dangers of alcohol essay

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Alcohol's Effects on Health

Research-based information on drinking and its impact.

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Alcohol's effects on the body.

Drinking too much – on a single occasion or over time – can take a serious toll on your health.  Here’s how alcohol can affect your body:

Brain: Alcohol interferes with the brain’s communication pathways, and can affect the way the brain looks and works. These disruptions can change mood and behavior, and make it harder to think clearly and move with coordination .  

Heart: Drinking a lot over a long time or too much on a single occasion can damage the heart, causing problems including:

• Cardiomyopathy – Stretching and drooping of heart muscle
• Arrhythmias – Irregular heart beat
• High blood pressure  

Liver: Heavy drinking takes a toll on the liver, and can lead to a variety of problems and liver inflammations including:

• Steatosis, or fatty liver
• Alcoholic hepatitis

Pancreas: Alcohol causes the pancreas to produce toxic substances that can eventually lead to pancreatitis , a dangerous inflammation in the pancreas that causes its swelling and pain (which may spread) and impairs its ability to make enzymes and hormones for proper digestion . 

Cancer: According to the National Cancer Institute: "There is a strong scientific consensus that alcohol drinking can cause several types of cancer. In its Report on Carcinogens, the National Toxicology Program of the US Department of Health and Human Services lists consumption of alcoholic beverages as a known human carcinogen.

"The evidence indicates that the more alcohol a person drinks–particularly the more alcohol a person drinks regularly over time–the higher his or her risk of developing an alcohol-associated cancer. Even those who have no more than one drink per day and people who binge drink (those who consume 4 or more drinks for women and 5 or more drinks for men in one sitting) have a modestly increased risk of some cancers. Based on data from 2009, an estimated 3.5% of cancer deaths in the United States (about 19,500 deaths were alcohol related."

Clear patterns have emerged between alcohol consumption and increased risks of certain types of cancer:

• Head and neck cancer, including oral cavity, pharynx, and larynx cancers.
• Esophageal cancer, particularly esophageal squamous cell carcinoma. In addition, people who inherit a deficiency in an enzyme that metabolizes alcohol have been found to have substantially increased risks of esophageal squamous cell carcinoma if they consume alcohol.
• Liver cancer.
• Breast cancer: Studies have consistently found an increased risk of breast cancer in women with increasing alcohol intake. Women who consume about 1 drink per day have a 5 to 9 percent higher chance of developing breast cancer than women who do not drink at all.
• Colorectal cancer.

For more information about alcohol and cancer, please visit the National Cancer Institute's webpage " Alcohol and Cancer Risk " (last accessed October 21, 2021).

Immune System: Drinking too much can weaken your immune system, making your body a much easier target for disease.  Chronic drinkers are more liable to contract diseases like pneumonia and tuberculosis than people who do not drink too much.  Drinking a lot on a single occasion slows your body’s ability to ward off infections – even up to 24 hours after getting drunk.

For more information about alcohol's effects on the body, please visit the  Interactive Body feature  on NIAAA's  College Drinking Prevention website .

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Alcohol and Your Brain: The Latest Scientific Insights

Want to protect your brain here's what you need to know about alcohol consumption..

Posted March 18, 2024 | Reviewed by Devon Frye

• What Is Alcoholism?
• Find a therapist to overcome addiction
• Transient memory loss, “blackouts,” and hangovers related to alcohol consumption are brain health risks.
• Alcohol use disorder (alcoholism) is a risk factor for developing dementia.
• Heavy or excessive alcohol consumption is dangerous to the brain for a number of reasons.
• The impact of mild to moderate alcohol consumption (1-3 drinks a day) on brain function is less clear.

Depending on who you ask, you might be told to drink a few glasses of red wine a day or to avoid alcohol altogether. The reasons for such recommendations are many, but, by and large, they tend to stem from a study someone read about or saw reported in the news.

So why is it so hard to know whether alcohol is good or bad for us—especially for our brains? In this post, we’ll explore the current science and some practical ideas on how to approach the topic.

What Is Alcohol Anyway?

When people talk about drinking “alcohol,” they’re almost always referring to the consumption of ethanol. Ethanol is a natural product that is formed from the fermentation of grains, fruits, and other sources of sugar. It’s found in a wide range of alcoholic beverages including beer, wine, and spirits like vodka, whiskey, rum, and gin.

Evidence for human consumption of alcohol dates back over 10,000 years. Consumption of alcohol has and continues to serve major roles in religious and cultural ceremonies around the world. But unlike most food products, in the last century, alcohol has been wrapped up in nearly perpetual controversy over its moral effects and health implications.

How Does Alcohol Impact the Brain?

As anyone who’s consumed alcohol knows, ethanol can directly influence brain function. Ethanol is classified as a “depressant” because it has a generally slowing effect on brain activity through activation of γ-aminobutyric acid (GABA) pathways.

In an acute sense, consumption of alcohol can lead to uninhibited behavior, sedation, lapses in judgment, and impairments in motor function. At higher levels, the effects can progress to coma and even death.

The Known Brain-Damaging Effects of Excess Alcohol

There is no debate here: Excessively high levels of alcohol consumption over short periods of time are toxic and potentially deadly, specifically because of its effects on the brain.

One critical fact to understand about the overall and brain-specific effects of alcohol is that the entirety of the debate around the risk/benefit ratio concerns mild to moderate alcohol consumption. As it relates to the effects of high amounts of alcohol on the body and brain, the research is consistent: It’s a very bad choice.

