In this monumental review of research showing substantial psychological benefits from consuming alcohol moderately, Stanton (with Archie Brodsky) shows how complex is the world of psychoactive substances. Those who drink moderately show improved feelings, better mental health, greater sociability and social integration, higher incomes, and particularly better long-term cognitive functioning. The latter has been demonstrated by prospective studies across a range of American and European populations, including with discordant (for drinking) identical twins. The public health enterprise of identifying the damages and costs due to alcohol consumption thus seems to require another column in its ledger.
Prepublication version of article appearing in Drug and Alcohol Dependence, 60: 221-247, 2000
© Copyright 2000 Stanton Peele. All rights reserved.
Exploring Psychological Benefits Associated with Moderate Alcohol Use: A Necessary Corrective to Assessments of Drinking Outcomes?
The Lindesmith Center
New York, NY
Department of Psychiatry
Harvard Medical School
The aim of this paper is to identify positive psychological concomitants of moderate alcohol consumption. Current research and public-health perspectives on alcohol emphasize harms disproportionately relative to benefits. The major exception is research establishing beneficial effects of moderate drinking on cardiovascular health and overall mortality. In addition, much observational and experiential data suggest the widespread prevalence of positive drinking experiences. This paper is one of the first attempts since 1985 to codify such benefits in epidemiological terms. Methodological difficulties in accomplishing this include defining moderate drinking, controlling for confounding variables, and establishing causality. Nonetheless, evidence of psychological benefits has been found in experimental, observational, interview, self-report, correlational, and some prospective research. These positive findings are in the areas of subjective health, mood enhancement, stress reduction, sociability, social integration, mental health, long-term cognitive functioning, and work income/disability. Problem drinkers and alcoholics also seek mood and other benefits from alcohol, but are more likely to drink to counteract negative feelings and to support their egos than are social drinkers. It is as yet impossible to determine to what extent moderate alcohol consumption causes positive psychological outcomes and to what extent it is part of a complex pattern of mutually reinforcing variables.
Keywords: Moderate drinking; Psychosocial models; Mental health; Cognitive performance; Alcohol consumption; Alcohol abuse
The detrimental effects of alcohol are real, evident, and large. There has been an emphasis in the public-health field towards identifying and attempting to reduce these effects. These efforts include campaigns to reduce overall alcohol consumption conducted by a number of prominent national and international public-health bodies and alcohol researchers (Edwards et al., 1994; World Health Organization, 1993). The question arises whether, given this emphasis, the range of styles and outcomes of drinking has been slighted so as to retard scientific and applied understanding of alcohol's effects.
For example, documented cardiovascular health benefits have yet to be incorporated into cost analyses of alcohol consumption over populations (National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, 1998; Single et al., 1998). At the same time, the psychological and social sequelae of alcohol abuse are often noted. Yet, parallel to the research on alcohol and cardiovascular health is a vast body of social and ethnographic research, as well as of individual report, indicating that drinking is often a positive experience for individuals and social groups. This perspective has barely begun to be incorporated into epidemiologic research and analyses.
1.1. Medical and mortality benefits
Evidence has now accumulated that moderate alcohol consumption exerts a protective effect against coronary artery disease (CAD), along with some other diseases (e.g., occlusive stroke, Sacco et al., 1999). Two meta-analyses (Holman et al., 1996; White, 1999), incorporating 15 and 20 longitudinal studies respectively, and a continuing flow of prospective studies, including two conducted recently by the NIAAA's epidemiology division (Dawson, 2000) and the NIAAA-funded national epidemiology research center (Greenfield et al., 1999), have found in addition that moderate consumption is associated with reduced risk of all-cause mortality. Studies such as Dawson and Greenfield et al. controlled for health behaviors and demographics (for Dawson, these included age, sex, ethnicity, marital status, education, income, working, body mass, and smoking), and employed more refined measures of consumption (type of beverage x number of drinking occasions x amount consumed per occasion, plus binge episodes) in response to a range of potential confounders and measurement weaknesses in earlier studies. The index group for comparison in these studies was lifetime abstainers, to counter the possibility that some abstainers have ceased drinking due to health problems. The largest potential mortality benefits from drinking are indicated for older individuals of both genders and those otherwise at risk for heart disease (Fuchs et al., 1995; Thun et al., 1997). Beyond mortality, improved overall health and a reduced incidence of chronic illnesses have been reported in prospective studies with younger populations (Power et al., 1998; San José et al., 1999). An important and interesting development has been that, since mortality and health benefits may be mediated by factors such as social isolation and depression (Andréasson, 1998), several recent prospective studies of mortality and drinking have controlled for these psychosocial variables as well (Greenfield et al., 1999; Murray et al., 1999; Roberts et al., 1995).
1.2. Establishing experiential benefits
Most people report consuming alcohol to achieve subjective rather than health benefits (Hall, 1996; Lowe, 1994; Pernanen, 1991). Can these subjective experiences be substantiated empirically? Several recent reviews have examined aspects of the relationship between moderate alcohol consumption and psychological and social measures (Midanik, 1995; Pittman, 1996; Poikolainen, 1994). The most comprehensive review of such psychosocial benefits, however, by Baum-Baicker (1985), is a decade and a half old. Baum-Baicker identified five areas of benefit: (1) stress reduction, (2) mood enhancement, (3) cognitive performance, (4) reduced clinical symptoms, primarily of depression, (5) improved functioning in the elderly. The current review, as does one simultaneously undertaken by Chick (1999), updates and in several areas expands Baum-Baicker's work.
1.3. Psychological benefits and methods of assessment
The psychological benefits associated with alcohol use covered in this paper include subjective health, mood enhancement, stress reduction, sociability, mental health, long-term cognitive functioning, and work performance/wages/disability. Psychological research is not, for the most part, as well established as medical research in terms of experimental and prospective cohort data. Unlike CAD benefits, positive drinking experiences often result from a single occasion of alcohol consumption, and have been studied by experimental, observational, and interview research. The results of habitual patterns of consumption have been studied based on self-report, ethnographic, correlational, and prospective research. Correlational and prospective research have yielded U- or J-shaped curves like those observed in standard health epidemiology studies, in which moderate drinkers display positive outcomes not found for either abstainers or heavier drinkers.
1.4. Methodological and definitional problems
1.4.1. Defining moderation
Moderate drinking is defined in the U.S. Dietary Guidelines as one drink daily for women and two for men (USDA and USDHHS, 1995). This is about the same level of drinking associated with the minimum risk of mortality in meta-analyses of alcohol consumption for English-speaking nations (Holman et al., 1996; White, 1999). Within the U.S., however, the level of drinking linked with lowest mortality has sometimes been measured to be substantially higher than this (Greenfield et al., 1999). Moreover, White noted that "most of the heterogeneity in the level of the nadir [lowest mortality rate] lay between countries" (p. 973), including a very high level of optimum drinking (up to an average of 78g daily) in terms of mortality rate in an Italian study (Farchi et al., 1992). Based on this and similar results with other high-consumption cohorts, Rehm and Bondy (1998) reported, "Heavier-drinking cohorts tend to display their minimum risk at relatively higher levels of alcohol intake than cohorts with lower alcohol consumption . . . ," for which there was "no satisfactory explanation" (p. 223).
Psychological variables fall short of the precision of mortality or other medical measures. They often do not allow risk calculations standard for prospective epidemiological studies. Thus, psychological benefits lack even the relative precision achieved in defining optimal drinking and moderation in mortality research. In particular, very different levels of drinking are acceptable or normative in different national cultures, ethnic groups, and social subcultures (Heath, 1995; MacAndrew and Edgerton, 1969). As a result, some anthropological and sociological concepts associated with appropriate drinking such as leisure, sociability, and social cohesion are virtually impossible to link to objective ranges of alcohol consumption. These areas of research, which emphasize the cultural relativity of drinking, do not fit into a epidemiological framework.
The current review focuses on research that conforms to such an epidemiologic model, with reference to ethnographic and other research. Nonetheless, this review will not definitively identify moderate drinking levels. In this respect, this review is perhaps not so different from those addressing the most objective potential benefit of alcohol consumption i.e., reduced mortality. Thus, Rehm and Bondy (1998) do not dismiss several studies demonstrating reduction in mortality merely because these occurred at up to 8 units (78g) daily (e.g., Farchi et al., 1992), even though a meta-analysis found the optimum mortality rate to occur at about one unit (9g) of alcohol per day for U.S. males (White, 1999). Instead, they seek to understand such national/cohort differences.
To some extent, national differences can be traced to variations in standard drink sizes (Doll, 1997). In the present review, note that most European and English-speaking nations outside of North America identify standard drinks to be about 10 grams of absolute alcohol, while in the U.S. and Canada the standard drink size is 1/2 ounce (about 14g). Researchers may mean very different things when using labels such as "light," "moderate," and "heavy" drinking (alcohol volume is specified when available). But the disparities are greater than this. As precisely measurable an area of psychological status as cognitive functioning shows a remarkable range of findings as to optimal drinking levels; as with mortality, these variations occur in association with the level of overall cohort drinking. For example, Hendrie et al. (1996) reported optimal cognitive functioning at fewer than 4 drinks a week, while Orgogozo et al. (1997) found the least dementia at 3-4 drinks of wine daily. Correspondingly, three-quarters of the Hendrie et al. elderly urban African American population abstained, compared with only 4 percent of an elderly sample from France in Orgogozo et al.
