In: S. Peele & M. Grant (Eds.), Alcohol and pleasure: A health perspective, Philadelphia: Brunner/Mazel, pp. 187-207
© Copyright 1999 Stanton Peele. All rights reserved.
Psychosocial Benefits of Moderate Alcohol Consumption
Alcohol's Role in a Broader Conception of Health and Well-being
Harvard Medical School
The initial hypothesis and evidence that moderate alcohol consumption reduces the overall mortality rate through its protective effect against cardiovascular disease are now broadly known and accepted (see Camargo, 1999; Klatsky, 1999). This evidence continues to accumulate, most recently in a study of nearly a half a million middle-aged and elderly people in the United States (Thun et al., 1997). Yet notwithstanding these findings - along with many long-held cultural beliefs that drinking improves health - most people consume alcohol for experiential rather than health reasons (Hall, 1996; Lowe, 1994b, 1999; Peele, 1999a; Snel, 1999). The critical role of pleasure not only as a motivation for drinking but as a potential cause or indicator of positive health outcomes is attracting medical attention. As an editorial in the British Medical Journal noted, "Public health campaigns have often ignored people's requirement for pleasure" (Cleare & Wessely, 1997, p. 1637). However, clinical medicine has begun to identify global quality of life and level of general functioning as essential dimensions of health outcomes (Orley, 1999; Wilson & Cleary, 1995). Taking into account the psychosocial as well as medical benefits of moderate drinking balances the heretofore exclusively negative public health emphasis on problematic psychosocial consequences of drinking (accidents, violence, addiction), which considers health consequences of drinking exclusively in terms of risk reduction (Edwards et al., 1994).
Baum-Baicker's (1985) earlier review identified five areas of psychosocial benefits from alcohol consumption: (a) stress reduction; (b) mood enhancement; (c) cognitive performance; (d) reduced clinical symptoms, primarily of depression; and (e) improved functioning in the elderly. Taking off from this and the more limited reviews that have appeared in recent years (Midanik, 1995; Pittman, 1996; Poikolainen, 1994), the present authors have updated Baum-Baicker and expanded Baum-Baicker's framework to include additional areas of benefit, drawing from ethnographic, psychological, and epidemiological research (Peele & Brodsky, 1998). This chapter summarizes these data as an invitation to take stock of their significance. Among the issues to be assessed are:
- The nature of the psychosocial benefits identified with alcohol consumption
- The types of evidence that support each and how firmly established each is
- Whether and which of these benefits assume the J-shaped and U-shaped curves regularly found in mortality rate studies, in which moderate drinkers have better outcomes than either abstainers or heavy drinkers
- The explanatory power for health outcomes of such psychosocial benefits associated with moderate alcohol consumption
Peele (1999b) explores the public health value of acknowledging such benefits in drinking.
What Constitutes Moderate Drinking?
The definition of optimal drinking for health purposes has been fairly well accepted in the United States and United Kingdom as one or two drinks daily and at the lower end of the range for women (Department of Health and Social Security, 1995; U.S. Departments of Agriculture/Department of Health and Human Services, 1995). Going farther afield, however, this range may expand. Grønbæk et al. (1995) found mortality-rate gains for men and women up to three to five drinks of wine daily in Denmark, as did Fuchs et al. (1995) with a sample of women in the United States. Doll (1997) summarized various factors contributing to the relativity of both reported and optimal unit consumption across national boundaries, including extremely different definitions of what constitutes a standard drinking unit and the common underreporting of alcohol consumption. Thus, in Poikolainen's (1995) cross-cultural review, minimum mortality was associated with consumption levels ranging from one to five drinks daily. In the current review, which includes ethnographic as well as epidemiologic data and covers a range of cultural settings beyond those involved in typical epidemiologic studies, moderation is an even more variable ideal.
Single (1998; see also Stockwell & Single, 1999) extended this relativity to both quantitative and qualitative dimensions of beneficial drinking, primarily the frequency and distribution of consumption: the person consuming 7 to 14 drinks a week all at one sitting is less likely to experience either the cardiovascular or psychosocial benefits experienced by the person who averages the same number of drinks spread evenly through the week. Single proposed the following dimensions of a beneficial pattern of drinking: frequency of drinking occasions, volume of consumption per occasion, drinking settings (safe and pleasurable, involving diverse activities, ceremonial), characteristics of drinking companions, alcohol expectancies, and the absence of special considerations (medical, cultural, or situational) contraindicating any drinking.