High amounts of alcohol use are causal risk factors in the development of disease in the heart, liver, pancreas, and brain (including the brains of children in utero). In fact, 1 in 8 deaths in Americans aged 20-64 is attributable to alcohol use. When it comes to adults, excessive alcohol use can cause multiple well-defined brain issues ranging from short-term confusion to dementia .

What Is “Excessive” or “High” Alcohol Use?

Key to the nuance in the conversation about alcohol use are definitions. Across the board, “excessive” or “high” alcohol use is linked to worse overall and brain health outcomes. So what does that mean?

While definitions can be variable, one way to look at this is the consumption of 4 or more drinks on an occasion (for women) and 5 or more for men. Additionally, excess alcohol is defined as drinking more than 8 drinks a week (women) and 15 a week (men), or consuming alcohol if you are pregnant or younger than age 21.

Beyond this, by definition, consuming enough alcohol to cause a “brownout,” “blackout,” hangover, or other overt brain symptomatology is evidence that the alcohol you’ve consumed is creating problems in your brain. Alcohol use disorder (or alcoholism ) is also a clear issue for the brain. It has been linked to a higher risk for dementia, especially early-onset dementia in a study of 262,000 adults, as well as to smaller brain size .

Is There a “Safe” Amount of Alcohol for the Brain?

In a highly publicized article from Nature Communications , researchers looked at brain imaging data from nearly 37,000 middle-aged to older adults and cross-referenced their brain scans with their reported alcohol consumption. The findings were profound: People who drank more alcohol had smaller brains, even in people drinking only one or two alcoholic beverages a day.

Conversely, other recent data suggest a lower risk for dementia in people consuming a few alcoholic beverages a day. This includes a 2022 study showing that in around 27,000 people, consuming up to 40 grams of alcohol (around 2.5 drinks) a day was linked to a lower risk for dementia versus abstinence in adults over age 60. A much larger study of almost 4 million people in Korea noted that mild to moderate alcohol consumption was linked to a lower risk for dementia compared to non-drinking.

How Do We Make Sense of This Data?

When it comes to the bottom line as it relates to alcohol consumption and brain health, the data are rather solid on some fronts, and a bit less so on others. There’s also the potential for confounding variables, including the fact that many people like to drink alcohol to enjoy and enhance social bonds (which we know are beneficial for the brain). Here’s a summary of what the most recent research is telling us.

• Experiencing transient memory loss, “blackouts,” or hangovers related to alcohol consumption is overt evidence of threats to brain health.
• The impact of mild to moderate alcohol consumption (1-3 drinks a day) on brain function is less clear, but it seems unreasonable to start alcohol use for brain health.

Austin Perlmutter, M.D. , is a board-certified internal medicine physician and the co-author of Brain Wash .

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Home — Essay Samples — Nursing & Health — Alcohol Abuse — The Impact of Alcohol Abuse: Causes, Effects, and Solutions

The Impact of Alcohol Abuse: Causes, Effects, and Solutions

• Categories: Alcohol Abuse Health Care Policy Social Justice

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Published: Mar 16, 2024

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The Risks Associated With Alcohol Use and Alcoholism

Alcohol consumption, particularly heavier drinking, is an important risk factor for many health problems and, thus, is a major contributor to the global burden of disease. In fact, alcohol is a necessary underlying cause for more than 30 conditions and a contributing factor to many more. The most common disease categories that are entirely or partly caused by alcohol consumption include infectious diseases, cancer, diabetes, neuropsychiatric diseases (including alcohol use disorders), cardiovascular disease, liver and pancreas disease, and unintentional and intentional injury. Knowledge of these disease risks has helped in the development of low-risk drinking guidelines. In addition to these disease risks that affect the drinker, alcohol consumption also can affect the health of others and cause social harm both to the drinker and to others, adding to the overall cost associated with alcohol consumption. These findings underscore the need to develop effective prevention efforts to reduce the pain and suffering, and the associated costs, resulting from excessive alcohol use.

Alcohol consumption has been identified as an important risk factor for illness, disability, and mortality ( Rehm et al. 2009 b ). In fact, in the last comparative risk assessment conducted by the World Health Organization (WHO), the detrimental impact of alcohol consumption on the global burden of disease and injury was surpassed only by unsafe sex and childhood underweight status but exceeded that of many classic risk factors, such as unsafe water and sanitation, hyper-tension, high cholesterol, or tobacco use ( WHO 2009 ). This risk assessment evaluated the net effect of all alcohol consumption—that is, it also took into account the beneficial effects that alcohol consumption (primarily moderate consumption) can have on ischemic diseases 1 and diabetes ( Baliunas et al. 2009 ; Corrao et al. 2000 ; Patra et al. 2010 ; Rehm et al. 2004 ). Although these statistics reflect the consequences of all alcohol consumption, it is clear that most of the burden associated with alcohol use stems from regular heavier drinking, defined, for instance, as drinking more than 40 grams of pure alcohol per day for men and 20 grams of pure alcohol per day for women 2 ( Patra et al. 2009 ; Rehm et al. 2004 ). In addition to the average volume of alcohol consumption, patterns of drinking—especially irregular heavy-drinking occasions, or binge drinking (defined as drinking at least 60 grams of pure alcohol or five standard drinks in one sitting)—markedly contribute to the associated burden of disease and injury ( Gmel et al. 2010 ; Rehm et al. 2004 ). This article first defines which conditions necessarily are caused by alcohol use and for which conditions alcohol use is a contributing factor. It then looks more closely at the most common disease risks associated with excessive alcohol use, before exploring how these risks have influenced guidelines for drinking limits. The article concludes with a discussion of the alcohol-related risk of harm to people other than the drinker.