1.4.2. Pattern versus volume of consumption
Both total volume and patterns of consumption are relevant to consequences of drinking (Room, 1998). However, in recent decades, level of consumption has been dominant, leading some researchers currently to refocus on patterns of drinking as predictors of medical outcomes and problem measures (Stockwell, 1998). In other words, having two drinks per day is associated with more benefits and fewer problems than having fourteen drinks over a weekend. Single and Leino (1998) have proposed that drinking patterns be assessed along the following dimensions: frequency of drinking occasions, volume of consumption per occasion, drinking settings, number and characteristics of drinking companions, and alcohol expectancies. Harburg et al. (1994), for example, found that a measure incorporating mood and setting variables with drinking had a better relationship with hypertension than did simple consumption levels. Dawson (2000) found that alcohol dependence interacted with consumption level to predict mortality outcomes.
1.4.3. Direction and possible confounders of causality
Medical epidemiology has developed tools to address causal factors in health outcomes. Prospective research, in which populations are categorized according to alcohol consumption prior to manifesting an outcome, supports a causal role for alcohol consumption (bolstered by biomedical research identifying plausible mechanisms to account for such benefits; cf. Klatsky, 1999). But others caution against prematurely reaching this conclusion in the case of mortality rates (Andréasson, 1998; Fillmore et al., 1998). Among possible confounders are demographic variables (like socioeconomic status) or other health behaviors (like diet or weight level) associated with moderate drinking that might account for coronary benefits attributed to drinking. One putative confounder in particular has been that the abstainer category contained ill people who could not drink, or else former problem drinkers who had quit drinking.
However, prospective research has gradually improved in its controls for such confounders. For example, most alcohol outcome research now assesses baseline health status and/or separates former drinkers from abstainers (e.g., using only lifetime abstainers as the index group, as in Dawson, 2000; Greenfield et al., 1999; Thun, 1997). Such research also often controls for social status (e.g., income, education variables). In addition, research conducted within homogeneous populations (e.g., nurses, cf. Fuchs et al., 1995; or physicians, Camargo et al., 1997), as well as that comparing racial and occupational groups (e.g., Thun et al., 1997), has found similar benefits associated with moderate drinking.
Going beyond demographic and health traits, there may be yet more subtle confounding factors, including some of the psychosocial variables (e.g., depression and isolation) identified in this review as having the same U- or J-shaped curves in relation to alcohol consumption as do cardiovascular or mortality benefits. Several recent studies have introduced controls for these possible confounders. In the U.S., Greenfield et al. (1999) found that male mortality was lowest at 2-4 drinks daily with controls for age, ethnicity, marital status, income, smoking, and measures of depression and isolation/ demoralization. In Canada, Murray et al. (1999) likewise found that mortality benefits for a high-risk male population remained unaffected by social-isolation measures. In the British Civil Servants study, Roberts et al. (1995) found that a number of psychological adjustment and mood variables did not confound the consumption-mortality association.
Nonetheless, attributing causality to drinking in relation to psychological and related variables remains difficult even more so than with medical outcomes. Attributions of causality are most plausibly made on the basis of experimental or prospective community studies, exemplified mainly by one or two areas of research on the impact of alcohol on psychological variables (e.g., long-term mental acuity, some types of tension-reduction). However, in most cases alcohol use and its beneficial concomitants are simply identified in particular cultural milieux or with particular lifestyles. This leaves open the question of whether moderate alcohol consumption causes positive psychosocial outcomes or is rather part of a cluster of variables in patterns of reciprocal causality.
1.5. The contributions of this paper
Despite the identified limitations, this paper argues that it is worthwhile to attempt to identify and evaluate psychological benefits associated with alcohol consumption. Balancing drinking problems and negative consequences with psychological as well as medical benefits is necessary to build a fully elaborated model of the effects of alcohol, including a true cost-benefit analysis. This is valuable not only as a scientific aim, but as a practical public-health goal, even in the presence of uncertainties about causation that occur with respect to costs as well as benefits. For example, in cost-of-illness studies, differentials in income for alcoholics or heavy drinkers relative to others may be calculated. Yet causality is no clearer for this finding than for the income differential favoring moderate drinkers over abstainers (as reported below). While noting that harmful concomitants of alcohol consumption are firmly established, this paper will focus on the other end of the spectrum of drinking styles and alcohol-related effects.
Given the scope and complexity of the subject, it will not be possible to fill in the full picture of alcohol's possible benefits. Rather, this review will survey the existing literature, referring to both ethnographic (mainly as background) and survey research. Integrating survey research with epidemiologic research represents a rare confluence of disparate traditions. According to Rehm (1998, p. 108): "An overview of the field of measurement of volume of alcohol consumption reveals that it is divided into a social, mainly survey, and an epidemiological tradition. Both sides hardly seem to notice each other; they do not cross-cite or seem to know important developments in the other side." Nonetheless, some of the available evidence on psychological benefits of drinking has arisen from prominent epidemiological research (see Table 1), such as the Epidemiological Catchment Area study of the National Institute of Mental Health (e.g., Lipton, 1994), the Established Populations for Epidemiologic Studies of the Elderly of the National Institute on Aging (Hebert et al., 1993), the Twin Panel of U.S. Veterans of the National Academy of Sciences-National Research Council (e.g., Christian et al., 1995), the National Household Survey on Alcohol Use of the National Institute on Alcohol Abuse and Alcoholism (Heien, 1996), the Whitehall Study of British Civil Servants (Roberts et al., 1995), the Framingham Heart Study (Elias et al., 1999), and others. A number of the studies are prospective in nature (e.g., Hebert et al., 1993; Orgogozo et al., 1997).
Yet much remains to be established. We will suggest some next steps researchers may take toward constructing a balanced, fully elaborated picture of the consequences of alcohol use. In areas where substantial evidence has emerged of an association (e.g., long-term cognitive functioning), scientists might be encouraged to investigate mechanisms to explain this observed relationship.
|Study and Sample||Type of Study and Controls||Results|
Grønbæk et al. (1999), WHO Copenhagen survey, random sample of 12,039 Danes age 18-100
Regression on subjective health
Adjusted OR, Suboptimal Healtha
Poikolainen and Vartiainen (1999), National FINRISK Study, random sample of 6,040 Finns aged 25-64 years
Regression on subjective health
Adjusted OR, Suboptimal Healthb
Power et al. (1998), 1958 cohort of all UK births (3/3-3/9), 9,605 of whom reported alcohol consumption
Within prospective study, cross-sectional analysis of self-report of health at 33 years old
Poor-Fair Self-Rated Healthc
Poikolainen et al. (1996), random sample of 6,040 Finns age 25-64
Regression on subjective health
Adjusted OR, Subjective Healthd
Leifman et al. (1995), total population, 45,746, of 18-19 year-old male Swedish military conscripts over two-year period
Percentage in each drinking category indicating various social integration/ sociability indicators
Often Insecure with Otherse
Camacho et al. (1987), panel study of probability sample of 4,590 residents of Alameda County, CA, 35 years and older
Covariates with alcohol consumption
|Mental Health - Depression et al.|
Lipton (1994), random sample, 928 non-Hispanic whites, Epidemiological Catchment Area study (LA)
Regression on Time 2 scores by drinking
Neff (1993), random sample, 1,784 residents of San Antonio, Texas
Analysis of variance by drinking
Neff and Husaini (1982), random sample, 713 adults in Tennessee
Regression on depression scores by drinking categories
Bell et al. (1977), random sample, 2,029 adults in 3 Southern U.S. counties
Group mean comparisons
|Mental Health - General|
Power et al. (1998), 1958 cohort of all UK births (3/3-3/9), 9,605 of whom reported alcohol consumption
Within prospective study, cross-sectional analysis of psychological distress at 33 years old
Roberts et al. (1995), Whitehall II study of 10,314 U.K. civil servants
Cross-sectional analysis of psychosocial measures at screening in a longitudinal study
Vaillant (1995), fifty-year longitudinal study of 443 inner-city Boston men
Percentage of each lifetime drinking group with each mental health indicator
Carmelli et al. (1999), 589 males in NHLBI twin study
Within prospective study, cross-sectional analysis of cognitive functioning
Adjusted OR, Poor Cognitive Function
Elias et al. (1999), 1,786 participants in Framingham Heart Study
Regression on cognitive measures of current and prospective (history of) drinking
Composite Neuropsychological Tests
Orgogozo et al. (1997), 3,777 65+ adults representative of communities in the Bordeaux region of France
3-year prospective study, regression on cognitive measures by drinking categories
Adjusted OR, Dementia
Dufouil et al. (1996), 1,389 59-71 adults from voting rolls in France (Nantes)
Regression on 10 neuropsychological tests by drinking categories
OR, High Cognitive Funct.
