the given ethnic/gender group. Reproduced from Caetano et al. (2010).

abrupt decline in the 30s that is sustained in older age groups. However, data on drinking by age for Blacks and Hispanics depart from this traditional pattern (Caetano, 1991; Hilton, 1991; Ramisetty-Mikler et al., 2010), slowing with age in both ethnic groups (e.g., Caetano, 1991). Such a pattern can lead to a higher prevalence of alcohol problems during middle age among Black and Hispanic men than Whites. Other predictors of drinking in US general population data, and among

ethnic minorities, include marital status, level of education, and employment status. Specifically, those who are single or divorced, those who are less educated, and those who are unemployed reported more drinking and more drinking of five or more drinks in a single day or at a sitting (Hilton, 1987; Dawson et al., 1995; Caetano et al., 2010). For Hispanics, birthplace was also an important predictor of drinking, with US-born Hispanics drinking more than those Hispanics born abroad.

EPIDEMIOLOGY OF DRINKING, ALCOHOL USE DISORDERS, AND RELATED PROBLEMS 633 These same variables also predicted higher levels of ALCOHOL USE DISORDERS AND OTHER binge drinking (Caetano et al., 2010). PROBLEMS AMONG WHITES, BLACKS, Different trajectories of drinking are also evident AND HISPANICS across Whites, Blacks, and Hispanics. For example, Alcohol use disorders reviewed in this section include NESARC data show that slightly more Hispanics alcohol abuse and dependence, as defined by DSM-IV. (7.9%) and Whites (7.1%) than Blacks (5.5%) reported Grant et al. (2004) examined unadjusted prevalence rates an early onset of drinking (i.e., before age 15: NIAAA, of alcohol use disorders for ethnic groups in NLAES and 2004; Chen et al., 2006). The rate of drinking onset NESARC. This analysis showed higher rates for DSMbefore age 15 was lower for women compared to men IV alcohol abuse among Whites (NLAES, 3.0%; in all ethnic groups, and lowest for Black women, at NEARC, 4.6%) than among Blacks (NLAES, 1.4%; 3.9%. Longitudinal analyses of changes in drinking also NESARC, 3.2%) and Hispanics (NLAES, 2.5%; show disparities between Whites, Blacks, and Hispanics. NESARC, 3.9%). These results were independent of genFor example, Caetano and Kaskutas’ (1995, 1996) anader. Overall rates of dependence were similar across lyses of 8-year changes in drinking and binge drinking Whites (NLAES, 4.3%; NESARC, 3.8%), Blacks between 1984 and 1992 showed that heavy drinking (NLAES, 3.8%; NESARC, 3.6%), and Hispanics (drinking five or more drinks in a day at least once a (NLAES, 5.8%; NESARC, 3.9%). The reduction in rates week) decreased only among White men (from 19% to between 1992 and 2002 for Whites and Hispanics was 12%). Among men, the incidence of heavy drinking statistically significant. Other national data, such as was 7% among Whites, 10% among Blacks, and 17% those in SAMHSA’s 2011 NSDUH, show similar among Hispanics. The persistence of heavy drinking 12-month rates for abuse plus dependence in Whites (proportion of heavy drinkers at time 1 who remained (7.0%) and Hispanics (7.5%) and lower rates for Blacks heavy drinkers at time 2) was greater among Black (5.6%: SAMHSA, 2012b). (51%) and Hispanic men (43%) than among White men Other trend analyses of NLAES and NESARC data (32%). Blacks and Hispanics were 2 times and 1.5 times, on DSM-IV alcohol abuse and dependence have been respectively, more likely than Whites to remain heavy reported by Caetano et al. (2011). The data in drinkers between time 1 and time 2 in the analysis. The Table 37.3 are from those analyses and show results mean number of drinks consumed per month by heavy for the overall prevalence of abuse among men and drinkers was also higher for Blacks and Hispanics than women as well as prevalence for each of the DSM-IV for Whites. Unfortunately, however, these results are abuse indicators. First, the prevalence of alcohol abuse now 20 years old, and it is not clear whether findings is lower than expected from the indicator-level data in from 1984 to 1992 would be applicable today given the table because some respondents reporting a particuchanges in consumption and rates of alcohol use since lar abuse indicator are also alcohol-dependent and, as 1992 (Grant et al., 2004; Schmidt et al., 2007; Caetano such, are not counted in estimation of the overall diaget al., 2010, 2011). nosis of abuse. In NLAES, 63% of the respondents with Longitudinal analyses of NESARC data (Chen et al., a dependence diagnosis were also alcohol abusers. In 2010), comparing 2002 wave 1 to the 2005 follow-up NESARC, the proportion was 65%. Given DSM-IV hierwave 2, provide crude results for change in drinking staarchic rules for diagnosis identification, dependence tus, and for the proportion of various groups of wave 1 takes precedence over abuse. Turning to the results in respondents who exceed low-risk drinking limits at wave Table 37.3, from 1992 to 2002, the prevalence of alcohol 2 by ethnicity. Exceeding low-risk drinking limits for abuse increased significantly among both men and men include drinking five or more drinks per day and women in all three ethnic groups, with the exception more than 14 drinks per week, and for women drinking of Hispanic women. Also, abuse was more prevalent four or more drinks per day and more than seven drinks among men than women both in 1992 and 2002. Trends per week. For instance, Hispanics were more likely than in alcohol abuse indicators show a significant increase in Whites and Blacks to return to drinking or become the proportion of hazardous use among White and Black drinkers at wave 2. Hispanic and Black non-current men. Among White men, there also was a significant drinkers at wave 1 were more likely than Whites to decrease in the proportion of legal problems. The prevexceed daily or weekly low-risk guidelines at wave 2, alence of “failure to fulfill role obligations” decreased in and did so at older ages (45 and more). Black and Hisall three groups for men. Among women, hazardous use panic current drinkers at wave 1 were more likely than prevalence increased from 1992 to 2002 in all three ethnic Whites to exceed daily and/or weekly low-risk guidelines groups. The prevalence of the indicator “failure to fulfill at wave 2. Black and Hispanic drinkers who exceeded major role obligations” decreased among White women low-drinking guidelines at wave 1 were more likely than only. A comparison of the overall prevalence rate of Whites to remain drinking above low-risk guidelines.