Disease and Injury Conditions Associated With Alcohol Use

Conditions for which alcohol is a necessary cause.

More than 30 conditions listed in the WHO’s International Classification of Diseases, 10th Edition (ICD–10) ( WHO 2007 ) include the term “alcohol” in their name or definition, indicating that alcohol consumption is a necessary cause underlying these conditions (see table 1 ). The most important disease conditions in this group are alcohol use disorders (AUDs), which include alcohol dependence and harmful use or alcohol abuse. 3 AUDs are less fatal than other chronic disease conditions but are linked to considerable disability ( Samokhvalov et al. 2010 d ). Overall, even though AUDs in themselves do not rank high as a cause of death globally, they are the fourth-most disabling disease category in low- to middle-income countries and the third-most disabling disease category in high-income countries ( WHO 2008 ). Thus, AUDs account for 18.4 million years of life lost to disability (YLDs), or 3.5 percent of all YLDs, in low- and middle-income countries and for 3.9 million YLDs, or 5.7 percent of all YLDs, in high-income countries. However, AUDs do not affect all population subgroups equally; for example, they mainly affect men, globally representing the second-most disabling disease and injury condition for men. In contrast, AUDs are not among the 10 most important causes of disabling disease and injury in women ( WHO 2008 ).

Disease Conditions That by Definition Are Attributable to Alcohol (AAF = 100%)

Note: ICD codes in italics represent subcodes within a main code of classification.

Abbreviations: AAF = alcohol-attributable fraction.

Alcoholic liver disease and alcohol-induced pancreatitis are other alcohol-specific disease categories that are of global importance. However, no global prevalence data on these disease categories exist because they cannot be validly assessed on a global level. Thus, these conditions are too specific to assess using verbal autopsies and other methods normally used in global-burden-of-disease studies ( Lopez et al. 2006 ; pancreatitis can be estimated indirectly Rajaratnam et al. 2010 ). Nevertheless, via the prevalence of alcohol exposure the prevalence of alcohol-attributable and relative risk for the wider, unspecific liver cirrhosis and alcohol-induced disease categories ( Rehm et al. 2010 a ).

Conditions for Which Alcohol Is a Component Cause

Disease and injury conditions for which alcohol consumption is a component cause contribute more to the global burden of disease than do alcohol-specific conditions. Overall, the following are the main disease and injury categories impacted by alcohol consumption (listed in the order of their ICD–10 codes):

• Infectious disease;
• Neuropsychiatric disease;
• Cardiovascular disease;
• Liver and pancreas disease; and
• Unintentional and intentional injury.

For all chronic disease categories for which detailed data are available, those data show that women have a higher risk of these conditions than men who have consumed the same amount of alcohol; however, the differences are small at lower levels of drinking ( Rehm et al. 2010 a ). The following sections will look at these disease categories individually.

Individual Disease and Injury Conditions Associated With Alcohol Use

Infectious diseases.

Although infectious diseases were not included in the WHO’s comparative risk assessments for alcohol conducted in 2000 ( Rehm et al. 2004 ) and 2004 ( Rehm et al. 2009 b ), evidence has been accumulating that alcohol consumption has a detrimental impact on key infectious diseases ( Rehm et al. 2009 a , 2010 a ), such as tuberculosis ( Lönnroth et al. 2008 ; Rehm et al. 2009 c ), infection with the human immunodeficiency virus (HIV) ( Baliunas et al. 2010 ; Shuper et al. 2010 ), and pneumonia ( Samokhvalov et al. 2010 c ). In fact, recent studies (Rehm and Parry 2009 ; Rehm et al. 2009 a ) found that the overall impact of alcohol consumption on infectious diseases is substantial, especially in sub-Saharan Africa.

One of the pathways through which alcohol increases risk for these diseases is via the immune system, which is adversely affected by alcohol consumption, especially heavy drinking ( Rehm et al. 2009 c ; Romeo et al. 2010 ). As a result, although risk for infectious diseases does not differ greatly for people drinking less than 40 grams of pure alcohol per day compared with abstainers, this risk increases substantially for those who drink larger amounts or have been diagnosed with an AUD ( Lönnroth et al. 2008 ; Samokhvalov et al. 2010 c ). In addition, alcohol consumption is associated with poorer outcomes from infectious disease for heavy drinkers by way of social factors. Thus, people with alcohol dependence often are stigmatized and have a higher chance of becoming unemployed and destitute; as a result, they tend to live in more crowded quarters with higher chances for infection and lower chances of recovery ( Lönnroth et al. 2009 ).