Launer et al. (1996), random sample of 939 Dutch (Zutphen) 65+ men
Regression on cognitive functioning by drinking categories
OR, Poor Cognitive Funct.q
Hendrie et al. (1996), 2,040 randomly selected 65+ Blacks in Indianapolis
Regression on cognitive tests by drinking categories
Cognitive, Memory, ADLr
Christian et al. (1995), 4,739 male Caucasian twins, U.S. veterans born 1917-27, maintained by NAS-NRC
Regression on 1990-1991 cognitive scores by previous (1970-1980s) drinking
Hebert et al. (1993), 1,201 65+ adults in community study (East Boston) in Established Populations for Epidemiologic Studies of the Elderly
3-year prospective study, linear regression on change in cognitive measures by drinking categories
Bates and Tracy (1990), random sample of 1,380 New Jersey residents age 18, 21, 24
Regression on composite cognitive measure for age-gender stratified groups
|Work Performance (Income)|
Slater et al. (1999), representative national commercial panel of 2,910 U.S. adults
Cluster analysis of alcohol-use predictor categories with demographic, health, and psychosocial variables
Heien (1996), national surveys
Regression on annual income
French and Zarkin (1995), random interviews, 910 workers at 4 sites
Regression on weekly wages
|Work Performance (Disability/Absence)|
Månsson et al. (1999), 5 complete birth-year cohorts of 3,751 men age 47-48 in Malmo, Sweden
11-year prospective study
Adjusted RR, Disability Pensiony
Vasse et al. (1998), 471 participants at three sites in a worksite health project in the Netherlands
Regression on sickness absence by stress x alcohol consumption interaction
OR, Sickness Absencez
Camacho et al. (1987), panel study of probability sample of 4,590 residents of Alameda County, CA, 35 years and older
Covariates with alcohol consumption
aNo significance tests reported.
2. Measured Psychological Benefits
2.1. Subjective health
Poikolainen et al. (1996), in a Finnish national cross-sectional survey, found that alcohol intake was associated with a self-perception of good health in a J-shaped pattern. The optimum self-assessment was at 3.3-9 drinks (40-99g) per week, although this was significantly different only from the highest drinking group. The researchers introduced controls for ex-drinkers or subjects who reduced drinking for health reasons, but there was no overall control for actual health status. Likewise, Power et al. (1998) found the highest levels of self-rated good health among moderate drinkers in a young-adult cohort (6-20 drinks per week for women, 11-35 for men), also without controlling for actual health status. Poikolainen et al. controlled for other potential demographic, health, and social confounders (age, gender, education, marital status, smoking, social isolation), although Power et al. utilized few controls. Subjective health may simply be an indicator of actual health status. In addition, moderate drinking could engender a rewarding sense of well-being beyond its association with good physical health.
Two recent studies of subjective health compared the self-rated health of those consuming different types of alcoholic beverages. Cross-sectional health surveys undertaken as part of the WHO Copenhagen Healthy City Survey of Danes aged 18-100 years (Grønbæk et al., 1999) and the National FINRISK Study of Finns aged 25-64 years (Poikolainen and Vartiainen, 1999) found that moderate consumption of wine but not of beer or spirits was associated with a self-perception of good health. However, the optimal level of drinking differed greatly between the two studies, according to the higher overall level of consumption in Denmark than in Finland (for the Danish study, optimum was 3-5 glasses of wine daily; for the Finnish, 5-9 glasses per week). Both studies employed elaborate controls, and Poikolainen et al. claimed it was unlikely that lifestyle factors produced the sense of good health associated with drinking wine.
2.2. Positive mood effects: Anticipated and experienced
2.2.1. Survey research
General population studies do not as a rule differentiate responses in terms of moderate versus heavier drinking. Their value, like that of observational studies, is simply to establish that most people perceive drinking as an ordinary, enjoyable experience. Respondents in surveys in the U.S., Canada, and Sweden predominantly mention positive sensations and experiences associated with drinking (e.g., relaxation, sociability), with little mention of harm (Pernanen, 1991). In two Australian surveys, most respondents (54% in 1994) identified relaxation, stress reduction, and improved psychological well-being (grouped together) as benefits of drinking (Hall, 1996; Hall et al., 1992). In Finland, both student and general populations reported positive effects more often than negative (Mäkelä and Mustonen, 1988; Mäkelä and Simpura, 1985; Nyström, 1992). Likewise, in the U.K., the Mass-Observation Archive (1943, 1948) focused on commonplace positive experiences drinkers identified, such as taste, the mood alcohol engendered, and the ritual and social elements of drinking. Lowe (1994), analyzing the Mass-Observation Archive data together with surveys of adolescent drinkers and temporary abstainers, reported that people usually found drinking enjoyable.
In surveys in the United States, respondents repeatedly report predominantly positive reactions to alcohol and reasons for imbibing. Cahalan (1970) found that the most common result of drinking reported by current drinkers was "felt happy and cheerful" (50% of male and 47% of female nonproblem drinkers). Roizen (1983) reported national survey data that 43 percent of adult male drinkers always/usually felt "friendly" when they drank (the most common effect; 70-80% of respondents mentioned at least one positive effect), compared with 8% who felt "aggressive" or 2% "sad." Leigh and Stacy (1994) found among several groups of drinkers that, when asked about the effects of alcohol, drinkers list positive effects first and foremost. On the other hand, when the perceived general effects of drinking are detached from personal experience as they were by Demers et al. (1996) in their study of "social representations" of drinking in Quebec people do frequently cite harmful effects from drinking, but as "objective" assessments of drinking's effects rather than based on their own drinking experiences.
General population survey data have not been used to construct models of drinking experiences based on level of consumption. Cahalan (1970) did find that problem drinkers, while even more frequently than nonproblem drinkers listing positive responses, also list more negative reactions. A tendency for a combination of exaggerated positive and negative expectations to co-occur also appears cross-culturally (e.g., Marin, 1996). Marlatt (1987; 1999), analyzing clinical and experimental data, found exaggerated expectations characterize the drinking of alcoholics and problem drinkers. Moreover, he noted, problematic drinking is biphasic i.e., positive anticipations are fulfilled early in the drinking cycle but then become increasingly negative as drinking continues. Freed (1978) earlier reviewed the discontinuous nature of problem/alcoholic drinking.
2.2.2. Expectancies: Differences according to culture
The same generally positive picture of alcohol's effects appears in expectancy research. Brown et al. (1980) identified six independent expectations of drinkers: (1) positive transformation of experience, (2) enhanced social and physical pleasure, (3) enhanced sexual performance and experience, (4) increased power and aggression, (5) increased social assertiveness, and (6) reduced tension. Brown (1985) further determined that regular but nonproblem drinkers emphasized expectations of social and physical pleasure while problem drinkers primarily anticipated tension reduction. Gustafson (1991b) reported that high alcohol consumers had higher expectations along all of these dimensions than low consumers. In summary, normal, moderate drinkers report consistent but mild positive expectations and experiences from drinking with respect to mood, physical sensations, and social benefits.
Although expectancy research has focused on U.S. populations, there are substantial cultural differences in the effects drinkers expect/experience, extending even to symptoms of alcohol dependence (Room et al., 1996). Mexican-Americans and other Hispanics, for example, expect both more positive and negative effects from alcohol than non-Hispanic whites (Marin, 1996; Marin et al., 1993). Among Irish and Canadian male alcoholics, the Irish drank more for asocial reasons (e.g., tranquilization, detachment, self-absorption), while Canadians drank more for social and sexual enhancement (Teahan, 1988). Clearly, drinking experiences and expectations include a cultural dimension.
2.2.3. Mood enhancement and problem drinking
Both survey (Cahalan, 1970) and expectancy (Brown, 1985; Brown et al., 1980; 1985) research have addressed differences between normal social drinking experiences and expectations and those of problem drinkers. Cooper and her colleagues have related social and other motives in drinking situations to drinking outcomes. Cooper et al. (1992) found three distinct motives for drinking: to enhance positive mood, to cope with negative emotions, and to affiliate with others. The research found that people who drink primarily to enhance positive affect tend to drink more heavily than those who drink to regulate negative affect, yet are less likely to report serious drinking problems. Those who drink for enhancement and social motives are more likely to drink in convivial social settings, while those who drink to cope are more likely to drink alone or with one partner.
Other research (Cooper et al., 1995; Cox and Klinger, 1988) has found that drinking to cope with negative emotions is more likely to be associated with alcohol abuse than is drinking for mood enhancement. Marlatt (1987; 1999), in literature reviews, concluded that problem drinkers, relative to ordinary social drinkers, seek to compensate for personal deficiencies. Thus, although problem as well as normal drinkers appear at first sight to be seeking similarly positive experiences, problem drinkers crave them more intensely because they drink to resolve more fundamental needs.
2.2.4. Experimental mood enhancement
As with Chick (1999) this review is not primarily concerned with acute effects of alcohol. We note, however, that experimental research has also measured alcohol's observed mood-enhancing effects, particularly when psychopharmacologists compare alcohol's mood elevation and other effects with those of other drugs. On the one hand, Gustafson (1991a) concluded that moderate doses of alcohol are a weak reinforcer of preexisting emotional states, whether positive or negative. Other psychopharmacologists report that "social drinkers reported more good feelings after ethanol" (Turkkan et al., 1988, p. 37). Light or social drinkers experience more positive feelings than alcoholics in the pharmacological view because the latter have developed tolerance for alcohol.
In the U.K., Lowe examined the relationship between alcohol consumption and laughter/humor using three different methodologies. Lowe and Taylor (1997) found that students who had been given alcohol (two 360-ml bottles of 8.2% alcoholic beverage) were observed to laugh more at a film comedy than entirely sober viewers. Lowe and Taylor (1993) found a significant correlation between weekly alcohol consumption (extending to the quite high level of 72 units; unit = 8g) and a scale measuring frequency of laughter and humor in daily life. Finally, Lowe et al. (1997) reported that young drinkers observed in pubs smiled and laughed more the more alcohol they consumed. While Lowe's research is strong because of its multimodality, it does not separate pharmacological from expectancy effects. Also, in this research, the mood-enhancing effects of alcohol were linear and not U-shaped.