634

R. CAETANO ET AL.

Table 37.3 Prevalence of alcohol abuse and abuse indicators among Whites, Blacks, and Hispanics in the US population by gender and survey year (NLAES ¼ 1992; NESARC ¼ 2002) White

Males Alcohol abuse Abuse indicators Interpersonal problems Hazardous use Legal problems Major role obligations

1992 (n ¼ 13 600)

Black 2002 (n ¼ 10 845)

Alcohol abuse Abuse indicators Interpersonal problems Hazardous use Legal problems Major role obligations

1992 (n ¼ 2100)

2002 (n ¼ 3041)

1992 (n ¼ 1194)

2002 (n ¼ 3722)

5.5

7.4{

2.7

5.7{

4.4

6.2*

2.3 8.1 1.3 3.2

2.4 10.4{ 0.9{ 1.0{

2.5 4.0 1.2 2.1

2.6 6.9{ 0.9 1.0*

2.9 6.8 1.4 3.0

3.9 7.5 1.8 1.5*

White

Females

Hispanic

Black

Hispanic

1992 (n ¼ 18 338)

2002 (n ¼ 13 662)

1992 (n ¼ 3855)

2002 (n ¼ 5204)

1992 (n ¼ 1620)

2002 (n ¼ 4586)

1.8

2.9{

0.7

1.4{

1.0

1.7

0.6 2.5 0.2 1.2

0.8 3.7{ 0.3 0.5{

0.7 1.0 0.2 0.7

0.8 2.0{ 0.3 0.5

0.3 1.0 0.2 0.4

0.6 2.1{ 0.1 0.3

Cells include weighted proportions. NESARC, National Epidemiologic Study on Alcohol and Related Conditions; NLAES, National Longitudinal Alcohol Epidemiology Study. *P < 0.05, {P < 0.01, {P < 0.001: indicates significant difference between survey years within the given ethnic/gender group. Reproduced from Caetano et al. (2011).

abuse with the prevalence rate for each abuse criterion shows that most abuse diagnoses were probably due to the hazardous drinking criterion in all three ethnic groups, independently of gender, because a positive diagnosis of abuse requires the presence of only one criterion. In addition to examining prevalence and trend data on alcohol abuse and dependence, other recent epidemiologic studies have used longitudinal data from waves 1 and 2 of the NESARC to examine the incidence of these two alcohol use disorders. Grant et al. (2007) examined predictors of first incidence of alcohol abuse and dependence, while Grant et al. (2009) examined the onset, persistence, and recurrence of alcohol use disorders. Grant et al. (2007) reported a slightly higher incidence of alcohol dependence for Blacks (2.7%) and Hispanics (2.4%) compared to Whites (1.5%), as well as a higher incidence among those who were younger, never married, and those who had lower income. Grant et al. (2009) reported a higher risk of persistence of alcohol dependence (but not abuse) among US-born Hispanic men under 40 years of age compared to Whites. This was not true for Black

men who were also compared to Whites. Among women, persistence of alcohol dependence was elevated among older (40 and more) Blacks and Hispanics relative to Whites. Other recent epidemiologic studies of alcohol dependence have also focused on recovery from this condition in the US population, showing that Whites hold some advantage over ethnic minorities in this area. For instance, in Dawson et al.’s (2005) analysis of longitudinal data from the NESARC, Whites had a decreased risk of continued/recurrent dependence compared to other ethnic groups. Persistence of prior to past year dependence was highest among Blacks (35%), followed by Hispanics (33%), then Whites (23%). Cross-sectional analyses of the symptom profiles among Whites, Blacks, and Hispanics can also provide clues about persistence of alcohol use disorders, especially alcohol dependence. Profiles characterized by physiologic signs and symptoms, such as withdrawal, tolerance, relief drinking, and unsuccessful attempts to cut down, may be more stable than others because of their association with