The relationship between alcohol consumption and HIV infection and acquired immunodeficiency syndrome (AIDS) is different from that with other infectious diseases. To become infected with HIV, people must exchange body fluids, in most cases either by injecting drugs with a contaminated needle or, more commonly in low-income societies, engaging in unsafe sex. Thus, although significant associations exist between alcohol use, especially heavy drinking, and HIV infection via alcohol’s general effects on the immune system ( Baliunas et al. 2010 ; Kalichman et al. 2007 ; Shuper et al. 2009 , 2010 ), it cannot be excluded that other variables, including personality characteristics, psychiatric disorders, and situational factors may be responsible for both risky drinking and unsafe sex ( Shuper et al. 2010 ). Researchers frequently have pointed out that personality characteristics, such as a propensity for risk-taking, sensation-seeking, and sexual compulsivity, may be involved in the risk of HIV infection. Indeed, a recent consensus meeting determined that there is not yet sufficient evidence to conclude that alcohol has a causal impact on HIV infection ( Parry et al. 2009 ). However, it can be argued that experimental studies in which alcohol consumption led to a greater inclination to engage in unsafe sex indicate that some causal relationship between alcohol and HIV infection exists (e.g., George et al. 2009 ; Norris et al. 2009 ).

Once a person is infected with HIV, alcohol clearly has a detrimental impact on the course of the disease, especially by interfering with effective antiretroviral treatment ( Pandrea et al. 2010 ). A recent meta-analysis found that problem drinking—defined as meeting the National Institute on Alcohol Abuse and Alcoholism (NIAAA)’s criteria for at-risk drinking or having an AUD—was associated with being less than half as likely to adhere to antiretroviral treatment guidelines ( Hendershot et al. 2009 ). Because the level of adherence to the treatment regimen affects treatment success as well as outright survival, alcohol consumption clearly is associated with negative outcomes for people living with HIV and AIDS.

Recently, the Monograph Working Group of the International Agency for Research on Cancer concluded that there was sufficient evidence for the carcinogenicity of alcohol in animals and classified alcoholic beverages as carcinogenic to humans ( Baan et al. 2007 ). In particular, the group confirmed, or newly established, the causal link between alcohol consumption and cancer of the oral cavity, pharynx, larynx, esophagus, liver, colorectum, and female breast. For stomach and lung cancer, carcinogenicity was judged as possible but not established. For all sites where alcohol’s causal role in cancer is established, there is evidence of a dose-response relationship, with relative risk rising linearly with an increasing volume of alcohol consumption ( Corrao et al. 2004 ).

The molecular and biochemical mechanisms by which chronic alcohol consumption leads to the development of cancers of various organs are not fully understood. It has been suggested that these mechanisms differ by target organ and include variations (i.e., polymorphisms) in genes encoding enzymes responsible for ethanol metabolism (e.g., alcohol dehydrogenase, aldehyde dehydrogenase, and cytochrome P450 2E1), increased estrogen concentrations, and changes in folate metabolism and DNA repair ( Boffetta and Hashibe 2006 ; Seitz and Becker 2007 ). In addition, the International Agency for Research on Cancer group concluded that acetaldehyde—which is produced when the body breaks down (i.e., metabolizes) beverage alcohol (i.e., ethanol) but also is ingested as a component of alcoholic beverages— itself is carcinogenic. It likely plays an important role in the development of cancers of the digestive tract, especially those of the upper digestive tract ( Lachenmeier et al. 2009 ; Seitz and Becker 2007 ).

The relationship between alcohol consumption and diabetes is complex. A curvilinear relationship exists between the average volume of alcohol consumption and the inception of diabetes ( Baliunas et al. 2009 )—that is, lower alcohol consumption levels have a protective effect, whereas higher consumption is associated with an increased risk. The greatest protective effect has been found with a consumption of about two standard drinks (28 grams of pure alcohol) per day, and a net detrimental effect has been found starting at about four standard drinks (50 to 60 grams of pure alcohol) per day.

Neuropsychiatric Disorders

With respect to neuropsychiatric disorders, alcohol consumption has by far the greatest impact on risk for alcohol dependence. However, alcohol also has been associated with basically all mental disorders (e.g., Kessler et al. 1997 ), although the causality of these associations is not clear. Thus, mental disorders may be caused by AUDs or alcohol use, AUDs may be caused by other mental disorders, or third variables may be causing both AUDs and other mental disorders. This complex relationship makes it difficult to determine the fraction of mental disorders actually caused by alcohol consumption (see Grant et al. 2009 ).

The relationship between alcohol and epilepsy is much clearer. There is substantial evidence that alcohol consumption can cause unprovoked seizures, and researchers have identified plausible biological pathways that may underlie this relationship ( Samokhvalov et al. 2010 a ). Most of the relevant studies found that a high percentage of heavy alcohol users with epilepsy meet the criteria of alcohol dependence.

Cardiovascular Diseases

The overall effect of alcohol consumption on the global cardiovascular disease burden is detrimental (see table 2 ). Cardiovascular disease is a general category that includes several specific conditions, and alcohol’s impact differs for the different conditions. For example, the effect of alcohol consumption on hypertension is almost entirely detrimental, with a dose-response relationship that shows a linear increase of the relative risk with increasing consumption ( Taylor et al. 2009 ). A similar dose-response relationship exists between alcohol consumption and the incidence of atrial fibrillation 4 ( Samokhvalov et al. 2010 b ). On the other hand, for heart disease caused by reduced blood supply to the heart (i.e., ischemic heart disease), the association with alcohol consumption is represented by a J-shaped curve ( Corrao et al. 2000 ), with regular light drinking showing some protective effects. Irregular heavy drinking occasions, however, can nullify any protective effect. In a recent systematic review and meta-analysis comparing the effects of different drinking patterns in people with an overall consumption of less than 60 grams of pure alcohol per day, Roerecke and Rehm (2010) found that consumption of 60 grams of pure alcohol on one occasion at least once a month eliminated any protective effect of alcohol consumption on mortality. The authors concluded that the cardio-protective effect of moderate alcohol consumption disappears when light to moderate drinking is mixed with irregular heavy-drinking occasions. These epidemiological results are consistent with the findings of biological studies that—based on alcohol’s effects on blood lipids and blood clotting—also predict beneficial effects of regular moderate drinking but detrimental effects of irregular heavy drinking ( Puddey et al. 1999 ; Rehm et al. 2003 ).