Types of Effects Studied
The studies cited here, reviewed in greater detail by Peele and Brodsky (1998), encompass four general areas of benefit: psychological benefits (subjective health, mood enhancement, stress reduction, mental health), social benefits (sociability, leisure, social cohesion), cognitive and performance benefits, and benefits specific to the young and the elderly. These potential benefits, set out in Table 1, are found with varying degrees of confirming evidence using various methods of investigation, including experimental studies, prospective studies in natural environments, general-population or community surveys or correlational studies, self-report questionnaires or interviews, and ethnographic observations. Finally, two levels of exposure to alcohol are considered: immediate and habitual. Experimental studies typically contrast the effects of a single occasion of consumption with those of no consumption. Community studies (prospective or correlational) contrast the cumulative effects for individuals of a pattern of moderate consumption with those of abstinence or persistent heavy consumption. Ethnographic observations may focus on either immediate or longer-term exposure. Our review places greater emphasis on sustained, habitual moderate drinking, pointing to questions of lifestyle and outlook.
|Areas of psychosocial benefit from alcohol and associated research on which each is based.|
|Benefit||Type of research|
|Pleasure, positive experiences||Survey, experimental, observational, correlational, ethnographic|
|Stress reduction||Experimental, observational, survey|
|Sociability||Survey, experimental, observational, correlational, ethnographic|
|Leisure experience||Survey, observational, ethnographic|
|Social cohesion||Observational, ethnographic|
|Creativity (idea generation, confidence)||Experimental, survey, observational|
Special Age Groups
|Youth adjustment||Correlational, ethnographic|
|Elderly functioning||Experimental, prospective|
In a general population survey, Poikolainen, Vartiainen, and Korhonen (1996) found that moderate drinkers have a more favorable self-perception of their health status than either abstainers or heavy drinkers, thus replicating the J-shaped pattern found in actual health outcome studies. This finding is predictable in so far as subjective perceptions of good health have been found to correlate with objective indicators of good health, which in turn are associated with moderate drinking. Because the researchers did not control for actual health status, various causal explanations may be offered, such as that healthy people (for both medical and social reasons) have more opportunities for social drinking.
Positive Sensations and Experiences
Respondents in surveys in the United States, Canada, and Sweden (Pernanen, 1991), Australia (Hall, 1996; Hall, Flaherty, & Homel, 1992), Finland (Mäkelä & Mustonen, 1988; Mäkelä & Simpura, 1985; Nyström, 1992), and the United Kingdom (Mass Observation Archive, 1943, 1948) associate drinking predominantly - and routinely - with positive sensations and experiences. These include taste, mood, ritual, relaxation, and socializing. In one U.S. survey, the most common outcome of drinking reported by nonproblem drinkers was "felt happy and cheerful" (Cahalan, 1970). In another, 43% of adult male drinkers always or usually felt "friendly" when they drank, compared with 8% who felt "aggressive" and 2% "sad" (Roizen, 1983).
These self-reports give a picture of normative drinking experiences in various countries without necessarily contrasting the self-reported experiences of drinkers (and nondrinkers) at different consumption levels. Such contrasts do emerge from alcohol expectancy research. For example, by performing a factor analysis of questionnaire responses, Brown, Goldman, Inn, and Anderson (1980) identified six independent expectations drinkers had about alcohol: (a) positive transformation of experience, (b) enhanced social and physical pleasure, (c) enhanced sexual performance and experience, (d) increased power and aggression, (e) increased social assertiveness, and (f) reduced tension. In this pioneering study of how expectancies vary with drinking patterns, less experienced drinkers had more global expectations, while the expectations of more experienced drinkers were more specifically focused on enhanced sexual and aggressive arousal. The implications of these findings for moderate versus heavy drinkers were made clearer in Brown (1985), in which frequent but nonproblem drinkers emphasized expectations of social and physical pleasure, and problem drinkers strongly anticipated tension reduction.
Problem as well as non-problem drinkers report positive expectations of and reactions to drinking; indeed, problem drinkers' positive as well as negative experiences of drinking are more intense than those of nonproblem drinkers (Cahalan, 1970). Brown's line of research suggests that problem drinkers seek positive effects for ego-enhancement and to compensate for personal deficiencies (see Marlatt, 1999), making them susceptible to seeking those sensations to unhealthy excess.
Enhanced Moods in Natural and Experimental Settings
For political, social, and ethical reasons, experimental research rarely has manipulated positive emotions (Stritzke, Lang, & Patrick, 1996; West & Sutker, 1990), although such studies did appear in an earlier, less constrained period. Freed (1978) reviewed a number of such studies, concluding that while nonalcoholics most often anticipate and attain enhanced feelings from drinking, alcoholics experience increasing dysphoria from alcohol. Combined with Brown and her colleagues' (Brown et al., 1980; Brown, Goldman, & Christiansen, 1985) demonstration that alcoholics seek intensely positive experiences from drinking, this finding indicates that moderate drinkers' expectations are more in line with the mood effects they actually experience than are those of alcoholics.