EPIDEMIOLOGY OF DRINKING, ALCOHOL USE DISORDERS, AND RELATED PROBLEMS 635 physiologic dependence. Grant (2000) showed that prothis group as a whole, without consideration for potential files of dependence among Blacks were more frequently differences across the various Latin American national characterized by signs of physiologic dependence (withgroups represented in the United States. Yet there are drawal, tolerance) and impairment of control over drinkconsiderable differences in drinking and alcohol use dising than those among Whites. Caetano et al. (2008) orders across Hispanic national groups. A random samreported similar findings, showing that the dependence ple household survey systematically examined these symptom profile for Blacks and Hispanics was characdifferences in drinking across US Hispanic national terized by a higher prevalence of tolerance and unsucgroups. The 2006 Hispanic Americans Baseline Alcohol cessful attempts to cut down. Survey (HABLAS) interviewed 5224 Hispanic adults in Like many other health problems, alcohol abuse and five metropolitan areas of the United States: Miami, dependence do not affect all individuals equally. The New York, Philadelphia, Houston, and Los Angeles. prevalence data reviewed above show that men had higher Trained bilingual interviewers conducted computerrates of abuse and dependence than women. In fact, men assisted personal interviews at the respondents’ home were about 2.5 times more likely than women to have that lasted about 1 hour. As can be seen in Table 37.4, alcohol abuse or dependence. Compared to those 65 years Puerto Rican and Mexican American men generally of age and older, the odds of developing an alcohol use reported higher drinking rates, weekly consumption, disorder (12-month data) were 13.2 (99% confidence interand binge drinking than South/Central and Cuban val (CI): 9.44–18.5) in the 18–29-year age group, 8.1 (99% Americans (Ramisetty-Mikler et al., 2010). Women CI: 5.8–11.2) in the 30–44-year age group, and 4.1 (99% CI: drank significantly less than men (Table 37.5). Mexican 2.9–5.7) in the 45–64-year age group (Hasin et al., 2007). American women reported the highest abstention rate Others who were also more at risk for alcohol use disor(61%), while Puerto Rican women drank more and binged ders were those who never married or who were widowed/ more frequently compared to their counterparts in other separated/divorced, those with lower education, and those national groups. Logistic analyses showed that being with an annual family income below $35 000 (Grant and younger, Puerto Rican or South/Central American, sinDawson, 1997; Hasin et al., 2007). gle, initiating drinking at < 14 years, US- or foreign-born Hispanic and Black ethnicity have also been associated men, and US-born women were significant predictors of with other alcohol-related problems. Hispanics are at a high binge drinking. Puerto Rican origin, initiating drinking at risk for alcohol-related motor vehicle fatalities (Hilton, < 17 years, and male gender (US- or foreign-born) were 2006), drinking and driving (Caetano and McGrath, significant predictors of volume of drinking. 2005; SAMHSA, 2005), intimate-partner violence Besides differences in drinking patterns and binge (Caetano et al., 2000, 2005), and alcoholic liver disease drinking, there also were substantial differences in (Stinson et al., 2001; Flores et al., 2008; Yoon and Yi, 12-month rates of alcohol use disorders across Hispanic 2008). Hispanics do not seem to profit from the protective national groups. Mexican American (5.6%) and Puerto effect that has been associated with moderate drinking on Rican men (5.2%) had higher rates than Cuban Americans all-cause mortality (Kerr et al., 2011). Blacks are at high risk (1.8%) and South/Central Americans (4.2%: Caetano for alcohol-related intimate-partner violence (Caetano et al., 2008). Among women, rates of alcohol abuse et al., 2000, 2005), fetal alcohol syndrome (FAS) (CDC, were lower, ranging from 1.1% to 0.2% across the dif2002; Russo et al., 2004), alcoholic liver disease (Flores ferent groups. Among men, rates of alcohol depenet al., 2008), and mortality from oral cavity and pharynx dence were also higher among Puerto Ricans (15.3%) (National Cancer Institute, 2011b). They also have a high and Mexican Americans (15.1%) compared to Cuban incidence and a high mortality from larynx cancer Americans (5.3%) and South/Central Americans (9%). (National Cancer Institute, 2011a) and esophageal cancer Puerto Rican women had the highest rates of alcohol (Day et al., 1993; Brown et al., 1994). Like Hispanics, Blacks dependence (6.4%), followed by Mexican Americans do not seem to benefit from a protective effect of moder(2.1%), Cuban Americans (1.6%), and South/Central ate drinking on cardiac diseases and all-cause mortality, Americans (0.8%). Further, while the highest rates of hypertension, and coronary heart diseases (Fuchs et al., abuse and dependence were among those in their 2001, 2004; Sempos et al., 2003; Kerr et al., 2011). 20s, the rate decline with age was not as strong as in the US population. Thus, Hispanics at older ages (i.e., 40–49 and 50–59 years) were at considerably more risk DRINKING, ALCOHOL USE DISORDERS, of dependence and its health consequences than the US AND OTHER PROBLEMS AMONG general population. This was particularly true of Puerto HISPANIC NATIONAL GROUPS Rican and Mexican American men. As stated above, much of the alcohol research with HisIn addition to alcohol abuse and dependence, there panics has described drinking and associated problems in were also significant national group differences in

Table 37.4 Current drinking and binge drinking among males by Hispanic national group and age: Proportions and means Hispanic national group

Drinking variable

Total

18–29 years

30–39 years

40–49 years

50 + years

Puerto Rican

Current drinker* Mean number of drinks per week {}}} Frequency of binge{{ One or more times per month
68.3 (687) 16.9  1.6 (448) (447) 6.3 42.3 51.4 66.1 (662) 8.4  0.9 (427) (425) 5.6 21.7 72.8 67.3 (635) 15.9  1.7 (435) (434) 6.7 39.5 53.8 68.2 (637)

72.2 (202) 18.1  2.8 (150) (148) 7.9 60.7 31.5 70.7 (84) 11.1  3.3 (61) (61) 11.4 27.0 61.7 74.6 (226) 15.3  2.6 (172) (174) 5.2 42.8 52.1 76.9 (212)

79.2 (148) 16.1  2.8 (112) (111) 4.1 40.0 55.9 77.1 (97) 7.9  1.6 (76) (75) 9.1 28.8 62.2 67.3 (179) 17.2  3.8 (119) (120) 10.3 45.0 44.7 74.3 (150)

58.1 (134) 24.3  6.1 (80) (80) 10.2 29.7 60.1 75.2 (134) 8.1  1.3 (100) (100) 2.8 29.9 67.4 68.1 (130) 16.8  3.4 (97) (95) 6.9 35.2 58.0 69.8 (117)

59.4 (203) 10.8  2.1 (106) (108) 4.6 29.3 66.1 57.4 (347) 7.7  1.4 (190) (189) 3.2 11.9 84.9 51.3 (100) 13.1  3.6 (47) (45) 2.1 23.9 74.0 52.5 (158)

Mean number of drinks per week{}{{

8.9  0.8 (442)

10.7  1.1 (163)

9.7  1.6 (116)

8.9  2.3 (79)

5.1  1.2 (84)

Frequency of binge{{ One or more times per month
(441) 6.5 36.4 57.1

(163) 11.5 37.2 51.3

(116) 4.1 44.4 51.5

(78) 6.7 36.6 56.8

(84) 0.8 26.0 73.2

Cuban American

Mexican American

Dominican/South Central (D/SC) American

{{}}

Numbers in parentheses are denominators used to compute proportions/means for a given subgroup; the proportions and means are weighted. *P < 0.001, {P < 0.05, indicates significant difference between age groups. { among current drinkers. } t-test significant between 40–49 and 50+ years. }} t-test significant between Puerto Rican and Cuban American. } t-test significant between Puerto Rican and D/SC. **t-test significant between Mexican American and Cuban American. {{ t-test significant between Mexican American and D/SC American. {{ t-test significant between 18–29 and 50+ years. }} t-test significant between 30–39 and 50+ years. Reproduced from Ramisetty-Mikler et al., (2010), copyright © 2010, Informa Healthcare. Reproduced with permission of Informa Healthcare.

