Date Published: , 2014
Publisher: National Institute on Alcohol Abuse and Alcoholism
Author(s): Karen G. Chartier, Patrice A.C. Vaeth, Raul Caetano.
Alcohol consumption is differentially associated with social and health harms across U.S. ethnic groups. Native Americans, Hispanics, and Blacks are disadvantaged by alcohol-attributed harms compared with Whites and Asians. Ethnicities with higher rates of risky drinking experience higher rates of drinking harms. Other factors that could contribute to the different effects of alcohol by ethnicity are social disadvantage, acculturation, drink preferences, and alcohol metabolism. This article examines the relationship of ethnicity and drinking to (1) unintentional injuries, (2) intentional injuries, (3) fetal alcohol syndrome (FAS), (4) gastrointestinal diseases, (5) cardiovascular diseases, (6) cancers, (7) diabetes, and (8) infectious diseases. Reviewed evidence shows that Native Americans have a disproportionate risk for alcohol-related motor vehicle fatalities, suicides and violence, FAS, and liver disease mortality. Hispanics are at increased risk for alcohol-related motor vehicle fatalities, suicide, liver disease, and cirrhosis mortality; and Blacks have increased risk for alcohol-related relationship violence, FAS, heart disease, and some cancers. However, the scientific evidence is incomplete for each of these harms. More research is needed on the relationship of alcohol consumption to cancers, diabetes, and HIV/AIDS across ethnic groups. Studies also are needed to delineate the mechanisms that give rise to and sustain these disparities in order to inform prevention strategies.
Heavy drinking and binge drinking contribute to a variety of alcohol-attributed social and health harms (Naimi et al. 2003; Rehm et al. 2010). Heavy alcohol use, as defined by the National Institute on Alcohol Abuse and Alcoholism’s (NIAAA’s) Helping Patients Who Drink Too Much: A Clinician’s Guide (NIAAA 2005), is defined as consuming more than 4 standard drinks per day (or more than 14 per week) for men and more than 3 per day (or more than 7 per week) for women. One standard drink is equivalent to 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Binge drinking is defined as consuming five or more drinks in approximately 2 hours for men and four or more drinks for women (NIAAA 2004).
Alcohol-attributed harms can be both acute and chronic conditions that are wholly caused (e.g., alcoholic liver cirrhosis) or associated with alcohol use via intoxication, alcohol dependence, and the toxic effects of alcohol (Rehm et al. 2010). The major injury and disease categories linked to alcohol consumption include (1) unintentional injuries, (2) intentional injuries, (3) FAS, (4) gastrointestinal diseases, (5) cardiovascular diseases, (6) cancers, (7) diabetes, and (8) infectious diseases (World Health Organization [WHO] 2011). Evidence is incomplete on the relationship between ethnicity, drinking, and each of these categories. Below, those alcohol-related harms are described that have available findings by ethnic group in addition to important gaps in this scientific literature. Alcohol use disorders are causally linked to drinking and vary by ethnicity (i.e., more likely in Native Americans and Whites) (Hasin et al. 2007), but this disease category is not described here.
Unintentional injuries associated with alcohol use include falls, drowning, and poisoning (WHO 2011). However, most available research on ethnicity, alcohol use, and injuries is focused on motor vehicle crashes. Alcohol-impaired driving and crash fatalities vary by ethnicity, with Native Americans and Hispanics being at higher risk than other ethnic minority groups. Past-year driving under the influence (DUI) estimates based on the 2007 National Survey on Drug Use and Health were highest for Whites (15.6 percent) and Native Americans (13.3 percent) relative to Blacks (10.0 percent), Hispanics (9.3 percent), and Asians (7.0 percent) (Substance Abuse and Mental Health Services Administration [SAMHSA] 2008). National surveys generally show lower DUI rates for Hispanics than Whites, but studies based on arrest data identify Hispanics as another high-risk group for DUI involvement (Caetano and McGrath 2005; SAMHSA 2005). The DUI arrest rate for Native Americans in 2001, according to the U.S. Department of Justice (Perry 2004), was 479 arrestees per 100,000 residents compared with 332 for all other U.S. ethnic groups.
