National Institute on Alcohol Abuse and Alcoholism
No. 23 PH 347 January 1994
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Alcohol and Minorities
Do blacks, Hispanics, American Indians, and Asians and Pacific
Islanders in the United States drink more or less than whites drink? Do
they have more alcohol-related medical problems? Do they receive
treatment in proportion to their problems? In 1990, 68.3 percent of
whites, 64.5 percent of Hispanics, and 55.6 percent of blacks used
alcohol (1). Although these percentages appear similar, different
patterns of use and abuse and varying prevalence of alcohol-related
problems underlie the numbers (2-9). This Alcohol Alert considers why
some minorities have more medical problems than others and whether
minorities receive adequate treatment and prevention services. It
examines genetic and environmental factors that may put minorities at
risk for or protect them from alcohol problems. It also reviews research
on screening to identify those at risk for alcoholism or alcohol
abuse.
Medical Consequences and Alcohol-Related
Trauma
Given major underreporting of alcohol-related diagnoses, minimum
estimates from one survey of non-Federal, short-stay hospitals in 1991
found 54.5 patient discharges for alcohol-related diagnoses for every
10,000 people in the United States over age 15 (10). The rate for whites
was 48.2 per 10,000; however, the rate for blacks was 102.9 per 10,000
population (10). Because it is not known whether the rates of
underreporting are equal among ethnic groups, it is difficult to
interpret the meaning of such reported differences.
A study of alcohol-related mortality in California showed that blacks
and Hispanics had higher rates of mortality from alcoholic cirrhosis than
did whites or Asian-Americans. Nationwide, death rates attributed to
alcohol dependence syndrome also were highest for blacks, although a
higher percentage of blacks than whites abstain from using alcohol
(5,11). The high rates of medical problems seen in blacks thus occur
among a smaller percentage of the black population when compared with
whites.
The California study suggests that for many alcohol-related causes of
death such as alcohol dependence syndrome and alcoholic hepatitis,
Hispanics had either similar or lower mortality rates compared with
whites. However, the mortality rate among Hispanics from alcohol-related
motor vehicle crashes was 9.16 per 100,000, significantly higher than the
rates for whites (8.15) or blacks (8.02) (11).
The group identified as “Asian/Other” in the California study had
lower rates of alcohol-related mortality than any other group for most
causes of death. Their mortality rate from motor vehicle crashes, for
example, was 5.39 per 100,000 (11). Asians tend to have lower rates of
drinking and alcohol abuse than whites (2).
Although highly variable among tribes, alcohol abuse is a factor in
five leading causes of death for American Indians, including motor
vehicle crashes, alcoholism, cirrhosis, suicide, and homicide. Mortality
rates for crashes and alcoholism are 5.5 and 3.8 times higher,
respectively, among American Indians than among the general population.
Among tribes with high rates of alcoholism, reports estimate that 75
percent of all accidents, the leading cause of death among American
Indians, are alcohol related (7).
Fetal Alcohol Syndrome (FAS)
The prevalence of FAS among select groups of Navajo, Pueblo, and
Southwestern Plains Indians has been studied. Among two populations of
Southwestern Plains Indians ages newborn to 14 years, 10.7 of every 1,000
children were born with FAS. This was compared with 2.2 per 1,000 for
Pueblo Indians and 1.6 for Navajo (12). Overall rates for FAS in the Un
ited States range from 1 to 3 per 1,000 (15). Cultural influences,
patterns of alcohol consumption, nutrition, and differing rates of
alcohol metabolism or other innate physiological differences may account
for the varying FAS rates among Indian communities (13).
The incidence of FAS among blacks appears to be about seven times
higher than among whites, although more blacks than whites abstain from
drinking (5,14,15). The reasons for this difference in FAS rates are not
yet known (14,15). Paradoxically, one study has found that black women
believe drinking is acceptable in fewer social situations than do white
women (6). Ten percent of black compared with 23 percent of white women
surveyed said that drinking more than one or two drinks at a bar with
friends is acceptable (6). This attitudinal difference could help to
explain why fewer black women are frequent, high-quantity drinkers than
are white women (6). Nevertheless, FAS seems to be more prevalent among
blacks than among whites.
Genetic Influences
Certain minority groups may possess genetic traits that either
predispose them to or protect them from becoming alcoholic. Few such
traits have so far been discovered. However, the flushing reaction, found
in the highest concentrations among people of Asian ancestry, is one
example.
Flushing has been linked to variants of genes for enzymes involved in
alcohol metabolism. It involves a reddening of the face and neck due to
increased blood flow to those areas and can be accompanied by headaches,
nausea, and other symptoms. Flushing can occur when even small amounts of
alcohol are consumed (16).
Japanese-Americans living in Los Angeles have been studied. Among
those with quick flushing responses (flushing occurs after one drink or
less), fewer consumed alcohol than did those with no or with slow
flushing responses (flushing occurs after two or more drinks)(17). In
another group of Japanese-American students in Los Angeles, flushing was
far less correlated with abstention from alcohol than it was in the first
group (17). Thus, although flushing appears to deter alcohol use, people
with the trait may nevertheless consume alcohol.