Social context also influences the mood effects of drinking. An early experimental study of the effects of low doses of alcohol in a social context found that "all measures of elation were significantly increased from sober levels" (Smith et al., 1975, p. 36). This was unusual among studies of alcohol-influenced social behavior in that subjects were couples who were already intimately involved. Pliner and Cappell (1974) found that subjects experienced greater euphoria when drinking in a group than when drinking the same quantity alone. In a placebo-controlled, double-blind choice study, Doty and de Wit (1995) found that both the reinforcing and subjective effects of alcohol were influenced by social context. Subjects tested in a social setting (i.e., with other subjects) chose alcohol over a placebo significantly more frequently than those tested alone. Moreover, subjects in the social condition had more positive reactions (liking the substance and feeling euphoria) than those in the socially isolated condition.
2.3. Stress reduction
2.3.1. Experimental research
Stress reduction, while cited as a positive expectation and experience in general surveys (Hall, 1996; Pernanen, 1991), has been used as a model to explain abusive drinking the tension-reduction model of problem drinking and alcoholism (Cappell and Greeley, 1987). Cole et al. (1990) showed that both stressful events and perceived stress increased, in order, among abstainers, normal drinkers, and problem drinkers. However, this result does not indicate whether (1) drinking causes or is a response to stress, or (2) alcohol actually lowers the stress experienced by those undergoing stressful events.
Stress reduction nonetheless remains a popular way of conceptualizing the benefits of drinking, because commonsensically people seem to drink alcohol to relax. Stress reduction has been a primary focus of explanatory models of the rewarding properties of alcohol (Baum-Baicker, 1985; Hull and Bond, 1986; Sher, 1987). These include stress-response dampening (Sher, 1987), social learning (Abrams and Niaura, 1987), expectancy (Goldman et al., 1987; Lang and Michalec, 1990; Stacy et al., 1990), self-awareness (Hull, 1981; 1987), attention-allocation (Steele and Josephs, 1988; 1990), appraisal-disruption (Sayette, 1993), and a comprehensive psychophysiological model of Stritzke et al. (1996). These theoretical models highlight different ways in which alcohol creates mood susceptibilities which social and individual expectancies then shape. The stress-reduction literature and the expectancy literature are thus closely related.
In controlled laboratory research, variables that encompass individual, gender, ethnic, beliefs and expectations, and setting or situational factors have been found to affect the relationship between stress reduction and drinking, in ways that are often inconsistent. It would take a separate review (cf. Pohorecky, 1991; Wilson, 1988) to survey in depth this literature. It is only rarely that alcohol in itself, irrespective of beliefs or gender, leads reliably to stress reduction (as occurred in Sayette et al., 1994). We can summarize here that, in general self-report surveys and naturalistic studies of drinking, relaxation and stress-reduction appear regularly, while in experimental and other single-occasion drinking studies, stress-reduction results are diverse and inconclusive.
2.3.2. Naturalistic research on stress reduction
Results of naturalistic studies are more consistent. Subjects recording their daily activities reported that moderate alcohol use had a calming effect even though they did not drink specifically to reduce anxiety (de Castro, 1990). Culbert (1989) found that moderate drinkers did not increase, and even reduced, their drinking in response to major life stresses. Krause (1995) found that alcohol reduces the negative impact of events arising in less critical social roles, but exacerbates the effects of more salient stressors. Moderate drinkers thus report that alcohol creates general calming sensations, but use of alcohol as a way of coping with major life issues is associated with problem drinking (Cooper et al., 1988; 1995). Of course, naturalistic studies are incapable of separating pharmacological effects from the socially learned or expectancy contributions to drinking experiences.
2.4.1. Sociability in ethnographic and observational research
Alcohol has been noted to encourage sociability and is a hallmark of social greetings and gatherings worldwide (Heath, 1995). Partanen (1991, p. 228) concluded that "alcohol is a social drug par excellence." Room (1972, p. 33) observed, "drinking and sociability are often so intertwined in American life that it is hard to separate the two functions" (cited in Pernanen, 1991). This supposition is supported by experimental research showing learned contextual effects (Doty and de Witt, 1995), but a direct pharmacological effect for sociability has also been measured (Smith et al., 1992). The latter effect is supported by the very universality of alcohol's role in social facilitation.
2.4.2. Self-report studies of sociability as a motive for drinking
Sociability is often mentioned in surveys as a primary motive for and consequence of drinking (see Lowe, 1994; Roizen, 1983). In a diary study among young adults in Australia, the top two reasons listed by both men and women for drinking were to be sociable (30%-49%) and to celebrate (19%-15%) (Wilks and Callan, 1990). In a questionnaire survey in four Scandinavian countries, the positive consequences of drinking were "manifested first and foremost by a loss of inhibitions in company with other people and being better able to establish contact with other people" (Hauge and Irgens-Jensen, 1990, p. 652). A survey of French-Canadians found conviviality the most prevalent (64%) perceived benefit of alcohol (Demers et al., 1996).
2.4.3. Social motivations and drinking outcomes
Drinking alcohol to gain social benefits could work in either of two ways. On the one hand, the social component serves to regulate drinking behavior (Caudill and Marlatt, 1975; Partanen, 1991). On the other hand, tavern studies show that sociable drinking can lead to greater excess than solitary drinking (Storm and Cutler, 1981). Partanen (1991) has equated drinking for sociability with intoxication. Cross-culturally, social celebrations and socially cohesive events are sometimes associated with decidedly heavy alcohol consumption (MacAndrew and Edgerton, 1969; cf. Peace, 1992).
Attempts to relate social drinking to levels and types of consumption have yielded mixed results. In a national survey, Kilty et al. (1987) labeled as "convivial" a style of drinking which occurred in a social context, and which was associated with fewer problems than other styles of drinking. However, a questionnaire study of college students (Wiggins and Wiggins, 1992) and a statewide survey (Smith et al., 1993) did not find a relationship between sociable motives for drinking and consumption levels. In a diary study, de Castro (1990) found positive mood associated with alcohol use was explained by the fact that alcohol was ingested in comfortable, pleasant, social conditions.
2.4.4. Experimental studies of sociability
We earlier discussed Pliner and Cappell's (1974) finding that mood-enhancing effects of alcohol are amplified in group settings. Here, participation in a group was the independent variable and general good feelings the dependent. An experiment showing that people both feel more sociable due to drinking and are perceived as being more sociable (objectively) because of alcohol consumption (the independent variable) was conducted by Smith et al. (1992). The researchers gave subjects either vodka and fruit juice or fruit juice alone. This study is one of the few to find that only those actually drinking alcohol were more sociable.
While Smith et al. demonstrated a significant independent pharmacological effect of alcohol, other research simultaneously indicates that expectancy and setting mediate alcohol's sociability function. In a placebo-controlled, double-blind study, for example, Doty and de Wit (1995, p. 26) reported "both the reinforcing and subjective effects of ethanol were influenced by the social context in which it was consumed." Utilizing this phenomenon, Fromme et al. (1994) trained at-risk college drinkers to reduce consumption by demonstrating that the students experienced enhanced mood and conviviality in a situation where they thought they were consuming alcohol but were not. This demonstrated to the students that their expectations of having a good time with others were sufficient by themselves to produce this effect without drinking. Clinicians utilize this so-called "challenge" effect as a treatment modality for problem drinkers (Darkes and Goldman, 1998).
A major area of experimental study (e.g., Bruch et al., 1992) has been the assessment of alcohol's effectiveness in reducing "social anxiety." Large differences by gender occur in such stress reduction (Wilson, 1988). Expectancy is also critical, so that male subjects feel less anxiety in social situations, but women feel more, when subjects believe they are drinking but are not in fact consuming alcohol (Abrams and Wilson, 1979; Wilson and Abrams, 1977). Yet de Boer et al. (1993, 1994) found almost the opposite expectancy effect in the Netherlands, where women (but not men) who believed they had consumed alcohol experienced reduced anxiety. Garrulousness, self-revelation, and guardedness likewise vary with drinking (Babor et al., 1983; Higgins and Stitzer, 1988; Hull et al., 1983; Stitzer et al., 1981) in complex gender, expectation, setting, and even cultural interactions (Caudill et al., 1987; Schippers et al., 1997). For the present review, self-disclosure as opposed to guardedness, and sociability in general, can be considered either as benefits or as risks (or both) depending on the setting.
2.5. Social integration and adjustment
In a Northern California population, Camacho et al. (1987) found that abstainers were less likely to be married or to have organizational memberships than drinkers at all levels, while those drinking 1-2 drinks daily were most likely to be married and group members. Other studies have found that more social interaction is associated with a greater likelihood of imbibing alcohol for example, in the U.S. in a community sample of adults (Berkman and Syme, 1979) and among male blue-collar workers (including both moderate and heavy drinking subcultures, Janes and Ames, 1989). In a Los Angeles sample, Seeman et al. (1988) found that powerlessness was associated with drinking problems, and "the highest intake and problems are found where high powerlessness and low engagement combine" (p. 193). At the same time, this study found, drinking with companions was associated with heavier drinking.