Using data from the 2001–2002 NESARC, Caetano and colleagues (2006) examined alcohol consumption, binge drinking, and alcohol abuse and dependence among women who were pregnant during the past year. Most women (88 percent) who reported being pregnant and also a drinker at any point in the past 12 months indicated that they did not drink during pregnancy. Rates of past-year alcohol abuse (0.8 percent to 2.3 percent) and dependence (1.2 percent to 2.8 percent) were similar and low in White, Black, Hispanic, and Asian pregnant women. Binge drinking and alcohol consumption without binge drinking among pregnant women were highest in Whites (21.1 percent and 45.0 percent, respectively) compared with other ethnic groups (0 percent to 10.7 percent and 21.0 percent to 37.3 percent). White women in this study were at greater risk for an alcohol-exposed pregnancy. However, other studies found that Black, Hispanic, and Asian women were less likely to reduce or quit heavy drinking after becoming pregnant (Morris et al. 2008; Tenkku et al. 2009). Blacks and Native Americans are at greater risk than Whites for FAS and fetal alcohol spectrum disorders (Russo et al. 2004). From 1995 to 1997, FAS rates averaged 0.4 per 1,000 live births across data-collection sites for the Fetal Alcohol Syndrome Surveillance Network and were highest for Black (1.1 percent) and Native American (3.2 percent) populations (CDC 2002).
Liver disease is an often-cited example of the disproportionate effect of alcohol on health across ethnic groups. Native Americans have higher mortality rates for alcoholic liver disease than other U.S. ethnic groups (see figure). According to the National Vital Statistical Reports (Miniño et al. 2011) on 2008 U.S. deaths, age-adjusted death rates attributed to alcoholic liver disease for Native American men and women were 20.4 and 15.3 per 100,000 people, respectively, compared with 6.9 and 2.4 per 100,000 for men and women in the general population.
Although moderate alcohol consumption has been associated with a reduced risk for coronary heart disease (CHD) (Goldberg and Soleas 2001), there is some evidence that ethnic groups differ in terms of this protective effect, particularly for Blacks compared with Whites. Sempos and colleagues (2003) found no protective health effect for moderate drinking in Blacks for all-cause mortality, as previously reported in Whites. Kerr and colleagues (2011) reported the absence of this protective effect for all-cause mortality in Blacks and Hispanics. Similar findings have been described for hyper-tension and CHD risks in Black men compared with White men and women (Fuchs et al. 2001, 2004) and for mortality among Black women without hypertension (Freiberg et al. 2009). Mukamal and colleagues (2010) also showed that the protective effects of light and moderate drinking in cardiovascular mortality were stronger among Whites than non-Whites. Pletcher and colleagues (2005) found evidence that the dose-response relationship between alcohol consumption and increased coronary calcification, a marker for CHD, was strongest among Black men.
In 1988, the WHO International Agency for Research on Cancer (IARC) reviewed the epidemiologic evidence on the association between alcohol consumption and cancer and found a consistent association between alcohol consumption and increased risk for cancers of the oral cavity, pharynx, larynx, esophagus, and liver (IARC 1988). Regardless of ethnicity, the risk of developing these cancers is significantly higher among men than women (National Cancer Institute 2011c, d, e). The incidence and mortality rates for these cancers also vary across ethnic groups. Regarding cancers of the oral cavity and pharynx, incidence rates among White and Black men are comparable (16.1 and 15.6 per 100,000, respectively); however, mortality rates are higher among Black men (6.0 versus 3.7 per 100,000 for White men) (National Cancer Institute 2011e). For cancer of the larynx, both incidence and mortality rates are higher among Black men than among White men (incidence, 9.8 and 6.0; mortality, 4.4 and 2.0) (National Cancer Institute 2011c). Although these differences may be explained by differential use of alcohol and tobacco in relation to gender and ethnicity, there is some evidence that even after controlling for alcohol and tobacco use, Blacks continue to be at increased risk for squamous cell esophageal cancer and cancers of the oral cavity and pharynx (Brown et al. 1994; Day et al. 1993).