Global Burden of Alcohol-Attributable Disease in Disability-Adjusted Life Years (DALYs) (in 1,000s) by Sex and Disease Category for the Year 2004

NOTE: M = men; W = women; T = total.

SOURCE: Rehm et al. 2009 a,b .

The effects of alcohol consumption on ischemic stroke 5 are similar to those on ischemic heart disease, both in terms of the risk curve and in terms of biological pathways ( Patra et al. 2010 ; Rehm et al. 2010 a ). On the other hand, alcohol consumption mainly has detrimental effects on the risk for hemorrhagic stroke, which are mediated at least in part by alcohol’s impact on hypertension.

Overall, the effects of alcohol consumption on cardiovascular disease are detrimental in all societies with large proportions of heavy-drinking occasions, which is true for most societies globally ( Rehm et al. 2003 a ). This conclusion also is supported by ecological analyses or natural experiments. For example, studies in Lithuania ( Chenet et al. 2001 ) found that cardiovascular deaths increased on weekends, when heavy drinking is more common. Also, when overall consumption was reduced in the former Soviet Union (a country with a high proportion of heavy-drinking occasions) between 1984 and 1994, the death rate from cardiovascular disease declined, indicating that alcohol consumption had an overall detrimental effect on this disease category ( Leon et al. 1997 ).

Diseases of the Liver and Pancreas

Alcohol consumption has marked and specific effects on the liver and pancreas, as evidenced by the existence of disease categories such as alcoholic liver disease, alcoholic liver cirrhosis, and alcohol-induced acute or chronic pancreatitis. For these disease categories, the dose-response functions for relative risk are close to exponential ( Irving et al. 2009 ; Rehm et al. 2010 b ), although the risks associated with light to moderate drinking (i.e., up to 24 grams of pure alcohol per day) are not necessarily different from the risks associated with abstention. Thus, the incidence of diseases of the liver and pancreas is associated primarily with heavy drinking.

It is important to note that given the same amount of drinking, the increase in the risk for mortality from these diseases is greater than the increase in risk for morbidity, especially at lower levels of consumption. This finding suggests that continued alcohol consumption, even in low doses, after the onset of liver or pancreas disease, increases the risk of severe consequences.

Unintentional Injuries

The link between alcohol and almost all kinds of unintentional injuries has long been established. It depends on the blood alcohol concentration (BAC) and shows an exponential dose-response relationship ( Taylor et al. 2010 ). Alcohol affects psychomotor abilities, with a threshold dose for negative effects generally found at BACs of approximately 0.04 to 0.05 percent (which typically are achieved after consuming two to three drinks in an hour); accordingly, injury resulting from alcohol’s disruption of psychomotor function could occur in people with BACs at this level ( Eckardt et al. 1998 ). However, the epidemiological literature shows that even at lower BACs, injury risk is increased compared with no alcohol consumption ( Taylor et al. 2010 ).

The acute effects of alcohol consumption on injury risk are mediated by how regularly the individual drinks. People who drink less frequently are more likely to be injured or to injure others at a given BAC compared with regular drinkers, presumably because of less tolerance ( Gmel et al. 2010 ). This correlation was demonstrated with respect to traffic injuries in a reanalysis ( Hurst et al. 1994 ) of a classic study conducted in Grand Rapids, Michigan ( Borkenstein et al. 1974 ). It also is important to realize that even if the absolute risk for injury may be relatively small for each occasion of moderate drinking (defined as drinking up 36 grams pure alcohol in one sitting), the lifetime risks from such drinking occasions sums up to a considerable risk for those who often drink at such a level ( Taylor et al. 2008 ).

Intentional Injuries

Alcohol consumption is linked not only to unintentional but also to intentional injury. Both average volume of alcohol consumption and the level of drinking before the event have been shown to affect suicide risk ( Borges and Loera 2010 ). There also is a clear link between alcohol consumption and aggression, including, but not limited to, homicides ( Rehm et al. 2003 b ). Several causal pathways have been identified that play a role in this link, including biological pathways acting via alcohol’s effect on receptors for the brain signaling molecules (i.e., neurotransmitters) serotonin and γ-aminobutyric acid or via alcohol’s effects on cognitive functioning ( Rehm et al. 2003 b ). Cultural factors that are related to both differences in drinking patterns and beliefs and expectations about the effects of alcohol also influence the relationship between drinking and aggression ( Bushman and Cooper 1990 ; Graham 2003 ; Leonard 2005 ; Room and Rossow 2001 ).