Leifman et al. (1995) found a U-shaped relationship between social integration and alcohol consumption. The investigators examined 50,000 Swedish conscripts (age 18-19), only 6 percent of whom abstained. Abstainers more often reported having few or no friends, being unpopular, being anxious socially, and never having intimate conversations results that also occurred for heavier drinkers in the sample. Watten (1996) found in Norway with a similarly aged group of college students that abstainers had significantly lower scores on sociability than those who drank moderately. In a study correlating personality attributes and drinking, Cook et al. (1998, p. 646) found that "abstainers are more submissive, less sociable, less self-confident, less empathic, more dependent on others and have a weaker social presence."
Examining the older end of the age spectrum, Hanson (1994) found that a range of social indices associated isolation both with greater quantity of consumption and with problem drinking indices. In a study of Western U.S. retirement communities, on the other hand, Alexander and Duff (1988) found greater social interaction was associated with heavier drinking; however, Alexander and Duff defined "heavy drinking" as only 2 or more drinks daily and did not identify drinking problems. A similar finding was obtained in a survey of the elderly in a small Eastern Ontario community (Graham, 1998). This study separated lifetime abstainers and former drinkers. Compared with both groups, current drinkers had larger social networks and engaged in more social activities.
2.5.1. Summary: Does social integration support healthier drinking?
Skog (1995) and Andréasson (1998) have argued that, since isolated individuals are more often both abstinent and unhealthy, social isolation confounds findings that abstainers have higher death rates than moderate drinkers (as does depression; see next section). There is some empirical support that a social isolation-integration scale has a U-shaped relationship to drinking, along with evidence that those with greater social contacts are more likely to drink, or drink regularly or heavily, depending on the peer group and other variables.
2.6. Mental Health
2.6.1. Community research
Bell et al. (1977) conducted a seminal study with 2000 randomly selected adults in a southern region of the United States on the relationship between drinking levels and anxiety and depression. Unfortunately, the researchers did not define their drinking categories (the 12-item anxiety and 18-item depression scales were created for this study). Abstainers scored highest on anxiety and heavy drinkers highest on depression, while moderate drinkers scored lowest on both, followed by light drinkers. Bell et al. (p. 121) concluded "that the heavy alcohol user cannot be differentiated from the abstainer on the basis of psychopathological symptom configurations."
Neff and Husaini (1982) studied alcohol consumption, depression (CES-D Scale), and life events in a rural Tennessee sample. In this light-drinking sample, moderate drinkers were defined by a limit of five drinks weekly. Moderate drinkers had lower depression scores than abstainers and heavy drinkers in the presence of five types of life events (the drinking x life events interaction was significant for two types of events). The researchers commented: "The interaction effect here is striking. Life events were most strongly related to depressive symptomatology for abstainers and heavy drinkers" (p. 311). They concluded that moderate drinking "buffered" life stressors. In a follow-up study, however, Neff (1993) interviewed a sample of residents of San Antonio, Texas, utilizing a similar categorization of drinkers, but eliminating from the analysis abstainers with previous alcohol problems. In contrast with the earlier study, depression was generally lower among abstainers than drinkers.
Lipton (1994) attempted to refine Neff's work in these two previous studies by analyzing the relationship between depression and drinking among non-Hispanic whites in the Los Angeles Epidemiological Catchment Area (LA ECA) study. The study carefully defined light, light-moderate, moderate, and heavy drinkers based on quantity and frequency of alcohol consumption, along with the occurrence of bingeing (note that Lipton thus anticipated suggestions of the need for a multi-dimensional classification of drinking styles; cf. Dawson, 2000), and utilized the same depression scale that Neff used. Measurements were taken two years apart, and six analyses of the relationship between depression and drinking at Time 2 were conducted in relation to the presence of financial strain and/or negative life events experienced at Time 1. The study resembled a prospective study in that analyses were controlled for depression at Time 1. In each of the six separate analyses conducted by Lipton, moderate drinkers had the lowest depression scores. Although moderate drinkers were significantly differentiated from abstainers, the highest depression scores were among light drinkers rather than abstainers.
In a study designed to investigate psychosocial variables as possible confounders of the relationship between alcohol consumption and cardiovascular health, Roberts et al. (1995) used the Whitehall II study of British civil servants data base to examine the relationship between measures of psychological well-being and level of alcohol consumption. On several measures taken at screening, light drinkers (for men, 1-10 units per week; for women, 1-6 units per week) showed better psychological well-being than either abstainers or heavy drinkers. For men, these measures included a general mental health scale (the GHQ), positive affect, level of upset, and hostility. For women, the U-shaped relationship held only for hostility. The study did not actually report data on these measures by drinking level. In similar fashion, Camacho et al. (1987) drew upon a long-term community study, the Human Population Laboratory (Alameda County, CA), to identify psychosocial covariates that might account for apparent mortality gains from moderate drinking. In this population the abstainers were more often depressed than all groups of drinkers (the relationship with consumption was inversely monotonic).
2.6.2. The mental health status of abstainers: Culturally specific?
One of the five community studies reviewed that addressed the question (Neff, 1993) found that abstainers did not suffer from greater depression than moderate drinkers. Neff attributed the difference between his findings and those of both Bell et al. (1977) and Neff and Husaini (1982) to the exclusion of former problem drinkers from the abstainer category. Lipton (1994), on the other hand, found uniformly that the highest depression scores in each category of negative life events were among light drinkers rather than abstainers, thus ruling out the possibility that ex-drinkers' greater depression underlay the U-shaped curve. Furthermore, in Neff and Husaini (1982), in which 66 percent of the sample abstained and yet abstainers had worse mental health than moderate drinkers, it seems hardly possible that former problem drinkers account for the difference.
An additional question is whether, to the extent that abstainers do show mental-health disadvantages, these flow from abstainers' deviation from normal patterns in a culture, or from their lacking the benefits (whether pharmacological or social) of moderate alcohol consumption. Orcutt (1991) suggested that in cultures where abstinence is normative, social or mental-health deficiencies will not appear in abstainers as they do where social drinking is the norm. If nearly an entire culture abstains (as in India), obviously they will represent a cross-section of the mental health of the society at large. What is the proportion of a population abstaining at which this is likely to be true? The Bell et al. (1977) and Neff and Husaini (1982) study samples where 42 percent of White and 58 percent of Black subjects, and two-thirds of all respondents, respectively, abstained still found abstainers to be at a disadvantage in mental-health terms. Thus, Orcutt's hypothesis was not confirmed for populations in which abstinence was far from deviant, although not total. On the other hand, in Leifman et al. (1995), abstainers whose fathers abstained did not show psychiatric/anxiety/emotional control disadvantages that were manifested by abstainers whose fathers drank. This finding suggests, in support of Orcutt's hypothesis, that those who abstain for normative or religious reasons differ from those who individually decide not to drink.
2.6.3. Mexican-American versus non-Hispanic white drinkers
Section 2.2.2 discussed differences noted in Hispanic versus non-Hispanic drinking expectancies. In fact, several studies have specifically addressed the mental health-drinking relationship in Mexican-Americans. Caetano (1987) found alcohol use was unrelated to depression among Hispanic men when socioeconomic status (SES) was controlled. In a study of Mexican-American and non-Hispanic white men and women part of the LA ECA study Golding et al. (1990) found that, for both ethnic groups, consuming large quantities of alcohol per occasion and (for men) daily drinking were associated with depression. But the study did not report depression by differential (e.g., low-moderate-high) drinking levels. Supporting the idea of bifurcated alcohol expectancies among Hispanics reported in section 2.2.2, Golding et al. noted, "Among women, the cultural and demographic characteristics of high-quantity drinkers and abstainers (both of whom tended to be Mexican-Americans) accounted for the association of alcohol use with depression" (p. 421).
Lipton (1997), analyzing the same LA ECA database on which he earlier reported for whites only (Lipton 1994), compared the relationship between drinking levels and depression in the presence of stressful events among U.S.-born Mexican-Americans, Mexican-Americans born in Mexico, and non-Hispanic whites. The U-shaped relationship between level of alcohol consumption and depression previously found for non-Hispanic whites also held for Mexican-American immigrants across all categories of stress. However, U.S.-born Mexican-Americans showed a reverse U-curve in which light and moderate drinkers had higher depression scores than abstainers and heavy drinkers. Results in this section indicate that lower depression rates found among moderate drinkers may not be apparent in Mexican-American and/or lower SES groups, possibly due to attenuated numbers of moderate drinkers in such groups.
2.6.4. Mental health benefits found specifically for younger drinkers
In Norway, Watten (1996) found that college students who abstained had significantly higher repressive coping styles and lower scores on sociability than those who drank moderately (in this study the youth of the drinkers presumably obviated the need to eliminate ex-drinkers). Cook et al. (1998), reported above, found abstainers more dependent, submissive, and withdrawn and less self-confident and competent than moderate drinkers. Leifman et al. (1995) noted among young Swedish conscripts that abstainers displayed both mental health advantages (less likelihood of anxiety) and disadvantages (more often had low emotional control or psychiatric diagnoses), compared with light drinkers (up to 2 drinks or 1-25g/week). Compared with abstainers whose fathers did not drink, abstainers from nonabstinent backgrounds more often manifested psychiatric diagnoses, low emotional control, and anxiety.
In Australia, Winefield et al. (1992) reported on two studies of young Australian adults, one of 483 school students followed from 1980-1989 who were 24 years old on average when their drinking was assessed in 1988. Moderate drinkers were defined as men having up to 28 glasses of alcohol per week and women up to 14. Male (but not female) moderate drinkers had across-the-board psychological advantages over heavy drinkers (but not abstainers) in self-esteem, depression, hopelessness, mood, and psychological disturbance. In a second study of 111 "mature age" university students, however, male (but not female) abstainers were significantly more psychologically disturbed than moderate drinkers, who were not differentiated from the small number of heavy drinkers.