Another genetic difference between ethnic groups occurs among other
enzymes involved in metabolizing alcohol in the liver. Variations have
been observed between the structures and activity levels of the enzymes
prevalent among Asians, blacks, and whites (18). One enzyme found in
Japanese, for example, has been associated with faster elimination of
alcohol from the body when compared with whites (19). Interesting leads
relating these varying rates of alcohol metabolism among minorities to
medical complications of alcoholism, such as liver disease, are now being
followed.
Influence of Acculturation
Acculturation has a dramatic effect on drinking patterns among
immigrants to the United States and successive generations. Comparisons
of drinking among immigrant and second and third generation
Mexican-American women reveal that drinking rates of successive
generations approach those of the general population of American women.
Seventy-five percent of Mexican immigrant women in one study abstained
from alcohol; only 38 percent of third generation Mexican-American women
abstained. This rate is close to the 36-percent abstention rate for women
in the general U.S. population (20). Rates of alcohol-related problems
also may be affected by acculturation. A study has found that Hispanic
women who are at least second generation Americans have higher rates of
social and personal problems than either foreign born or first generation
Hispanic women (3). Studies of Asian-Americans have suggested that their
drinking rates conform to those of the U.S. population as acculturation
occurs (17,21).
Identification and Treatment
Do screening instruments for alcohol-relat ed problems, validated in
primarily white populations, accurately detect alcohol problems among
minorities? One study evaluated the Self-Administered Alcoholism
Screening Test (SAAST), translated into Spanish, in Mexico City and the
original English version in Rochester, MN. The Spanish translation
identified alcoholics and nonalcoholics at rates comparable to those of
the English version. The study found that the questions that best
predicted alcoholism were the same in both versions (22). This study
suggests that translations or other revisions of screening tools may be
just as accurate as the original instruments, but more studies are needed
before firm conclusions can be drawn.
It is not known whether all treatment programs are effective for
members of minority groups. Among minority patients who enter treatment
programs for the general population, success rates are equal to those of
whites in the same programs (23,24). Also, despite the existence of
programs designed to treat specific minority groups, no evidence exists
that either supports or denies their ability to produce improved outcomes
(25,26).
Do minorities have the same access to alcoholism treatment as do
whites? Access to treatment for minorities has not been assessed widely,
but several factors have been studied. There is evidence that not
everyone in these groups who needs treatment receives it. For example,
Hispanics and blacks are less likely to have health insurance and more
likely to be below the poverty level than whites, factors that may
decrease their access to treatment (24,27,28).
No studies focus on access to alcoholism treatment for the U.S.
Hispanic population as a whole (28). Some culturally sensitive programs
exist for Hispanics and are often aimed at specific cultures within this
group, such as Puerto Ricans. These programs have not been evaluated
(24,28).
Prevention
Prevention efforts that work among the general population have been
shown to be effective among some minorities (29). However, it is unclear
whether interventions designed for specific minorities also would be
beneficial. For example, programs incorporating peer counseling,
enhancing adolescents’ coping skills, and alcohol education appear to be
effective among American Indians. One study has demonstrated that
specific populations of American Indian adolescents who completed such a
program used less alcohol when compared with their peers 6 months after
completion of the program (29). A second study showed that American
Indian participants in another program decreased their own use of alcohol
when evaluated 12 months after the program’s completion (30).
The effectiveness of warning labels on alcoholic beverage containers
has been evaluated in a group of black women (31). A study showed that 6
months after the label was mandated by law, pregnant black women who were
light drinkers slightly reduced their drinking during pregnancy, whereas
black women who were heavier drinkers did not change their drinking
habits (31).
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Alcohol and Minorities–A Commentary by
NIAAA Director Enoch Gordis, M.D.
The increasing number of studies of alcohol problems among minorities
has produced both important findings and new questions to answer. Higher
abstention rates among African-Americans coexist with higher cirrhosis
mortality. Native American groups vary greatly in their drinking
practices, but the specific contributions of social, cultural, and
genetic influences to these variations are not yet known. We need to
understand why acculturation seems to increase drinking among successive
generations of Hispanics and diminishes the “protective” effect of the
flushing reaction among succeeding generations of Asian-Americans.
Finally, we need to know more about disparities in access to treatment
and prevention among minority groups and whether culturally relevant
treatment appr oaches improve treatment outcome.
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All material contained in the Alcohol Alert is in the public
domain and may be used or reproduced without permission from NIAAA.
Citation of the source is appreciated.
Copies of the Alcohol Alert are available free of charge from
the Scientific Communications Branch, Office of Scientific Affairs,
NIAAA, 6000 Executive Boulevard, Room 409, Rockville, MD
20892-7003.Telephone: 301-443-3860.
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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service * National Institutes of Health