Implications of Alcohol-Related Risks for Drinking Guidelines

Overall, the various risks associated with alcohol use at various levels can be combined to derive low-risk drinking guidelines. Such analyses found that overall, any increase in drinking beyond one standard drink on average per day is associated with an increased net risk for morbidity and mortality in high-income countries ( Rehm et al. 2009 ). Moreover, at any given consumption level this risk increase is larger for women than for men. NIAAA has translated the epidemiological findings into low-risk drinking limits of no more than 14 standard drinks per week for men and 7 standard drinks per week for women ( NIAAA 2010 ). These guidelines also specify that to limit the risk of acute consequences, daily consumption should not exceed four standard drinks for men and three for women ( NIAAA 2010 ).

Overall Global Impact of Alcohol Consumption on Burden of Disease

The most recent systematic overview on the effects of alcohol on global burden of disease was based on data for the year 2004 ( Rehm et al. 2009 a , b ) (see table 2 ). The analyses found that although AUDs (which constitute the major part of the neuropsychiatric disorders listed in the table) clearly are important contributors to global burden of disease, they only account for less than one-third of the overall impact of alcohol consumption. Almost equally important are the acute effects of alcohol consumption on the risk of both unintentional and intentional injury. In addition, alcohol has a sizable effect on the burden of disease associated with infectious diseases, cancer, cardiovascular disease, and liver cirrhosis. However, alcohol consumption also has beneficial effects on the burden of disease, mainly on diabetes and the ischemic disease subcategory of cardiovascular diseases. Yet these effects are by far outweighed by the detrimental consequences of alcohol consumption.

Effects of Alcohol on People Other Than the Drinker

So far, the discussion has centered on alcohol’s effects on health as measured by indicators that primarily are based on the records of hospitals and health systems. Reflecting the information contained in those records, most of the effects considered refer to the health of the drinker. However, this analytic approach omits two large classes of adverse consequences of alcohol: social harm to the drinker and social and health harms to others that result from the drinker’s alcohol consumption. According to the Constitution of the WHO ( WHO 1946 ), health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (p. 100); this definition therefore takes into account not just physical and mental harms but also social harms, both for the drinker and for others.

A few examples of harm to others are included in the analysis of alcohol’s contribution to the global burden of disease listed in table 2 . These include perinatal conditions attributable to the mother’s drinking during pregnancy and injuries, particularly assault injuries. However, the scope of alcohol-related social harm and of harm to others stretches well beyond these items. Thus, a recent study in Australia ( Laslett et al. 2010 ) identified the following harms to others associated with drinking:

• Harms identified based on records—these included deaths and hospitalizations (e.g., attributed to traffic injuries because of driving under the influence), child abuse or neglect cases involving a caregiver’s drinking, and domestic and other assaults; and
• Harms based on survey reports—these included negative effects on coworkers, household members, other relatives and friends, strangers, and on the community as a whole.

These effects were quite prevalent. Thus, the researchers estimated that within 1 year, more than 350 deaths were attributed to drinking by others, and more than 10 million Australians (or 70 percent of all adults) were negatively affected by a stranger’s drinking ( Laslett et al. 2010 ).

Social Harm

Drinkers also experience a range of social harms because of their own drinking, including family disruption, problems at the workplace (including unemployment), criminal convictions, and financial problems ( Casswell and Thamarangsi 2009 ; Klingemann and Gmel 2001 ). Unfortunately, assessment of these problems is much less standardized than assessment of health problems, and many of these harms are not reported continuously. Social-cost studies provide irregular updates of alcohol-attributable consequences in selected countries (for an overview, see Rehm et al. 2009 b ; Thavorncharoensap et al. 2009 ). These studies regularly find that health care costs comprise only a small portion of the overall costs associated with alcohol use and that most of the alcohol-associated costs are attributable to productivity losses. In total, the costs associated with alcohol use seem to amount to 1 to 3 percent of the gross domestic product in high-income countries; the alcohol-associated costs in South Korea and Thailand, the only two mid-income countries for which similar studies are available, were at about the same level.

Conclusions

As this review has shown, alcohol use is associated with tremendous costs to the drinker, those around him or her, and society as a whole. These costs result from the increased health risks (both physical and mental) associated with alcohol consumption as well as from the social harms caused by alcohol. To reduce alcohol’s impact on the burden of disease as well as on other social, legal, and monetary costs, it therefore is imperative to develop effective interventions that can prevent or delay initiation of drinking among those who do not drink, particularly adolescents, and limit consumption to low-risk drinking levels among those who do consume alcohol. The remaining articles in this journal issue present several such intervention approaches that are being implemented and evaluated in a variety of settings and/or are targeted at different population subgroups. Together with alcohol-related prevention policies, the implementation of specific interventions with proven effectiveness can help reduce the pain and suffering, and the associated costs, resulting from excessive alcohol use.

Acknowledgments

Financial support for this study was provided by NIAAA contract HHSN267200700041C to conduct the study titled “Alcohol- and Drug-Attributable Burden of Disease and Injury in the U.S.”

The views expressed here do not necessarily reflect the views of the funding agency.

F inancial D isclosure

Jürgen Rehm, Ph.D., received a salary and infrastructure support from the Ontario Ministry of Health and Long-Term Care. No potential conflicts of interest relevant to this article were reported.

1 Ischemic diseases are all conditions that are related to the formation of blood clots, which prevent adequate blood flow to certain tissues.

2 In the United States, a standard drink usually is considered to contain 0.6 fluid ounces (or 14 grams) of pure alcohol. This is the amount of ethanol found in approximately 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of distilled spirits. However, many drinks, as actually poured, contain more alcohol. Thus, for example, a glass of wine often contains more than 5 fluid ounces and therefore may correspond to one and a half or even two standard drinks.