A birth-cohort study in the United Kingdom (Power et al., 1998) examined cross-sectionally the relationship between alcohol consumption and (in addition to self-reported health and chronic illness) psychological distress at age 33. Drinking measures for this cohort at age 23 were used to control for the possibility that heavy/problem drinkers at that age might appear as abstainers a decade later. With such ex-problem drinkers eliminated from the analysis, the U-shaped relationship between alcohol consumption and psychological distress was nonetheless evident for both men and women.
Vaillant (1995) reported on one of the longest longitudinal studies in history a fifty-year follow up of 443 Boston urban white youths and a college sample. The investigator characterized levels of drinking according to a peak 5-10-year period over subjects' lives, and combined heavy consumption with the appearance of 2 or more problems on a Problem Drinking Scale to identify alcohol abusers. Among the inner-city group, future abstainers both had greater emotional problems as children and as adults shared with those who ever abused alcohol approximately twice the rate of psychiatric diagnosis as moderate drinkers. Abstainers more than twice as often as moderate drinkers utilized "defenses associated with character disorder" (p. 136) and received a psychiatric diagnosis (independent of the study). A fifth (19%) of abstainers scored low on a global mental health measure (HSRS), while virtually no moderate drinkers did (1%). Alcohol abusers did worst on most measures. The college sample had virtually no abstainers.
2.6.5. Summary: Measured mental health benefits and remaining questions
This section has reviewed fifteen studies of mental health in relation to alcohol consumption (Bell et al., 1977; Caetano, 1987; Camacho et al., 1987; Golding et al., 1990; Leifman et al., 1995; Lipton, 1994; 1997; Neff, 1993; Neff and Husaini, 1982; Power et al., 1998; Roberts et al., 1995; Watten, 1996; Vaillant, 1995; two studies in Winefield et al., 1992), eleven of which found moderate drinkers to have an advantage over abstainers. (One other intriguing mental health-related result occurred in an ecological-type study. Utilizing aggregate data for each state between 1977 and 1988, Liu et al., 1995-96, found a U-shaped relationship between suicide and alcohol consumption.) These studies were conducted in Norway, Australia, the United Kingdom, and rural and urban areas of the U.S. with both genders and a range of age groups. They provide substantial evidence that moderate drinking is associated with superior mental health. However, it may not be possible to go beyond documenting this association to determine the extent to which moderate drinking encourages mental health or mentally healthy people drink moderately. Furthermore, the failure to find this advantage in several cases among Mexican-Americans suggests that minority and/or lower SES groups do not show this pattern as reliably as other populations studied, perhaps because lower SES is associated both with abstention from alcohol and with poorer mental health (Camacho et al., 1987).
2.7. Cognitive Benefits
Baum-Baicker (1985), Dufour (1994), and Pittman (1996) cite studies showing low-dose alcohol consumption to enhance performance on certain cognitive tasks. Finnigan and Hammersley (1992), on the other hand, emphasized primarily negative effects on cognitive and psychomotor performance from immediate exposure to alcohol. In a comprehensive review, Pihl et al. (1998) found impairment of most mental abilities, including complex motor skills, decision-making, and verbal learning and recall, with little impairment of simple learning or verbal ability, and actual enhancement of verbal and visual recall (cf. Hewitt et al., 1996). However, the field has changed its primary research focus from acute ingestion to the long-term effects of drinking (Parsons and Nixon, 1998). Parsons and Nixon summarized research since 1986 as indicating that alcohol ingestion causes a distinct drop in cognitive efficiency at a threshold of 5-6 drinks per day over an extended period of time.
Notwithstanding the largely impairing effects of concurrent alcohol consumption and intoxication and the negative neuropsychological consequences of chronic alcoholism and high-level drinking, regular moderate consumption is often associated with cognitive faculties superior to those shown by abstainers. Bates and Tracy (1990, p. 247), for example, found drinking positively correlated with a composite cognitive measure for six youthful age-gender groups, significantly so for 21-year-old men and women and 24-year-old women. Likewise, studies of alcohol consumption among the elderly in a number of countries show either no relationship with cognitive ability (Dent et al., 1997) or more often a curvilinear (Carmelli et al., 1999; Christian et al., 1995; Elias et al., 1999; Hebert et al., 1993; Orgogozo et al., 1997), bifurcated (i.e., drinking vs. nondrinking, Iliffe et al., 1991) or a direct positive relationship (Dufouil et al., 1997, for women only; Launer et al., 1996, only for drinkers with cardiovascular disease or diabetes).
2.7.1. Benefits of concurrent and past drinking for inner-city U.S. population
Hendrie et al. (1996) found light drinking (< 4 drinks weekly) to be statistically significantly associated with the best cognitive functioning (relative to both abstainers and heavier drinkers) in a community study of 2,040 elderly black Americans of both genders. Tested measures included a total cognitive function score, a measure of memory, and an Activities of Daily Living (ADL) score. The African-American population was extremely abstemious (76%). Past drinkers (35%) in the study showed the same cognitive and ADL benefits as current drinkers. It is not clear whether this result was due to alcohol's protective effects, even though the investigators controlled for demographic and risk factors. The investigators noted that the abstemiousness of this population made it unlikely that abstainers as a group had special problems.
2.7.2. Prospective research on long-term cognitive functioning
Orgogozo et al. (1997), in a prospective study in a wine-producing region of France, found a curvilinear relationship between alcohol consumption and risk for dementia (measured by a battery of tests) and Alzheimer's disease for both men and women. The significant drop in risk for dementia relative to abstainers occurred between mild 2 drinks weekly-2 drinks daily drinking (.81) and moderate 3-4 drinks daily drinking (.19). The lowest relative risk for Alzheimer's (.28) was likewise among moderate drinkers. Adjusted risk for dementia was .31 and for Alzheimer's .48 for heavy drinkers relative to nondrinkers. The level of drinking in this population is notably higher than in Hendrie et al. or virtually all American studies: only 4 percent of 2,273 subjects were nondrinkers, classified as those drinking no more than a glass of wine weekly.
These results are supported by a prospective study of identical twin veterans aged 63-73 in the National Academy of Sciences-National Research Council (the NHLBI twin study) data base (Christian et al., 1995). Comparing the drinking habits of 4,739 individuals assessed in the 1970s and 1980s with a cognitive scale measurement taken by phone in 1990-1991 produced a U-shaped curve, with the highest scores in cognitive functioning found among those having about 1-2 drinks daily (8.2-16.0 drinks/week). These drinkers scored higher than abstainers, those drinking less than 1 drink a week, and those drinking more than 16 drinks weekly, but only significantly so relative to the latter two groups. A comparison in this study of monozygotic (MZ) twins discordant for drinking found those drinking about 1-2 drinks daily scored higher than did their twins who drank less at the same level of significance (p<.05) as such drinkers did compared to unrelated veterans.
The Hendrie et al. results are supported by a prospective study of an urban, light-drinking American elderly group conducted by Hebert et al. (1993). (This study was part of the Established Populations for Epidemiological Studies of the Elderly program of the National Institute on Aging.) Seniors in East Boston who scored sufficiently well on three baseline cognitive functioning tests were assessed three years later on the same tests in terms of their smoking and drinking habits. Controlling for smoking, age, gender, education, income, and health status, very light drinkers (<.05 oz./day, or about a drink a week) scored significantly better than abstainers on changes in a digit-span (repeating numbers) test, while the highest measured category of drinkers (>1 oz./>2 drinks/day) scored better, but not significantly so, than abstainers on an immediate memory test.
The Framingham Heart Study (Elias et al., 1999) analyzed current and historical drinking patterns and cognitive functioning in 733 men and 1,053 women in order to investigate gender differences found in earlier research (cf. Dufouil et al., 1997). The study utilized eight memory and cognitive performance tests and controlled for demographic and CAD risk factors and disease. For women, there was no difference between cognitive measures for current very light drinkers (<½ drink/day) and abstainers and some significant advantages for light drinkers (½-2 drinks). However, the moderate drinking group (>2-4) performed significantly better than the abstainers on all measures. For men, relative to abstainers there were no differences for either very light or light drinkers and one difference in a single measure in favor of moderate drinkers. But heavy drinkers (>4-8) performed significantly better than abstainers on two composite scores (including the total composite). In addition, a regression analysis of cognitive scores by mean level of consumption over the 24 prior years showed that greater consumption led to a significantly higher score on one measure for men and on all but one measure for women.
Finally, 589 male participants in the NHLBI twin study were investigated in a longitudinal study of cognitive functioning in relation to smoking and drinking (Carmelli et al., 1999). Controlling for SES and cardiovascular health, all drinkers had lower rates of poor cognitive function than abstainers, but only light drinkers (up to one drink daily) significantly so. The study offered clues to possible biological mechanisms by separating the population into carriers of a specific gene allele (APOE 4); carriers showed a lower prevalence of poor cognitive function in the low drinking category, but actually showed higher rates in the higher drinking category.
