National Institute on Alcohol Abuse and Alcoholism No. 23 PH 347 January 1994

Alcohol and Minorities

Do blacks, Hispanics, American Indians, and Asians and Pacific Islanders in the United States drink more or less than whites drink? Do they have more alcohol-related medical problems? Do they receive treatment in proportion to their problems? In 1990, 68.3 percent of whites, 64.5 percent of Hispanics, and 55.6 percent of blacks used alcohol (1). Although these percentages appear similar, different patterns of use and abuse and varying prevalence of alcohol-related problems underlie the numbers (2-9). This Alcohol Alert considers why some minorities have more medical problems than others and whether minorities receive adequate treatment and prevention services. It examines genetic and environmental factors that may put minorities at risk for or protect them from alcohol problems. It also reviews research on screening to identify those at risk for alcoholism or alcohol abuse.

Medical Consequences and Alcohol-Related Trauma

Given major underreporting of alcohol-related diagnoses, minimum estimates from one survey of non-Federal, short-stay hospitals in 1991 found 54.5 patient discharges for alcohol-related diagnoses for every 10,000 people in the United States over age 15 (10). The rate for whites was 48.2 per 10,000; however, the rate for blacks was 102.9 per 10,000 population (10). Because it is not known whether the rates of underreporting are equal among ethnic groups, it is difficult to interpret the meaning of such reported differences.

A study of alcohol-related mortality in California showed that blacks and Hispanics had higher rates of mortality from alcoholic cirrhosis than did whites or Asian-Americans. Nationwide, death rates attributed to alcohol dependence syndrome also were highest for blacks, although a higher percentage of blacks than whites abstain from using alcohol (5,11). The high rates of medical problems seen in blacks thus occur among a smaller percentage of the black population when compared with whites.

The California study suggests that for many alcohol-related causes of death such as alcohol dependence syndrome and alcoholic hepatitis, Hispanics had either similar or lower mortality rates compared with whites. However, the mortality rate among Hispanics from alcohol-related motor vehicle crashes was 9.16 per 100,000, significantly higher than the rates for whites (8.15) or blacks (8.02) (11).

The group identified as "Asian/Other" in the California study had lower rates of alcohol-related mortality than any other group for most causes of death. Their mortality rate from motor vehicle crashes, for example, was 5.39 per 100,000 (11). Asians tend to have lower rates of drinking and alcohol abuse than whites (2).

Although highly variable among tribes, alcohol abuse is a factor in five leading causes of death for American Indians, including motor vehicle crashes, alcoholism, cirrhosis, suicide, and homicide. Mortality rates for crashes and alcoholism are 5.5 and 3.8 times higher, respectively, among American Indians than among the general population. Among tribes with high rates of alcoholism, reports estimate that 75 percent of all accidents, the leading cause of death among American Indians, are alcohol related (7).

Fetal Alcohol Syndrome (FAS)

The prevalence of FAS among select groups of Navajo, Pueblo, and Southwestern Plains Indians has been studied. Among two populations of Southwestern Plains Indians ages newborn to 14 years, 10.7 of every 1,000 children were born with FAS. This was compared with 2.2 per 1,000 for Pueblo Indians and 1.6 for Navajo (12). Overall rates for FAS in the Un ited States range from 1 to 3 per 1,000 (15). Cultural influences, patterns of alcohol consumption, nutrition, and differing rates of alcohol metabolism or other innate physiological differences may account for the varying FAS rates among Indian communities (13).

The incidence of FAS among blacks appears to be about seven times higher than among whites, although more blacks than whites abstain from drinking (5,14,15). The reasons for this difference in FAS rates are not yet known (14,15). Paradoxically, one study has found that black women believe drinking is acceptable in fewer social situations than do white women (6). Ten percent of black compared with 23 percent of white women surveyed said that drinking more than one or two drinks at a bar with friends is acceptable (6). This attitudinal difference could help to explain why fewer black women are frequent, high-quantity drinkers than are white women (6). Nevertheless, FAS seems to be more prevalent among blacks than among whites.

Genetic Influences

Certain minority groups may possess genetic traits that either predispose them to or protect them from becoming alcoholic. Few such traits have so far been discovered. However, the flushing reaction, found in the highest concentrations among people of Asian ancestry, is one example.

Flushing has been linked to variants of genes for enzymes involved in alcohol metabolism. It involves a reddening of the face and neck due to increased blood flow to those areas and can be accompanied by headaches, nausea, and other symptoms. Flushing can occur when even small amounts of alcohol are consumed (16).

Japanese-Americans living in Los Angeles have been studied. Among those with quick flushing responses (flushing occurs after one drink or less), fewer consumed alcohol than did those with no or with slow flushing responses (flushing occurs after two or more drinks)(17). In another group of Japanese-American students in Los Angeles, flushing was far less correlated with abstention from alcohol than it was in the first group (17). Thus, although flushing appears to deter alcohol use, people with the trait may nevertheless consume alcohol.