Table 37.5 Current drinking and binge drinking among females by Hispanic national group and age: Proportions and means Hispanic national group

Drinking variable

Total

18–29 years

30–39 years

40–49 years

50+ years

Puerto Rican

Current drinker* Mean number of drinks per week{}}** Frequency of binge{ One or more times per month
43.1 (640) 9.5  2.3 (267) (266) 5.3 45.8 48.9 43.5 (661) 3.4  1.1 (230) (232) 0.6 21.8 77.6 39.3 (644) 3.0  1.0 (214)

53.1 (159) 9.2  2.0 (94) (92) 5.3 44.4 50.3 62.9 (66) 2.9  1.0 (38) (38) 2.3 28.7 69.0 45.5 (190) 1.9  0.4 (87)

44.8 (122) 13.2  7.2 (51) (51) 16.5 44.5 39.0 47.8 (119) 1.2  0.4 (48) (48) 0.0 8.7 91.3 30.8 (126) 2.6  1.2 (30)

30.7 (229) 11.9  7.0 (64) (63) 0.0 35.7 64.3 27.8 (368) 5.0  2.9 (87) (87) 0.0 7.7 92.3 40.0 (107) 7.1  4.7 (27)

Frequency of binge{ One or more times per month
(215) 1.0 25.1 73.9 46.7 (635)

(86) 1.9 28.4 69.8 50.1 (122)

46.0 (130) 4.3  1.6 (58) (60) 1.3 58.2 40.5 65.9 (108) 3.4  1.4 (57) (59) 0.0 42.2 57.8 38.5 (221) 1.9  0.6 (70) (71) 0.9 29.8 69.3 48.4 (152)

(31) 0.9 22.7 76.4 55.6 (171)

(27) 0.0 13.9 86.1 32.7 (190)

Mean number of drinks per week{** Frequency of binge{ One or more times per month
3.8  0.6 (286) (286) 0.6 26.7 72.8

4.2  0.9 (69) (69) 0.9 32.9 66.2

5.4  1.9 (74) (74) 1.4 33.7 65.0

2.6  0.8 (93) (93) 0.0 17.5 82.5

3.3  1.0 (50) (50) 0.0 26.4 73.6

Cuban American

Mexican American

Dominican/South Central (D/SC) American

Numbers in parentheses are denominators used to compute proportions/means for a given subgroup; the proportions and means are weighted. *P < 0.01, {P < 0.001: indicates significant difference between age groups. { among current drinkers. } t-test significant between 18–29 and 30–39 years. }} t-test significant between Puerto Rican and Cuban American. } t-test significant between Puerto Rican and Mexican American. **t-test significant between Puerto Rican and D/SC American. Reproduced from Ramisetty-Mikler et al. (2010), copyright © 2010, Informa Healthcare. Reproduced with permission of Informa Healthcare.

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alcohol-related problems. Alcohol problems can be dependence-related, as discussed above (i.e., increased tolerance, impaired control, prolonged intoxication), or social in nature (i.e., legal, interpersonal, or jobrelated). Although US Hispanics as a whole were less likely to report problems than non-Hispanics (Hilton, 1991; Caetano, 1997), Mexican Americans and Puerto Ricans appeared to be at greater risk than Cuban Americans (Caetano, 1998; Vaeth et al., 2009). Particularly, data from HABLAS show that, among men, 28% of Mexican Americans and 23% of Puerto Ricans reported two or more problems compared to 18% of South/Central Americans and 9% of Cuban Americans (Vaeth et al., 2009). Among women, Puerto Ricans were most likely to report two or more problems (i.e., 9%) versus 4% of Mexican Americans and South/Central Americans and 2% of Cuban Americans. Regarding the prevalence of specific types of problems, men, in general, regardless of national group, appeared to experience more dependence-related problems than social consequences. These included increased tolerance, impaired control, and salience of drinking. The most commonly reported social consequences included financial problems, belligerence, and problems with one’s spouse. Two additional points regarding Hispanic national group differences are worth noting. First, acculturation to life in the United States is a known positive predictor of drinking and alcohol problems (Caetano, 1987; Caetano et al., 2009). Moreover, its effect is also known to vary by gender, with stronger effects typically observed for women (Zemore, 2007). Results from the HABLAS sample have revealed that, although acculturation effects on drinking are comparable across Hispanic national groups (Mills and Caetano, 2010), effects on alcohol problems (abuse in particular) were slightly stronger among Puerto Ricans (Caetano et al., 2009). Future alcohol research with Hispanics must take this heterogeneity across national Hispanic group into consideration by conducting national-group specific analyses as often as possible. Because US Hispanics are still geographically divided, with different national groups concentrated in different areas of the country (e.g., Mexican Americans mostly in the Southwest, Puerto Ricans mostly in the Northeast, Cuban American mostly in Florida), local prevention and treatment efforts must effectively rely on research results specific to the dominant national group in that local area. Public health actions must also be guided by findings indicating that, in spite of many similarities, Puerto Ricans and Mexican Americans are at higher risk for abuse, dependence, and the associated consequences than the other two groups of US Hispanics.