2.7.3. Summary: Important cognitive benefits demonstrated for moderate drinking
A range of recent results across varied populations and utilizing different measures of cognitive functioning have found that long-term cognitive functioning is often superior for moderate drinkers relative to abstainers. This research, usually involving older populations, includes a number of prospective studies as well as a comparison of MZ twins who either drank moderately or abstained. The status of the research in this area resembles that of research on CAD and drinking a decade and more ago; we now see "second generation" studies emerging (testing hypotheses generated in earlier research). But considerably more research needs to be done to permit meta-analyses in the area. In some cases, unexplained variations in optimal drinking levels have appeared which need to be resolved. Furthermore, investigation of the mechanisms by which alcohol consumption might improve cognitive performance could strengthen or weaken the case for a causal relationship. A preliminary step in this direction was taken by examining one proposed genetic mediator in the NHLBI twin study (Carmelli et al., 1999). From the standpoint of practical significance, reduced rates of Alzheimer's and dementia/poor cognitive function have been associated with light-moderate drinking, along with enhanced Activities of Daily Living.
2.8. Work Performance
Although the immediate effects of alcohol ingestion are likely to be detrimental to work performance (Streufert et al., 1994), the cumulative lifestyle effects tend to favor moderate drinkers over both extremes. Heien (1996) analyzed data from three national surveys (the National Household Survey on Alcohol Use for 1979 and 1984 and the Quality of Employment Survey, 1972-73). Considering ex-drinkers separately, he found that the highest earnings occurred for those who drank in the range of 2.0-3.5 drinks/day. French and Zarkin (1995), based on a questionnaire administered to randomly selected employees at four U.S. worksites, found that "controlling for other variables and conditional on working, moderate alcohol users have higher wages than abstainers and heavy drinkers at these worksites." Wages peaked at 1.69-2.4 drinks/day. These optimal drinking levels for wages are quite similar, as Heien noted, to those for which the lowest risk of CAD prevails. In a cluster analysis to differentiate groups of nonclinical alcohol users in two U.S. general population surveys, Slater et al. (1999) found that moderate drinkers (average two drinks per occasion, drinking on average over 3 times week) had twice the annual income (average $71,400) of any other group, i.e., nondrinkers ($35,900) and light, episodic, and heavy drinkers.
2.8.2. Work absence and disability
Possible links between moderate drinking and success at work include better physical health and psychosocial adjustment for the individual, as well as greater involvement in employment-related social experiences by drinkers. The drinking-health-work connection is reflected in studies of work attendance and disability by drinking levels. Vasse et al. (1998), in the Netherlands, found that, when stress was present, abstainers were significantly more likely (and excessive drinkers nonsignificantly so) to be absent than moderate drinkers, leading to the conclusion "abstinence is at least as unhealthy as excessive drinking" (p. 240). The investigators opined that "moderate drinking [less than 3 drinks/day for men and 2 drinks/day for women] has a buffering effect on the association between stress and sickness. . . ." (p. 240). This parallels the role Lipton (1994) attributed to alcohol in buffering stress so as to protect against depression. The study did not, however, control for medical reasons for abstaining.
Other studies have measured disability in relation to drinking. In their study of possible psychosocial confounders of mortality, Camacho et al. (1987) discovered a reverse-J function, where abstainers were by far most likely to be disabled (27%) relative to all drinkers, with the lowest disability rate (10%) at 2-3 drinks/day. Since disability was one of the controls introduced for mortality, however, the researchers did not employ it as a dependent variable with controls for health status. In a prospective study of Swedish men, Månsson et al. (1999) found during an 11-year follow-up that abstainers had the highest RR (1.8) for receiving a disability pension, with low alcohol consumers as the index; high consumers had an intermediate RR (1.3). This study used the MAST alcohol problems scale to identify low versus high alcohol consumers. A control for perceived health ruled out the "sick abstainer" phenomenon as a confounder.
3. Specific Age Groups
Research showing positive psychosocial associations with drinking encompasses young people and the elderly (as was clear in the section on cognitive functioning) as well as other age groups, even as the young and the old remain the objects of heightened public health concern over the dangers of drinking.
Youthful drinking is heavier and more often takes the form of episodes of intensive drinking than is true for other age groups (Helzer et al., 1991; Hilton and Clark, 1991; Wechsler et al., 1994; 1998), creating dangers from driving and other at-risk behavior while intoxicated. However, research shows a rapid decline in such drinking habits after high school and college, so that by age 24 more than 80 percent of youths were not regular binge drinkers, including nearly two-thirds of those who had frequently engaged in such drinking as high school seniors (Schulenberg et al., 1996).
Research finds some beneficial associations with youthful drinking. Among young adults, Bates and Tracy (1990) found positive relationships between drinking and a variety of cognitive measures. For example, correlations between drinking and verbal IQ scores for 21- and 24-year-old women were .72-.75. Correlations among 18-year-olds, for whom drinking was illegal, were also largely positive. The authors reacted: "We can suggest no straightforward explanation for the large number of significant positive correlations between use intensity and cognitive abilities..." (p. 247). Although a small number of negative correlations occurred with episodes of concentrated consumption, "the data provide quite limited support for young nonclinical males and females being at increased risk" (p. 246). Positive associations with drinking were demonstrated with 18-19 year-old Swedish conscripts in regards to sociability, and also mental health when considering abstainers whose fathers had been drinkers (Leifman et al., 1995).
In Canada, Smart et al. (1996) reported that underage drinkers were not more likely to be heavy or problem drinkers than drinkers of legal age. Indeed, some studies have found that young people who experiment with alcohol are better adjusted than those who abstain or who regularly drink excessively. In Norway, Pape and Hammer (1996) found that young males (but not females) who first got drunk in middle adolescence, as opposed to either earlier or later ages, had fewer psychological problems. Those who got drunk at earlier than average ages had the poorest mental health. Grant and Dawson (1997), on the other hand, found in a U.S. national survey that the earlier any drinking occurred, the greater the likelihood of subsequent alcohol abuse/dependence. Finally, in a longitudinal study in New Jersey, Labouvie et al. (1997) did not find earlier drinking among teens predicted later alcohol problems.
A difficulty in interpreting findings of mental-health advantages among some youthful drinkers is that healthier, socially adjusted youths find themselves more often in drinking situations and drink more. This phenomenon, rather than that drinking produces healthier outlooks, could explain the observed associations; i.e., the relationship between drinking and psychological adjustment may be selective rather than causal.
Perhaps even more controversial was a finding by Nezlek et al. (1994) that college students who had some intense drinking episodes had more social interaction (with greater intimacy and disclosure) than those who reported no such episodes as well as those who had a greater frequency of them. The drop-off in intimacy was dramatic for "high-binging" men. This study elicits uneasiness including from its authors. "It appears that Disraeli's observation that 'There is moderation even in excess' provides an appropriate context for the present results. . . . [t]hese results suggest, as many have suspected, that alcohol consumption and social behavior are related. However, the results also suggest that these relationships may be more complicated than many have imagined them to be" (p. 350). Obviously, normative drinking confers some acceptability by peers. There are limits in the extent to which normative behavior means behavior that is either healthy or moderate, however. For example, Kilty (1990) showed that some styles of "normal" drinking by youths are associated with drinking problems.
Concern over problem drinking by the elderly combined with negative effects of mixing prescription medications with alcohol is growing (see American Medical Association Council on Scientific Affairs, 1996). Notwithstanding problem substance use by a minority of this age group, the elderly, like other adult populations, reduce their risk of death through moderate alcohol consumption (Mertens et al., 1996; Scherr et al., 1992; Simons et al., 1996). Indeed, since age is related to CAD risk, research (e.g., Thun et al., 1997) indicates that alcohol confers even more evident cardiovascular and overall health benefits for the elderly than for younger adult drinkers.
Other research shows that drinking by the elderly is associated with greater social contact and involvement. The study of psychosocial concomitants of alcohol for the elderly was at one time an active area for research (e.g., Black, 1969; Chien, 1971; Mishara and Kastenbaum, 1974; Volpe and Kastenbaum, 1967). Mishara and Kastenbaum (1980) and their colleagues conducted a series of studies of social drinking by the elderly, including matched comparisons and experiments introducing mild regular drinking in geriatric wards and nursing homes. Compared with control groups, those given beer or wine daily showed increased social interaction and participation in the milieu; improved cognitive performance, orientation, general functioning, and morale; and reduced use of sleeping medications. The research designs of these studies were generally weak (Poikolainen, 1994). Nonetheless, a summary of this work produced by the NIAAA (Dufour et al., 1992) found its results promising and deserving of further investigation. Dufour et al. (1992) pointed out that the best controlled study in this series, Mishara et al. (1975), continued to find the benefits identified by other research by this group.