In 2010, the prevalence of diabetes was 7.1 percent, 12.6 percent, 11.8 percent, and 8.4 percent among Whites, Blacks, Hispanics, and Asians, respectively (National Institute of Diabetes and Digestive and Kidney Diseases 2011). Age-adjusted mortality rates in 2007 were 20.5, 42.8, 28.9, and 16.2 per 100,000 people among Whites, Blacks, Hispanics, and Asians (National Center for Health Statistics 2011). Data on mortality rates for diabetes among Hispanics may be underreported as a result of inconsistencies in the reporting of Hispanic origin on death certificates (Heron et al. 2009). Despite higher risks for the development of and death from diabetes in Hispanics and Blacks compared with Whites, little evidence is available to delineate the relationship of alcohol to diabetes across ethnic groups. Studies among both diabetics and nondiabetics demonstrate a J- or U-shaped curve between alcohol consumption and insulin sensitivity (Bell et al. 2000; Davies et al. 2002; Greenfield et al. 2003; Kroenke et al. 2003). Likewise, two large epidemiologic studies among diabetic subjects show that moderate alcohol consumption is associated with better glycemic control (Ahmed et al. 2008; Mackenzie et al. 2006). An important limitation of these studies, however, is that few included ethnic minority groups or failed to emphasize possible differences in relation to ethnicity in their analyses.
Among the infectious diseases attributable to alcohol (e.g., pneumonia, tuberculosis) (WHO 2011), human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are most relevant to U.S. ethnic health disparities. In 2009, Blacks represented 44 percent of new HIV infections and Hispanics represented 20 percent. Infection rates by gender for Blacks were 15 times (for men) and 6.5 times (for women) those of Whites, and rates for Hispanics were 4.5 times for men and 2.5 times for women, compared with rates for Whites (CDC 2011). In addition, alcohol consumption has been associated with increased HIV infection risk (Bryant et al. 2010). Caetano and Hines (1995) showed that heavy drinking predicted high-risk sexual behaviors in White, Black, and Hispanic men and women, with more Blacks than Whites and Hispanics reporting risky sexual behaviors. Among HIV-infected patients, there also is evidence that increased alcohol consumption negatively affects adherence to antiretroviral medication regimens (Chander et al. 2006; Cook et al. 2001; Samet et al. 2004) and HIV disease progression (Conigliaro et al. 2003; Samet et al. 2003). Despite these strong individual associations between ethnicity and HIV/AIDS and alcohol and HIV/AIDS, there is limited research across ethnicities on alcohol use and HIV infection or disease progression.
This article identifies U.S. ethnic-group differences in alcohol-attributed social and health-related harms. Three minority ethnicities are particularly disadvantaged by alcohol-related harms. Native Americans, relative to other ethnic groups, have higher rates of alcohol-related motor vehicle fatalities, suicide, violence, FAS, and liver disease mortality. Unlike other ethnic groups, in which men are primarily at risk for alcohol-related harms, both Native American men and women are high-risk groups. Hispanics have higher rates of alcohol-related motor vehicle fatalities, suicide, and cirrhosis mortality. Blacks have higher rates of FAS, intimate partner violence, and some head and neck cancers, and there is limited empirical support in Blacks for a protective health effect from moderate drinking. These patterns of findings provide recognition of the health disparities in alcohol-attributed harms across U.S. ethnicities. However, further research is needed to identify the mechanisms that give rise to and sustain these disparities in order to develop prevention strategies. The contributing factors include the higher rates of consumption found in Native Americans and Hispanics, but more broadly range from biological factors to the social environment. More research on the relationship of alcohol to some cancers, diabetes, and HIV/AIDs across ethnic groups is also needed. There is limited evidence for how drinking differentially affects ethnic differences in breast and colorectal cancers and in diabetes and HIV/AIDS onset and care, and few findings for how alcohol-attributed harms vary across ethnic subgroups.