DRINKING, ALCOHOL USE DISORDERS, AND OTHER PROBLEMS AMONG ASIAN AMERICANS Studies examining differences in drinking and alcohol use disorders across Asian American and Pacific Islander groups are less extensive than those for Hispanic national groups. For instance, the first two waves of the NESARC oversampled Blacks and Hispanics but not Asian Americans, limiting the utility of this national dataset for subgroup analyses by Asian American national groups. This apparent neglect results in part from the fact that, in spite of continuous population growth, Asian Americans are still about 5% of the US population. They are also seen as a group with low risk for alcohol problems because of their overall lower use of alcohol than other US ethnic groups. This perceived lower risk for excessive alcohol use and problems in Asian Americans is partially linked to research on alcohol-metabolizing gene variants, including the ALDH2*2 allele, which is observed at higher frequencies in Asians and reported to be protective for alcohol dependence in Japanese, Koreans, and Chinese (Kimura and Higuchi, 2011). Based on the NESARC, Asian Americans had a lower rate of past-year drinking (48.4%) when compared to other ethnicities (53.2–69.5%: Chen et al., 2006). However, there was considerable variation in drinking and binge drinking across Asian American national groups. Figure 37.1 shows data from the 2004-2008 NSDUH for adults 18 years and older (SAMHSA, 2010). Korean Americans had the highest rates of both past 30-day drinking and binge drinking. Japanese Americans also had higher rates of drinking than other groups, but similar rates of binge drinking to Filipino Americans and Vietnamese Americans. Asian Indians reported lower rates of both drinking measures, while Chinese Americans had the lowest rate of binge drinking but Past-30 Day Any alcohol use 51.9

Binge drinking

48.3 41.3

38.7

38.1 32.1

25.9 14.5

14.0 8.4

Korean

15.0 9.5

Japanese Chinese Vietnamese Filipino Asian Indian

Fig. 37.1. Drinking by Asian American subgroups, 2004–2008. Data from the National Survey on Drug Use and Health; numbers shown are percentages; respondents are adults (18 years or older); data for Pacific Islanders not available. (Reproduced from Substance Abuse and Mental Health Services Administration [SAMHSA], 2010.)

EPIDEMIOLOGY OF DRINKING, ALCOHOL USE DISORDERS, AND RELATED PROBLEMS similar drinking rates to Vietnamese and Filipino Americans. This report further showed that Asian Americans born in the United States had higher prevalence of drinking and binge drinking compared to those born outside the United States. Sakai et al. (2010), using 1999–2002 NSDUH data for respondents 12 years and older, compared rates of drinking between multiracial and single-race Asian Americans. Most multiracial Native Hawaiians, other Pacific Islanders, and Asian Americans reported a higher prevalence of lifetime alcohol use when compared to their respective single-race subgroups, but a lower prevalence compared to single-race Whites. The exception was for Japanese Americans, with single-race Japanese reporting higher drinking rates than multiracial Japanese. Data from the 2006 NSDUH described results for Native Hawaiians and Pacific Islanders separate from other Asian groups. Prevalence rates of 30-day binge (26.8%) and heavy alcohol use (12.6%) for Pacific Islander groups ages 18 or older were more than double that of other Asian groups (12.5% and 2.6%: SAMHSA, 2007). Regarding alcohol use disorders, trend data on alcohol abuse and dependence comparing NLAES and NESARC show that Asian Americans had the lowest rate of 12-month abuse (1% in NLAES, 2% in NESARC) and dependence (2.3% in NLAES, 2.4% in NESARC). The 2% rate of abuse in NESARC, the most recent survey, was 2.5 times lower than the rate for Whites and Native Americans, two times lower than the rate for Hispanics, and 1.6 times lower than the rate for Blacks. The 2.4% rate for dependence was 2.6–1.6 times lower than the rate in other ethnic groups. Hasin et al. (2007), reported similar findings when comparing Asian Americans and Whites, indicating that the former were less likely than Whites to meet criteria for 12-month and lifetime alcohol abuse and dependence. Takeuchi et al. (2007), using data from the 2002–2003 National Latino and Asian American Study, reported lifetime prevalence rates for substance use disorders among Asian American national groups. Filipinos were 2.3 times more likely to report a lifetime substance use disorder than Chinese Americans, with no statistical differences found between Chinese, Vietnamese, and other Asian Americans. Chae et al. (2008), based on data from the same survey, reported a 3.6% lifetime estimate of alcohol disorders in Asian Americans. Comparatively, Filipino Americans (20.2%) had a lower prevalence of lifetime alcohol disorders than other Asian Americans (39.3%), but a higher prevalence than Chinese Americans (10.3%) and Vietnamese Americans (2.5%). Price et al. (2002), also using US national data, reported a 12.8% lifetime rate of alcohol dependence for Japanese Americans, followed by 10.1% for Filipino Americans, and 9.7% for Korean

639

Americans, and with lower rates for Chinese (4.5%) and Vietnamese Americans (3.4%). For past-year alcohol dependence, Sakai et al. (2010) showed that multiracial Native Hawaiians and Filipinos had higher prevalence than both their respective single-race Asian subgroups (Native Hawaiians and Filipinos) and Whites (Filipinos only). Regarding other problems associated with alcohol use, data for liver cancers and motor vehicle deaths are relevant to Asian Americans. The majority (approximately 90%) of all primary liver cancers are hepatocellular carcinomas (HCC: Altekruse et al., 2009). Alcohol-related and non-alcohol-related liver cirrhosis usually precede HCC and are the two most common risk factors (Pelucchi et al., 2006; Altekruse et al., 2009; El-Serag, 2011). The relative risk for developing this cancer increases with increased levels of alcohol consumption (Pelucchi et al., 2006). By ethnic group, 2003–2005 age-adjusted incidence rates for HCC per 100 000 persons were highest among Asians (11.7), followed by Hispanics (8.0), Blacks (7.0), Native Americans (6.6), and Whites (3.9: Altekruse et al., 2009). Death rates for HCC per 100 000 people also were higher among minority groups, particularly Asian Americans (i.e., 8.9, 6.7, 5.8, 4.9, and 3.5 for Asians, Hispanics, Blacks, Native Americans, and Whites, respectively). Finally, the Centers for Disease Control and Prevention (CDC, 2009) statistics on alcohol-related motor vehicle crash deaths point to an important subgroup difference for Asian Americans. In 2006, the overall death rate among Asians (1.8 per 100 000 population) obscured the death rate among Native Hawaiians and other Pacific Islanders (5.9), which was less than the rate for Native Americans but similar to that for Hispanics (14.5 and 5.2, respectively).