3 The condition referred to as “harmful use” in the ICD–10 loosely corresponds to “alcohol abuse,” as defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Diseases, 4th Edition (DSM–IV).

4 Atrial fibrillation is an abnormal heart rhythm involving the two upper chambers (i.e., atria) of the heart.

5 A stroke is the disruption of normal blood flow to a brain region. In the case of an ischemic stroke, this is caused by blockage of a blood vessel that prevents the blood from reaching neighboring brain areas. In the case of a hemorrhagic stroke, rupture of a blood vessel and bleeding into the brain occurs, which prevents normal blood supply to other brain regions.

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Discussion Question One

The main objectives of the program were to raise awareness as well as to educate on the dangers of alcohol and substance abuse. The program was also designed to educate the youth on how to subdue the influence of the social environment towards alcohol and substance abuse. Finally, the program was designed to educate the youth on financial and recreational time management in order to prevent the tendency towards the alcohol and substance abuse. The outcomes evaluation was performed based on these objectives. At the end of the project, the literacy levels of the participants, especially on the dangers of alcohol and substance abuse. The outcomes evaluation was done through a written examination that was administered to the participants. The results of this evaluation were compared with the results in the baseline evaluation at the beginning of the project. The comparison of the results showed a marked improvement in the awareness of the participants on the dangers of alcohol and substance abuse (Geshi et al., 2007).

The increased awareness on the dangers of alcohol and substance abuse also lead to a change in the attitudes towards alcohol and substance abuse. In the baseline evaluation, I sought to determine the attitudes of the participants on whether alcohol and substance abuse merited as a social problem. The outcomes evaluation showed that more participants considered alcohol and substance abuse a social problem that required a concerted effort to solve. Additionally, the outcome evaluations showed that more participants would be willing to take part in other educational programs designed to raise awareness of the dangers of alcohol and substance abuse. 78% of the participants committed to a challenge where for one year, they would not consume alcohol, use illegal substances and prescription drugs (National Drugs Campaign, 2013).

Through the implementation of the program, I learnt a number of lessons. Firstly, the design of the program incorporated many aspects without considering the amount of time available for the project and the literacy levels of the participants. Due to the low literacy levels, more time was required to comprehend each aspect of the health education program. I also learnt that diverse cultures have a bearing on the success and effectiveness of a health education program. Different cultures have different perspectives on issues of alcohol and substance abuse. As highlighted in the previous discussion, culture was one of the barriers (Timmerman, 2007). People form the Carribean region found it difficult to understand why marijuana was highlighted as one of the banned substances. Their influence on other participants was antagonistic to the achievements that the program hoped to achieve.

Discussion Question Two

If I were to design this program in the future, I would do a number of things differently. Firstly, I would reduce the scope of the program so as to increase its effectiveness and cover the various aspects of the program more comprehensively. This was a problem during the implementation of the program. The low literacy levels required more time on various aspects of the program (Singleton & Krause, 2009). Reducing the scope of the program would enhance the effectiveness and behavior change. Overcoming this challenge required the use of informative films and giving handouts.

If I were to design this program in the future, I would use other instructors in order to enhance better delivery. This could also be helpful with the barrier of low English proficiency, especially if the instructors are ethnically diverse. The current program used the peers to translate where communication was hampered by low proficiency in English. This might have affected the effectiveness of the program, especially because the peers were also there to learn. More instructors for the health lectures would also add credibility to the programs, especially if the instructors had different areas of expertise (Cairns et al., 2011).

Cairns, et al., G. (2011). Investigating the Effectiveness of Education in Relation to Alcohol: A Systematic Investigation of Critical Elements for Optimum Effectiveness of Promising Approaches and Delivery Methods in School and Family Linked Alcohol Education. Retrieved from> http://alcoholresearchuk.org/downloads/finalReports/FinalReport_ 0083.pdf Geshi, M. et al., (2007). Effects of Alcohol-related Health Education on Alcohol and Drinking Behavior Awareness among Japanese Junior College Students: A Randomized Controlled Trial, Acta Medica Okayama,61(6): 345-354. National Drugs Campaign (2013). How drug use can impact your life. Retrieved from> http://www.drugs.health.gov.au/internet/drugs/publishing.nsf/content/youth4 Singleton, K. & Krause, E. (2009). Understanding cultural and linguistic barriers to health literacy. The online journal of issues in nursing, 14 (3): Manuscript 4. Timmerman, G. (2007). Addressing barriers to health promotion in underserved women, Family & community health, 30 (1): 34-42

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Ethan Crumbley’s Parents Were Just Part of a Much Bigger Problem

By Elizabeth Spiers

Ms. Spiers, a contributing Opinion writer, is a journalist and digital media strategist.

James and Jennifer Crumbley never anticipated that their then-15-year-old son, Ethan, would use the 9-millimeter Sig Sauer handgun Mr. Crumbley had bought — ostensibly as an early Christmas present — to kill four students at a Michigan high school. At least that’s the argument their lawyers made in court before Ms. Crumbley, last month, and Mr. Crumbley, almost two weeks ago, were convicted of involuntary manslaughter in separate trials. Prosecutors argued that the Crumbleys did not do enough to secure the gun and ignored warning signs that Ethan was planning to use it.