Another genetic difference between ethnic groups occurs among other enzymes involved in metabolizing alcohol in the liver. Variations have been observed between the structures and activity levels of the enzymes prevalent among Asians, blacks, and whites (18). One enzyme found in Japanese, for example, has been associated with faster elimination of alcohol from the body when compared with whites (19). Interesting leads relating these varying rates of alcohol metabolism among minorities to medical complications of alcoholism, such as liver disease, are now being followed.

Influence of Acculturation

Acculturation has a dramatic effect on drinking patterns among immigrants to the United States and successive generations. Comparisons of drinking among immigrant and second and third generation Mexican-American women reveal that drinking rates of successive generations approach those of the general population of American women. Seventy-five percent of Mexican immigrant women in one study abstained from alcohol; only 38 percent of third generation Mexican-American women abstained. This rate is close to the 36-percent abstention rate for women in the general U.S. population (20). Rates of alcohol-related problems also may be affected by acculturation. A study has found that Hispanic women who are at least second generation Americans have higher rates of social and personal problems than either foreign born or first generation Hispanic women (3). Studies of Asian-Americans have suggested that their drinking rates conform to those of the U.S. population as acculturation occurs (17,21).

Identification and Treatment

Do screening instruments for alcohol-relat ed problems, validated in primarily white populations, accurately detect alcohol problems among minorities? One study evaluated the Self-Administered Alcoholism Screening Test (SAAST), translated into Spanish, in Mexico City and the original English version in Rochester, MN. The Spanish translation identified alcoholics and nonalcoholics at rates comparable to those of the English version. The study found that the questions that best predicted alcoholism were the same in both versions (22). This study suggests that translations or other revisions of screening tools may be just as accurate as the original instruments, but more studies are needed before firm conclusions can be drawn.

It is not known whether all treatment programs are effective for members of minority groups. Among minority patients who enter treatment programs for the general population, success rates are equal to those of whites in the same programs (23,24). Also, despite the existence of programs designed to treat specific minority groups, no evidence exists that either supports or denies their ability to produce improved outcomes (25,26).

Do minorities have the same access to alcoholism treatment as do whites? Access to treatment for minorities has not been assessed widely, but several factors have been studied. There is evidence that not everyone in these groups who needs treatment receives it. For example, Hispanics and blacks are less likely to have health insurance and more likely to be below the poverty level than whites, factors that may decrease their access to treatment (24,27,28).

No studies focus on access to alcoholism treatment for the U.S. Hispanic population as a whole (28). Some culturally sensitive programs exist for Hispanics and are often aimed at specific cultures within this group, such as Puerto Ricans. These programs have not been evaluated (24,28).

Prevention

Prevention efforts that work among the general population have been shown to be effective among some minorities (29). However, it is unclear whether interventions designed for specific minorities also would be beneficial. For example, programs incorporating peer counseling, enhancing adolescents' coping skills, and alcohol education appear to be effective among American Indians. One study has demonstrated that specific populations of American Indian adolescents who completed such a program used less alcohol when compared with their peers 6 months after completion of the program (29). A second study showed that American Indian participants in another program decreased their own use of alcohol when evaluated 12 months after the program's completion (30).

The effectiveness of warning labels on alcoholic beverage containers has been evaluated in a group of black women (31). A study showed that 6 months after the label was mandated by law, pregnant black women who were light drinkers slightly reduced their drinking during pregnancy, whereas black women who were heavier drinkers did not change their drinking habits (31).

Alcohol and Minorities--A Commentary by
NIAAA Director Enoch Gordis, M.D.

The increasing number of studies of alcohol problems among minorities has produced both important findings and new questions to answer. Higher abstention rates among African-Americans coexist with higher cirrhosis mortality. Native American groups vary greatly in their drinking practices, but the specific contributions of social, cultural, and genetic influences to these variations are not yet known. We need to understand why acculturation seems to increase drinking among successive generations of Hispanics and diminishes the "protective" effect of the flushing reaction among succeeding generations of Asian-Americans. Finally, we need to know more about disparities in access to treatment and prevention among minority groups and whether culturally relevant treatment appr oaches improve treatment outcome.