DRINKING, ALCOHOL USE DISORDERS, AND OTHER PROBLEMS AMONG AMERICAN INDIANS AND ALASKA NATIVES American Indians/Alaskan Natives are highlighted here separately as a high-risk ethnic minority group for heavier drinking and adverse alcohol consequences. Unlike some other ethnic groups, in which men are primarily at greater risk for alcohol problems, both Native American men and women are high-risk groups. It should be acknowledged that differences in drinking and alcohol problems for Native Americans by tribe and US geographic region have been identified (May and Gossage, 2001a, b; Beals et al., 2003, 2005; Koss et al., 2003). In the US adult population, American Indians/Alaskan Natives have lower rates of abstinence than other ethnic minority groups. Seventeen percent (17.1%) of

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Native Americans reported lifetime abstinence from alcohol, according to the NESARC (Chen et al., 2006), a rate that is higher than Whites (13.4%), but lower than Hispanics (25.7%), Blacks (24.7%), and Asian Americans (39.1%). Among US adult drinkers (Fig. 37.2), American Indians/Alaskan Natives reported lower rates of daily heavy drinking (28.4%, exceeding daily drinking guidelines) than Hispanics (33.9%), similar to Whites (27.3%), and higher than Blacks (22.5%) and Asian Americans (19.2%). However, weekly heavy drinking (exceeding weekly drinking guidelines) was highest among American Indians/Alaskan Natives (21.9%) compared to all other ethnic groups (Whites, 16.3%; Blacks, 16.4%; Hispanics, 11.8%; Asians, 9.8%). The 2011 NSDUH (SAMHSA, 2012a) reported rates of binge drinking in the past 30 days of 24.3% for American Indians/Alaskan Natives. This rate was similar to that for Whites (23.9%) and Hispanics (23.4%), and higher than that for Blacks (19.4%) and Asian Americans (11.6%). Heavy drinking (binge drinking on at least 5 days in the past 30 days) was at least two times higher among American Indians/Alaskan Natives (over 10%) than among Blacks, Hispanics, and Asian Americans. Drinking among American Indians only (excluding Alaskan Natives) has been examined in the American Indian-Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP). This epidemiologic study interviewed a sample of randomly selected (from tribal rolls) American Indians 18-54 years of age living in the Southwest and Northern Plains (O’Connell et al., 2005). The Southwest sample drank less than the Northern Plains sample. For instance, in the heaviest-drinking category (most drinks consumed in a day were 18 or more and the number of drinking days during the past month was higher than four), 16% of the male group was from the Southwest, compared to 84% from the Northern Plains. Among women the percentages in this heaviest-drinking category were 12% for Current Drinkers Daily heavy drinking

Weekly heavy drinking 33.9

28.4

27.3 22.5

21.9 16.3

19.2

16.4 11.8

Native Americans†

Whites†

Blacks†

Hispanics

9.8

Asians†*

Fig. 37.2. Heavy drinking for US ethnic groups by gender. Data are from the 2002 National Epidemiologic Survey on Alcohol and Related Conditions; numbers shown are percentages; { Non-Hispanic; *includes Pacific Islanders. (Reproduced from Chen CM, Yi H-y, Falk DE, et al., 2006.)

Southwest Indians and 88% for Northern Plains. Other analyses of AI-SUPERPFP focusing on binge drinking showed that, among men, Northern Plains and Southwest Indians were six and two times more likely, respectively, to report binge drinking than a US reference population from the NLAES sample (all races excluding American Indians: O’Connell et al., 2005). Among women, Northern Plains and Southwest Indians were six times and 1.7 times more likely than the US NLAES reference group to engage in binge drinking. These high rates of heavy drinking increase risk in Native Americans for experiencing adverse alcohol consequences, including alcohol abuse and dependence. Hasin et al. (2007) reported for American Indians/ Alaskan Natives a higher prevalence of 12-month (12.1%) and lifetime (43.0%) alcohol use disorder compared to other ethnic groups (12-month, 4.5–8.9%; lifetime, 11.6–34.1%). Grant et al. (2004) reported rates of 12-month abuse and dependence in the 2002 NESARC by ethnicity. American Indians/Alaskan Natives had the highest rates of abuse (5.7%), followed by Whites (5.1%), Hispanics (3.9%), Blacks (3.3%), and Asian Americans (2.1%). A similar distribution of rates was reported for dependence. American Indians/Alaskan Natives had the highest rate (6.3%), followed by Hispanics (3.9%), Whites (3.8%), Blacks (3.6%), and Asian Americans (2.4%). Twelve-month prevalence rates for DSM-III-R abuse and dependence (American Psychiatric Association, 1987) for the AI-SUPERPFP dataset compared to the National Comorbidity Study (NCS: Kessler et al., 1994) were reported by Beals et al. (2005). These results show that, among men, the rates of abuse and dependence were 3.2% and 12.2% for Southwest Indians, 4.5% and 13% for Northern Plain Indians, and 3.5% and 10.7% for the NCS US national sample. Thus, rates of abuse were similar across the three groups, but rates of dependence were slightly higher (one or two percentage points) among the American Indians. Rates for women for abuse and dependence were 0.6% and 1.3% for Southwest Indians, 2.5% and 7.6% for Northern Plain Indians, and 1.6% and 3.7% for the NCS US national sample. Thus, the NCS national sample fell in the middle of the prevalence range, between the two Indian samples, with Northern Plain Indians reporting the highest prevalence rates. American Indians/Alaskan Natives are also at high risk for a series of other problems associated with excessive drinking. Driving under the influence (DUI) is an important alcohol-related problem. Caetano and McGrath (2005) reported higher 12-month self-report rates for DUI in White (22.0%) and Native American (20.8%) men and men of mixed race (22.5%) compared to other ethnicities (16.8–12.0%). Rates of self-reported DUI for women were highest for Native Americans and

