The traditions within a society exert a strong influence on use. A drug may be available with easy access and low cost, but cultural factors may either forbid use or keep use within moderate bounds. Actively religious Amish, Mormon, Jewish, and Moslem people have extremely low rates of alcoholism in association with strong cultural norms for moderate drinking (i.e., Amish and Jewish) or total abstinence (i.e., Mormons and Moslems).
Some cultural groups have an ideal norm that values abstinence, but with a behavioral norm that tolerates heavy drinking. This pattern of an ideal/behavioral norm split prevails among the Celtic peoples (e.g., Irish, Scottish, Welsh), many American Indian groups, and many Buddhist peoples in Asia. This norm split pattern is associated with high rates of alcoholism.
Certain alcohol related causes of death have increased over the last century in the U.S. These include liver cirrhosis, violent death and alcohol related cancers. At the same time, other diseases associated with alcoholism have decreased. These include pulmonary tuberculosis and pneumonia - long the most common causes of death during the last century and in the early days of this century. Public health laws, quarantine, and medications have greatly reduced tuberculosis rates. Early diagnosis and antibiotic therapy have had a similar effect on pneumonia death rates. Alcoholics now live longer and die of more chronic complications, such as cirrhosis and neoplasms. Access to high speed vehicles and greater levels of social violence have resulted in more alcohol related violence. Thus, there has been a replacement of some alcohol related problems (e.g., tuberculosis, pneumonia) by other alcohol related problems (e.g., cirrhosis, violence, laryngeal cancer) in association with changes in medical science, technology, economics, and culture.
Among people in their late teens and twenties, especially males, certain rates have been increasing. In addition, other drug-related problems, such as hepatitis and acquired immune deficiency syndrome (AIDS), have been increasing. What do these data indicate? One might optimistically interpret them as indicating a drop in alcoholism in association with greater public awareness and more available treatment. Or alcoholism may simply be occurring earlier, and in frequent association with drug dependence, but without any substantial decrease despite expenditures now into the many billions of dollars over the last few decades. Time and further studies should clarify the issue.
Studies are generally based on statistical association, rather than all-or-none, A-causes-B research. Statistical association does not prove causation. In addition, substance abuse is associated with many other factors that may or may not play a causal role. For example, alcoholism tends to be associated with cigarette smoking, divorce, and poor nourishment. These associated factors may add to the risk of developing alcohol abuse (and such alcohol related problems as, e.g., upper respiratory cancers, suicide, Korsakoff's psychosis). Individual vulnerability or invulnerability to pharmacological factors must also be considered. For example, a person's flushing response to alcohol may offer some protection against alcoholism, but not against other sedative or opioid abuse.
Another methodological problem involves distinguishing cause and effect. Did the alcoholism cause the marital problem or did the marital problem cause the alcoholism? Or as often occurs, did each exacerbate the other? Since these problems develop over long periods outside the ken of clinicians and investigators, this further adds to the difficulty of ascertaining cause-effect relationships.
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