References

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Journal of Studies on Alcohol 51(3):221-232, 1990. (5) Herd, D. The epidemiology of drinking patterns and alcohol-related problems among U.S. blacks. In: Alcohol Use Among U.S. Ethnic Minorities. National Institute on Alcohol Abuse and Alcoholism Research Monograph No. 18. DHHS Pub. No. (ADM)89-1435. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1989. pp. 3-50. (6) Herd, D. An analysis of alcohol-related problems in black and white women drinkers. Addiction Research 1(3):181-198, 1993. (7) Manson, S.M.; Shore, J.H.; Baron, A.E.; Ackerson, L.; & Neligh, G. Alcohol abuse and dependence among American Indians. In: Helzer, J.E., and Canino, G.J., eds. Alcoholism in North America, Europe, and Asia. New York: Oxford University Press, 1992. pp. 113-130. (8) Manson, S.M.; Shore, J.H.; Bloom, J.D.; Keepers, G.; & Neligh, G. Alcohol abuse and major affective disorders: Advances in epidemiologic research among American Indians. In: Alcohol Use Among U.S. Ethnic Minorities. National Institute on Alcohol Abuse and Alcoholism Research Monograph No. 18. DHHS Pub. No. (ADM)89-1435. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1989. pp. 291-300. (9) Windle, M. Alcohol use and abuse: Some findings from the National Adolescent Student Health Survey. Alcohol Health & Research World 15(1):5-10, 1991. (10) Caces, M.F., & Dufour, M.C. Surveillance Report #28: Trends in Alcohol-Related Morbidity Among Short-Stay Community Hospital Discharges, United States: 1979-91. National Institute on Alcohol Abuse and Alcoholism. Division of Biometry and Epidemiology. Dec. 1993. (11) Sutocky, J.W.; Shultz, J.M.; & Kizer, K.W. Alcohol-related mortality in California, 1980 to 1989. American Journal of Public Health 83(6):817-823, 1993. (12) May, P.A. Fetal alcohol effects among North American Indians: Evidence and implications for society. Alcohol Health & Research World 15(3):239-248, 1991. (13) Aase, J.M. The fetal alcohol syndrome in American Indians: A high risk group. Neurobehavioral Toxicology and Teratology 3(2):153-156, 1981. (14) Chávez, G.F.; Cordero, J.F.; & Becerra, J.E. Leading major congenital malformations among minority groups in the United States, 1981-1986. Journal of the American Medical Association 261(2):205-209, 1989. (15) Sokol, R.J.; Ager, J.; & Martier, S. Significant determinants of susceptibility to alcohol teratogenicity. Annals of the New York Academy of Sciences 477:87-102, 1986. (16) Thomasson, H.R., & Li, T.-K. How alcohol and aldehyde dehydrogenase genes modify alcohol drinking, alcohol flushing, and the risk for alcoholism. Alcohol Health & Research World 17(2):167-172, 1993. (17) Nakawatase, T.V.; Yamamoto, J.; & Toshiaki, S. The association between fast-flushing response and alcohol use among Japanese Americans. Journal of Studies on Alcohol 54(1):48-53, 1993. (18) Burnell, J.C., & Bosron, W.F. Genetic polymorphism of human liver alcohol dehydrogenase and kinetic properties of the isoenzymes. In: Crow, K.E., and Batt, R.D., eds. Human Metabolism of Alcohol: Volume 2. Regulation, Enzymology, and Metabolites of Ethanol. Boca Raton, FL: CRC Press, 1989. pp. 65-75. (19) Meier-Tackmann, D.; Leonhardt, R.A.; Agarwal, D.P.; & Goedde, H.W. Effect of acute ethanol drinking on alcohol metabolism in subjects with different ADH and ALDH genotypes. Alcohol 7(5):413-418, 1990. (20) Gilbert, M.J. Acculturation and changes in drinking patterns among Mexican-American women. Alcohol Health & Research World 15(3):234-238, 1991. (21) Johnson, R.C., & Nagoshi, C.T. Asians, Asian-Americans and alcohol. Journal of Psychoactive Drugs 22(1):45-52, 1990. (22) Davis, L.J., Jr.; de la Fuente, J.-R.; Morse, R.M.; Landa, E.; & O'Brien, P.C. Self-Administered Alcoholism Screening Test (SAAST): Comparison of classificatory accuracy in two cultures. Alcoholism: Clinical and Experimental Research 13(2):224-228, 1989. (23) Gilbert, M.J., & Cervantes, R.C. Alcohol services for Mexican Americans: A review of utilization patterns, treatment considerations and prevention activities. Hispanic Journal of Behavioral Sciences 8(3):191-223, 1986. (24) Institute of Medicine. Populations defined by structural characteristics. In: Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press, 1990. pp. 356-380. (25) Institute of Medicine. Patient-treatment matching and outcome improvement in alcohol rehabilitation. In: Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: National Academy Press, 1989. pp. 231-246. (26) Westermeyer, J. Alcoholism and services for ethnic populations. In: Pattison, E., and Kaufman, E., eds. Encyclopedic Handbook of Alcoholism. New York: Gardner Press, 1982. pp. 709-717. (27) Anderson, R.M.; Giachello, A.L.; & Aday, L.A. Access of Hispanics to health care and cuts in services: A state-of-the-art overview. Public Health Reports 101(3):238-252, 1986. (28) Caetano, R. Priorities for alcohol treatment research among U.S. Hispanics. Journal of Psychoactive Drugs 25(1):53-60, 1993. (29) Gilchrist, L.D.; Schinke, S.P.; Trimble, J.E.; & Cvetkovich, G.T. Skills enhancement to prevent substance abuse among American Indian adolescents. International Journal of the Addictions 22(9):869-879, 1987. (30) Carpenter, R.A.; Lyons, C.A.; & Miller, W.R. Peer-managed self-control program for prevention of alcohol abuse in American Indian high school students: A pilot evaluation study. International Journal of the Addictions 20(2):299-310, 1985. (31) Hankin, J.R.; Firestone, I.J.; Sloan, J.J.; Ager, J.W.; Goodman, A.C.; Sokol, R.J.; & Martier, S.S. The impact of the alcohol warning label on drinking during pregnancy. Journal of Public Policy & Marketing 12(1):10-18, 1993.

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