The association noted above between moderate drinking and social integration and involvement is especially strong in the elderly (Adams, 1996; Alexander and Duff, 1988; Busby et al., 1988; Graham, 1998; Hanson, 1994; Meyers et al., 1985-86). (See Table 2) Problematic drinking in this age group disproportionately involves isolated individuals (Hanson, 1994). This may be because part of the drop in problem drinking as people age occurs from a reduction in the socially based excessive drinking more common in youth and middle age. Hilton and Clark (1991) found the lowest rates of problem drinking in the 60-plus age group, especially for men. The concomitant positive aspects of drinking by the elderly were captured in a study by Adams (1996, p. 1082) of three retirement communities. The study noted that, while "regular alcohol use was prevalent . . ., heavy and abusive drinking were uncommon.. Drinking appears to be associated with more social contacts and, possibly, better health status."
|Study and Sample||Results|
Adams (1996), survey of 317 residents (77% female) of three retirement communities, Milwaukee suburbs, mean age = 83
regular alcohol use prevalent
Alexander & Duff (1988), random sample of 260 middle-class residents (68.5% female) of three retirement communities, Southern California, Oregon, mean age = 76
drinking associated with social activity
Busby et al. (1988), community survey of 774 elderly (58% female) in Mosgiel, New Zealand, age 70+
drinking associated with social activity
Hanson (1994), random sample of 500 males born in Malmo, Sweden, in 1914, age 68
heavy drinking in men associated with social isolation, less integrated social network
Meyers et al. (1986), community sample of 920 mixed-ethnicity residents (63% female) in Boston metropolitan area, age 60+
older people drank mainly in social contexts and to facilitate social interaction
4.1. The findings and their significance
This review has found a range of positive psychological outcomes associated with moderate alcohol consumption. Some of these outcomes are associated with individual drinking events, but increasingly the focus is on long-term outcomes. To a greater degree than either abstainers or heavy drinkers, moderate drinkers have been found to experience a sense of psychological, physical, and social well-being; elevated mood; reduced stress (under some circumstances); reduced psychopathology, particularly depression; enhanced sociability and social participation; and higher incomes and less work absence or disability. The elderly often have higher levels of involvement and activity in association with moderate drinking, while often showing better-than-average cognitive functioning following long-term moderate alcohol consumption. To substantiate that alcohol brings about some psychological advantages still requires further research. In an area where the research has progressed to prospective, controlled studies namely, cognitive functioning plausible mechanisms must be identified to account for the improved functioning.
Much research also indicates that heavy drinking clearly worsens psychological experiences and outcomes. Thus, the universe of U-shaped relationships involving alcohol consumption may extend beyond health outcomes to psychological well-being. The observed benefits of moderate drinking take shape as a function of drinking habits experienced in a context conditioned by culture, social environment, and expectation (Peele, 1998). One reflection of this complex interplay is the effort to control for psychosocial factors in studies of drinking in relation to mortality rates (e.g., Greenfield et al., 1999; Murray et al., 1999), at the same time that studies of psychological outcomes increasingly employ controls for cardiovascular and other health factors (Carmelli et al., 1999; Launer et al., 1996; Månsson et al., 1999).
An illustration of complex interactions among alcohol, psychological variables, and health was provided by research by Cohen et al. (1993), in which nonsmoking moderate drinkers were resistant in a dose-response relationship to the experimental introduction of common-cold germs. The researchers favored physiological and immunological explanations for this phenomenon due to alcohol's pharmacological effects. Alternately, alcohol can create mood or stress-reduction effects that reduce susceptibility to illness. Indeed, the interactions of these various factors may not be separable: Slater et al. (1999, p. 673) observed that "the health status of moderate drinkers might be attributed to an intertwined set of social, cultural, and behavioral norms that can be expected to influence nearly all health-related behaviors." The researchers identified criteria according to which such clusters can be validated scientifically: "(1) consistency with existing research, (2) predictive validity. . . , and (3) . . . explanatory value above and beyond that provided by behavior-based distinctions alone."
4.2. Unanswered questions: Confounders and prospective research
Much of the work reported in this review goes beyond the ethnographic and social impression data that at one time formed the basis for the idea that alcohol has psychosocial benefits. This newer research, which conforms better to modern epidemiological approaches, has appeared in prominent peer-reviewed journals in a number of related fields. Indeed, the interdisciplinary character of this collective research enterprise lends credibility to the findings. Nonetheless, the exploration of the long-term effects of consuming alcohol leaves unanswered questions.
The classical method for determining the pharmacological impact of a substance is the randomized controlled experiment. Although such research has been used to measure the effects of a single episode of alcohol consumption, ethical and practical considerations rule it out in the study of the long-term effects (medical or psychological) of alcohol. This leaves prospective studies as the most powerful and reliable tool available for garnering a coherent understanding of a complex interactive field. When we move from biomedical to psychological outcomes, the interpretive difficulties multiply. Prospective research may never be able to determine, for example, whether mentally healthier or more socially integrated individuals are better able to drink moderately, whether drinking per se improves mental health and social integration, or whether psychosocial and demographic factors that covary with drinking patterns produce these positive outcomes.
From another direction, the questioning of the causal role of alcohol consumption in mortality outcomes has occurred in a line of research that lies outside the epidemiological mainstream. In a prospective study (1973-1988), Grossarth-Maticek and Eysenck (1995) predicted health, disease, and mortality outcomes in over 12,000 men and women in Heidelberg, Germany. In addition to improved mortality and health through moderate drinking, the investigators found that an orientation to life that emphasized "self-regulation" reduced mortality.
Moreover, the investigators found that motives for drinking were crucial in mortality outcomes: those who drank to drown their sorrow had higher death rates than those who drank to provide feelings of pleasure, so that pleasure drinkers without major life stress had lower mortality levels than sorrow drinkers undergoing stress, no matter at what level either group was drinking (Grossarth-Maticek and Eysenck, 1991). Likewise, Harburg and his associates showed that set and mood while drinking were more important in determining severity of hangover (Harburg et al., 1993) and blood pressure (Harburg et al., 1994) than level of alcohol consumption. Grossarth-Maticek et al. (1995) developed a separate alcohol self-regulation measure, comprising items showing use of alcohol as a positive e.g., improved relationships with others, sex, mood, etc. or negative coping mechanism. Those for whom alcohol improved functioning had better survival and health rates at every level of drinking than those for whom alcohol decreased self-regulation. If these findings are to be taken seriously, the causes of the advantageous health status of moderate drinkers must be regarded as multiple and the direction(s) of causality as indeterminate.
Intrapsychic determinants of variations in drinking are likely to be mirrored by the social contexts of drinking. For example, Cooper et al. (1992, 1995) found that those who drink to enhance pleasurable feelings are more likely to drink in a congenial social context. The importance of such contextual variables as drinking with meals and in the company of heterogeneous (by age and gender) family and social units as determinants of drinking outcomes has been a major theme of anthropological research (Heath, 1995; Marshall, 1979; Peele and Brodsky, 1996). In a macrosocietal application of such an integrative analysis, Sagan (1987) and Wilkinson (1997) have demonstrated that, even contrary to other health indicators (e.g., diet, sanitation, poverty, war), social cohesion can create superior health outcomes for heart- and infectious disease rates and overall life expectancy.
4.3. Research lessons and next steps
4.3.1. Allowing for curvilinear relationships
Research on decrements in psychological performance or experience that postulates only a straightforward dose-response relationship will submerge potential beneficial effects found in moderate drinkers. A standard practice should be to test curvilinear models in order to detect positive outcomes associated with lower or moderate levels of consumption.
4.3.2. Casting a broader net in outcome studies
Epidemiologic and outcome studies of psychosocial consequences of alcohol consumption, as well as those measuring drinking and life problems, should also measure alleviation of problems or actual life-enhancements, so as to permit a full plotting of the effects of alcohol over the population according to levels of consumption.
4.3.3. Cost-benefit analyses
Several major cost studies have been undertaken in order to estimate the social costs of drinking. These studies accept findings of costs whose bases are not clearly more causal than comparable calculations of benefits. The same is true for many negative and positive medical outcomes. In this context, Rehm (1999, p. 48) has concluded, "Alcohol has beneficial effects of public health relevance that should be included in the shaping of alcohol policy."
4.3.4. Prospective research
Currently, prospective research on alcohol has focused almost exclusively on medical outcomes. The one area reviewed in this paper in which prospective research has begun to appear is in cognitive functioning/dementia. Yet other areas could support such research, including mental health, work performance, social adjustment, life satisfaction, and complex psychological syndromes such as demoralization and self-regulation.
4.3.5. Introducing controls in studies of psychological benefits
Community and prospective studies in the psychological realm need to incorporate plausible confounders in their designs. These include medical (e.g., baseline health, drinking history), dispositional (e.g., religious or ethical prohibitions on drinking), demographic, and socioeconomic factors. Such controls can reduce the indeterminacy that currently inhibits efforts to make causal inferences from correlations. In particular, adequate controls would help elucidate the significance of findings about abstainers.
4.3.6. Investigating mechanisms for psychological benefits
Mechanisms thought to account for reduced CAD due to alcohol consumption (such as enhanced HDL levels) raise the credibility of observed outcomes from moderate drinking. Attributions to moderate drinking of psychological benefits such as mental health (e.g., reduced depression), better earnings and productivity, and improved long-term cognitive functioning need to be deconstructed to more elemental levels to acquire similar credibility.
At this early stage of research into psychological benefits (or concomitants) of moderate alcohol consumption, it would be imprudent to dismiss any part of the variegated body of work on this complex subject, including rich ethnographic material. Progress in this field will be a matter of achieving greater rigor without sacrificing breadth and variety. Sound and useful cost-benefit analyses, as a basis both for policy decisions and models of drinking behavior, should more accurately and completely reflect the range of societal and personal drinking experiences.
Material in this paper has been presented at the conference, "Permission for Pleasure," in New York, NY, June 28-July 1, 1998 and the 25th annual meeting of the Kettil Bruun Society in Montreal, June 1-4, 1999. The Distilled Spirits Council of the United States, Inc. (DISCUS) and the Wine Institute provided unrestricted grants that were used to fund this work. The views and opinions reflected in this article are those of its authors, and do not necessarily reflect those of the funders or their member companies. Alan Lang, James Orcutt, Eric Single, Geoff Lowe, and the librarians at the Rutgers Center of Alcohol Studies made valuable contributions to this paper.
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