EPIDEMIOLOGY OF DRINKING, ALCOHOL USE DISORDERS, AND RELATED PROBLEMS 641 women of mixed race (15.2% and 14.2%, respectively; of Research on Minority Health (NIMHD, 2013). In other ethnicities 11.8–6.8%). The DUI arrest rate for 1993, Public Law 103-43, the Health Revitalization Act Native Americans in 2001 was 479 arrestees per of 1993, established the Office of Research on Minority 100 000 residents compared with 332 for all other US ethHealth in the Office of the Director, NIH. In 2000, the nic groups (Perry, 2004). Rates of intoxication (i.e., National Center on Minority Health and Health Disparblood alcohol concentration (BAC)  0.08%) for drivers ities was established by the passage of the Minority who were fatally injured in a motor vehicle crash were Health and Health Disparities Research and Education highest for Native Americans (57%) and lowest for Act of 2000. The Institute of Medicine (IOM) of the Asians (approximately 20%), with Hispanics, Whites, National Academy of Sciences has released at least three and Blacks falling in between (Hilton, 2006). reports examining health disparities in the United States Native Americans are also overrepresented in (IOM, 2001, 2003, 2012). The 2003 IOM report defined national estimates of alcohol-involved suicides and health disparities as “racial or ethnic differences in the crime. Recent alcohol use, according to the CDC quality of healthcare that are not due to access-related (2009), was reported among suicide victims in 46% of factors, or clinical needs, preferences, and appropriateNative Americans compared to 30% of Hispanics, ness of interventions.” In spite of this recognition and a 26% of Whites, 16% of Blacks, and 15% of Asians. number of studies identifying specific areas of disparity, A high proportion (47%) of Native American suicide vicdifferences in access to health services and quality treattims tested positive for intoxication (BAC  0.08%: ment persist (IOM, 2012). Caetano et al., 2013). These proportions were lower in An important theoretic framework from which Hispanics (38%) and Whites (33%), and particularly health disparities across US ethnic groups can be underBlacks (26%) and Asians (23%). Native American suistood is that of cumulative adversity (Turner and Lloyd, cide victims testing positive for alcohol had the highest 1995; Hatch, 2005). The cumulative adversity theory mean BAC among these ethnic groups. Alcohol use also proposes that certain health problems, such as alcohol contributes to violence victimization among Native use disorders, are the consequence of long-term or Americans. According to the US Department of Justice simultaneous cumulative hardships that frequently (Perry, 2004), Native American violent crime victims are affect ethnic minorities. According to this model, ethmore likely (62%) than other violent crime victims, nic minority status shapes the opportunities to which including Whites (43%), Blacks (35%), and Asians one is exposed over the life course and influences (33%), to report alcohol use by their offender. health status. Hardships to which minority groups are FAS and liver disease are often-cited examples of the exposed include, but are not limited to, income disparnegative health effects for Native Americans. From 1995 ities (Lynch et al., 2000; Gallo and Matthews, 2003; to 1997, FAS rates averaged 0.4 per 1000 live births Meyer et al., 2008), unemployment, residential segreaccording to the Fetal Alcohol Syndrome Surveillance gation, substandard housing, discrimination (Krieger Network, with the highest rates reported by Native and Sidney, 1996; Brondolo et al., 2003; Mays et al., Americans (3.2 per 1000: CDC, 2002). Native Americans 2007), and decreased access to healthcare (Smedley have higher mortality rates for alcoholic liver disease et al., 2003). Within this framework, an accumulation than other US ethnic groups. The National Vital of adversities acting over time leads to an increased Statistical Reports (Minin˜o et al., 2011) on 2008 US allostatic load and results in negative coping behaviors deaths presented age-adjusted rates for alcoholic liver such as excessive alcohol use and greater vulnerability disease. Death rates for alcoholic liver disease in Native to ill health (McEwen, 2004). American men and women were 20.4 and 15.3 per Much of the research on health disparities in the 100 000 people, respectively, compared with 6.9 and United States is based on this model. For example, studies 2.4 for men and women in the general population. From have demonstrated how the cumulative adversities of low 2001 to 2005, alcohol-attributed deaths accounted for socioeconomic status, ethnic stigma/discrimination, and 11.7% of all Native American deaths, greater than twice other indicators of disadvantage impact drinking and the rate in the general population (CDC, 2008). substance use outcomes. Zemore et al. (2011) showed that perceived ethnic stigma was associated with alcohol dependence problems among those living below the povA THEORYABOUT HEALTH erty line. Lo and Cheng (2012) also showed that perceived DISPARITIES: CUMULATIVE discrimination had a positive association with substance ADVERSITIES use disorders among Hispanics, but that this association Health disparities across ethnic groups in US society was strongest among those with low income. Mulia et al. have been recognized for over 30 years. In 1990, the (2008) similarly found that extreme disadvantage, a National Institutes of Health (NIH) created the Office measure that included ethnic stigma, perceived unfair

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treatment, and poverty, was associated with problem drinking among Hispanics. Cerda´ et al. (2010) found that, among White and Black men and women, increased neighborhood poverty was associated with an increased likelihood of binge drinking and an increased number of drinks consumed per week. Neighborhood disadvantage has also been associated with heavy drinking (Karriker-Jaffe et al., 2012) and alcohol-related problems (Jones-Webb et al., 1997; Karriker-Jaffe et al., 2012). The research evidence on individual-level correlates (Hilton, 1991; Caetano and Kaskutas, 1995; Grant and Dawson, 1997; Grant et al., 2001; Hingson et al., 2006; Mulia et al., 2008) and neighborhood-level studies supports that socioeconomic adversities such as unemployment, lower education, lower family income, and negative life events are associated with a higher likelihood of heavier drinking and alcohol-related problems. Grant and Dawson (1997) and Hasin et al. (2007) reported that those with lower education and those with an annual family income below $35 000 have a higher risk of alcohol use disorders compared to those with higher education and higher income. Grant et al.’s (2007) results also showed a higher incidence of alcohol dependence among Blacks and Hispanics and those with a lower income. Although exceptions exist (Ennett et al., 1997; Pollack et al., 2005; Galea et al., 2007), studies of the effect of socioeconomic disadvantage at the neighborhood level have also reported positive associations between neighborhood poverty, drinking, and intimate-partner violence (Cunradi et al., 2000), neighborhood poverty, and binge drinking for men but not for women (McKinney et al., 2009), neighborhood poverty and alcohol-related problems among Black men (Jones-Webb et al., 1997), and alcohol outlet density (number of outlets per capita) and an increased risk of alcohol-related harms such as motor vehicle accidents, unintentional injuries, and sexually transmitted diseases (Scribner et al., 1999; Treno et al., 2001, 2007; Escobedo and Ortiz, 2002; Zhu et al., 2004; Cohen et al., 2006). There are a number of other factors that characterize ethnicity and alcohol use and alcohol use disorder. These include attitudes towards alcohol consumption, biologic vulnerabilities, and norms associated with drinking. These factors may provide other explanations for the disparities that are reported across ethnic groups. Some ethnic groups are more likely to consume high-alcoholcontent beverages (e.g., malt liquor), which could have greater social and health consequences (Vilamovska et al., 2009). Preference for such beverages seems to be more common in lower-income ethnic minority communities (Bluthenthal et al., 2005). Chartier and Caetano (2011) showed that Blacks and Hispanics underutilized some alcohol services compared to Whites, and Blacks and Hispanics with higher alcohol severity were less likely to use alcohol services. Studies also show a strong