After every mass shooting by a teenager at a school, there is an instinct to look to the shooter’s parents to understand what went wrong. In the case of the Crumbleys, this seems obvious: Ethan left disturbing journal entries fantasizing about shooting up the school, and stating that he had asked his parents for help with his mental health issues but didn’t get it. His father said the family had a gun safe but the safe’s combination was the default factory setting, 0-0-0.

One factor that’s gotten less attention, however, is how the Crumbleys’ attitudes and actions reflect an increasingly insidious gun culture that treats guns as instruments of defiance and rebellion rather than as a means of last resort.

I’ve been thinking about this case a lot because I grew up in the 1980s and ’90s in a rural part of the Deep South where almost everyone I knew had guns in the house, unsecured, and mental illness was stigmatized and often went untreated. Church was considered a superior venue for counseling, and only “crazy” people sought professional help. If the evidence for criminal negligence is a failure to lock up a gun and ignoring signs of mental illness, many of the adults I grew up around would have been (and still would be) vulnerable to the same charges as the Crumbleys.

It’s convenient and comforting for many people to believe that if it had been their child, they’d have prevented this tragedy. But prison visiting rooms are full of good, diligent parents who never thought their kid would be capable of landing there.

My parents didn’t own a gun safe, but kept guns hidden away from us, which, like many gun owners at the time, they thought of as “secured.” The men in my family were all hunters and the guns they kept were hunting rifles, not AR-15s. (You can’t feed a family with deer meat that’s been blown to bits.) I knew my parents kept a handgun, too, but it was never shown to us, or treated as a shiny new toy.

Gun culture was different then. It would have never occurred to my parents to acquire an entire arsenal of guns and display them prominently around the house, as some people now do, or ludicrously suggest that Jesus Christ would have carried one . They did not, as more than a few Republican politicians have done, send out Christmas photos of their children posing with weapons designed explicitly to kill people at an age when those children likely still believed Santa existed. Open carry was legal, but if you were to walk into the local barbecue joint with a semiautomatic rifle on your back emblazoned with fake military insignia, people would think you were creepy and potentially dangerous, not an exemplar of masculinity and patriotism.

All of these things happen now with regularity, and they’re considered normal by gun owners who believe that any kind of control infringes on their Second Amendment rights. Children are introduced at a young age to guns like the Sig Sauer that Ethan Crumbley used. They’re taught to view guns as emblematic of freedom and the right to self-defense — two concepts that have been expanded to include whatever might justify unlimited accumulation of weapons.

“Freedom” is short for not being told what to do, even though the law very much dictates how and when guns should be used. “Self-defense” is often talked about as a justifiable precaution in the event of home invasion, though home invasions are as rare as four-leaf clovers and do not require an arsenal unless the invader is a small army. (It’s also worth noting that basic home security systems are far less expensive than many popular guns, which suggests that at the very least, some gun owners may be intentionally opting for the most violent potential scenario.) Most important, too many children are taught that guns confer power and can and should be used to intimidate other people. (Relatedly, any time I write about gun control, at least one gun owner emails to say he’d love to shoot me, which is not exactly evidence of responsible gun ownership.)

Mass shooters often begin with a grievance — toward certain populations, individuals they feel wronged by, society at large — and escalate their behavior from fantasizing about violence to planning actual attacks. A study from 2019 suggests that feeling inadequate may make gun owners more inclined toward violence. In the study, gun owners were given a task to perform and then told that they failed it. Later they were asked a number of questions, including whether they would be willing to kill someone who broke into their home, even if the intruder was leaving. “We found that the experience of failure increased participants’ view of guns as a means of empowerment,” wrote one researcher , “and enhanced their readiness to shoot and kill a home intruder.”

The study hypothesized that these gun owners “may be seeking a compensatory means to interact more effectively with their environment.”

Good parents model healthy interactions all the time. If their kids are struggling with a sense of inferiority or are having trouble dealing with failure, we teach them self-confidence and resilience. Parents who treat guns as a mechanism for feeling more significant and powerful are modeling an extremely dangerous way to interact with their environment.

What’s particularly hypocritical here is that the most strident defenders of this culture skew conservative and talk a lot about what isn’t appropriate for children and teenagers. What they think is inappropriate often includes educating kids about sex, about the fact that some people are gay or transsexual and about racism. It’s a perverse state of affairs: Exposing children to simple facts is dangerous, but exposing them to machines designed to kill is not. You can’t get your driver’s license until you’re a teenager, or buy cigarettes and alcohol until you’re 21, but much earlier than that, kids can, with adult supervision, legally learn how to end someone’s life.

Parents can’t ensure that their child won’t ever feel inferior or disempowered, or even in some cases become delusional or filled with rage. Teenagers do things that their parents would never anticipate every day, even if they’re close and communicative. Some develop serious drug habits or become radicalized into extremism or take their own lives.

One thing parents can ensure is that their children cannot get access to a gun in their house. The only foolproof way to do that is to ensure that there’s no gun in the house to begin with. Barring that, parents can make sure they are not reinforcing a toxic gun culture that says that displaying and threatening to use lethal machines is a reasonable way to deal with anger or adversity. That message makes the idea of killing someone seem almost ordinary.

That doesn’t prevent school shooters; it primes them.

Elizabeth Spiers, a contributing Opinion writer, is a journalist and digital media strategist.

Source photographs by CSA-Printstock and John Storey, via Getty Images.

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