positive association between acculturation to US society and drinking among Hispanic women (Caetano, 1987; Caetano and Medina-Mora, 1988). Discrimination experiences have also received increasing attention in health disparities research as a means of explaining ethnic group differences in health outcomes that remain after accounting for socioeconomic inequalities between Whites and ethnic minorities (Brondolo et al., 2009; Williams et al., 2010). Based on the 2005 NESARC, 25% of Blacks and 15% of Hispanics reported experiencing discrimination in the past year (McLaughlin et al., 2010). Experiences of ethnic discrimination are associated with any drinking, greater drinking frequency, and problem drinking among Blacks (Martin et al., 2003; Borrell et al., 2007, 2010; Tran et al., 2010) and greater drinking frequency, binge, and heavy drinking among Hispanics (Borrell et al., 2010; Tran et al., 2010). Mulia et al. (2008) examined the related variables of perceived ethnic group stigma and unfair treatment (not specifically based on ethnicity), and found positive relationships for these variables in predicting problem drinking among Blacks and Hispanics. Experiencing multiple forms of social adversities (stigma, unfair treatment, and poverty) also increased risk for problem drinking across ethnic groups. Zemore et al. (2011) showed that adversities accumulate in their association with alcohol problems. Unfair treatment for Blacks and perceived ethnic stigma for Hispanics was associated with alcohol dependence problems among those living below the poverty level but not above. Ethnic discrimination for Asians was associated with a greater likelihood of alcohol use disorders among individuals with low levels of ethnic identification (Chae et al., 2008).

CONCLUSIONS The existing epidemiologic evidence indicates that there are serious alcohol-related health disparities across racial and ethnic groups in the United States. Some of the areas in which disparities are evident are, for example, rates of alcohol abuse and dependence, liver cirrhosis, FAS, drinking and driving, alcohol-related suicides, and certain types of cancer. There also are disparities in access to treatment and recovery from alcohol use disorders. Among ethnic minority groups, American Indians and Alaska Natives seem to be disproportionately affected by alcohol problems, having some of the highest rates for alcohol abuse, dependence, and drinking and driving. Asian Americans, on the other hand, are less affected than other ethnic groups and even the White majority. Blacks and Hispanics are sometimes at a disadvantage, and sometimes have problem rates similar to Whites. The diversity in drinking and problems rates that is seen across these various groups also exists within

EPIDEMIOLOGY OF DRINKING, ALCOHOL USE DISORDERS, AND RELATED PROBLEMS groups, especially immigrant groups such as Hispanics and Asian Americans. This is because of the variety of drinking cultures that exist in the various countries from which these immigrants originate, as well as because of the variety of experiences that they have after their arrival in the United States. However, American Indians and Alaskan Natives are also quite diverse, and different tribes have very different patterns of alcohol use and problems. Finally, the White majority is not uniform either. Many Whites are immigrants, who came to the United States from a variety of countries in Europe and Scandinavia. These countries too, like those in Asia and Latin America, have different drinking cultures and thus the potential for difference in rates of alcoholrelated problems. The reasons for these health disparities are complex. Some are rooted in patterns of racial discrimination which themselves are linked to broader historic and persistent socioeconomic disadvantage characterizing minorities. This socioeconomic disadvantage is present at the individual level, being translated then as lack of opportunities for personal development through education, professional training, having secure and rewarding jobs, access to good healthcare, and also opportunities for creative and stimulating leisure activities. Socioeconomic disadvantage also affects the living environment, the neighborhoods where minorities live. These neighborhoods are frequently in inner-city areas, which are racially and economically segregated and characterized by substandard housing, poor schools, high crime, an excessive number of alcohol outlets, gang-related violence, and general social disorganization. Excessive drinking can be used as a coping mechanism for life in these conditions. Research has an important role to play in society’s attempts to ameliorate the problems associated with excessive alcohol use. First, research can identify the problems and provide accurate unbiased descriptions of their magnitude and nature. Alcohol epidemiology studies in the United States have provided such descriptions for the past 30 years. Much has been learned about drinking among ethnic groups during these years. Yet, as seen in the text above, much of the information collected applies only to ethnic groups combined in such a broad way that limits considerably the use of this knowledge. As ethnic minority group representation in US society grows, research must become more specific, describing alcohol-related problems at national-group level for immigrant groups and tribes or groups of tribes for American Indians and Alaska Natives. Research must also go beyond a purely descriptive level to include testing of specific hypotheses about the origin of health disparities. Theories about why such disparities exist have been developed but not tested in a systematic manner.

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A number of unique epidemiologic studies that can clarify important questions related to health disparities are yet to be conducted. For instance, important questions related to the role of immigration, acculturation, acculturation stress, and birthplace can only be appropriately answered with longitudinal studies of recently arrived immigrants, perhaps with comparison groups formed by members of the same immigrant group born in the United States. These studies are difficult to conduct and costly, which makes them especially challenging in an era of diminishing funding for health research. As they become more specific in description or hypothesis testing, these studies must meet the challenge of remaining relevant to a broader context in US society.

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