In the current review, mood enhancement in individuals is considered separately from collective mood enhancement in social groups (termed sociability below), which is most commonly documented in naturalistic, ethnographic research. Yet, in the experimental setting as in real life, it is difficult to disentangle the individual's mood from the social context, which both conditions expectations of and interprets reactions to alcohol. Pliner and Cappell (1974), in an experimental variation that is almost unique in the human alcohol literature (Lang & Michalec, 1990), found that subjects experienced greater euphoria when drinking the same quantity in a group than when drinking alone. In an early experimental test of the effects of low doses of alcohol, the subjects were couples who were already involved with each other. This special kind of social context clearly influenced the finding that "all measures of elation were significantly increased from sober levels" (Smith, Parker, & Noble, 1975, p. 36).
The complexity of the relationship between mood enhancement and social facilitation was explored by Cooper, Russell, Skinner, and Windle (1992). These researchers identified the existence of three distinct motives for drinking: to enhance positive motives, to cope with negative emotions, and to affiliate socially with others. They established that mood enhancement and social motives are interrelated components of a normative pattern of drinking. They also 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; those who drink to cope are more likely to drink alone or else with one partner. The researchers inferred that social and mood-enhancing drinkers, more so than coping drinkers, benefit from both external (from the social environment) and internal (from greater emotional and behavioral control) constraints on their drinking.
In view of the difficulty researchers have had in documenting (other than naturalistically) the near-universal perception and reported experience that drinking within moderate limits makes people feel better, Lowe's (1996b) work in the United Kingdom is notable for its use of three different methodologies to establish a relationship between alcohol consumption and humor: (a) comparing the reactions of students who were given alcohol and nondrinking students to a film comedy (Lowe & Taylor, 1997), (b) correlating weekly alcohol consumption with frequency of laughter and humor in daily life (Lowe & Taylor, 1993), and (c) observing young drinkers in pubs smiling and laughing more the more alcohol they consumed (Lowe, 1996b). In addition, Warburton (1999) and his colleagues have demonstrated experimentally that social levels of alcohol consumption (8 g) enhance selective memory of positive words without detracting from ordinary memory.
Stress reduction is perhaps the most studied psychological effect of alcohol consumption (Baum-Baicker, 1985; Hull & Bond, 1986; Sher, 1987), bringing together as it does two major strands of alcohol research. On one side of its lineage, stress reduction descends from the tension-reduction model of problem drinking and alcoholism (Cappell & Greeley, 1987). On the other, alcohol's calming effect is also a major motivation for drinking identified in general-population surveys (Hall, 1996; Pernanen, 1991). Thus, stress reduction has been a major concern of both theoretical and empirical research over the whole continuum of moderate to heavy drinkers.
On the theoretical side, stress reduction has been a primary focus of explanatory models of the rewarding properties of alcohol. These include social learning (Abrams & Niaura, 1987), expectancy (Goldman, Brown, & Christiansen, 1987; Lang & Michalec, 1990; Leigh, 1990, 1999), and psychophysiological (Stritzke et al., 1996) theories. These theoretical models highlight different ways in which pharmacological, cognitive, and other psychological and social processes may interact to shape people's drinking experiences. At the most general level, they propose that alcohol creates general mood susceptibilities on which social and individual expectancies imprint themselves. Experimental research (designed in many cases to confirm or disconfirm the above theories) has explored exhaustively how, when, and with whom alcohol reduces stress. This research has produced complex interactions with respect to individual, gender, ethnic, expectancy, and setting or situational differences (Pohorecky, 1991; Wilson, 1988).
Several naturalistic studies have described how moderate drinkers experience stress reduction in ordinary settings, suggesting essential differences from the way problem drinkers drink in reaction to stress. In daily activity logs, subjects reported that moderate alcohol use had a calming effect even though they did not use it deliberately to reduce anxiety (de Castro, 1990). Culbert (1989) found that moderate drinkers reduced their drinking in response to major life stresses, presumably to mobilize higher-order coping mechanisms. Krause (1995) found that alcohol reduces stress arising in a person's less critical social roles, but exacerbates stress occurring in more salient roles. These results support the idea that alcohol is effective for general calming purposes but not as a primary coping tool (Cooper, Frone, Russell, & Mudar, 1995; Cooper, Russell, & George, 1988; Cox & Klinger, 1988) and that, compared with heavy or problem drinkers, moderate drinkers are less intensely and specifically motivated to drink to reduce stress (Brown, 1985; Brown et al., 1985; Brown et al., 1980).
That moderate alcohol consumption may be beneficial to mental health was initially suggested by Bell, Keeley, and Buhl's (1977) seminal correlational study based on interviews with 2000 randomly selected adults in the southern United States. Abstainers (including former heavy drinkers, a confounding factor) scored highest on anxiety and heavy drinkers highest on depression; light or moderate drinkers scored lowest on both. Bell et al. (p. 121) concluded "that the heavy alcohol user cannot be differentiated from the abstainer on the basis of psychopathological symptom configurations." The finding that abstainers often display rigid, avoidant coping styles has been supported by more recent research (Mertens, Moos & Brennan, 1996; Watten, 1996). These findings suggest that abstainers share certain coping characteristics with problem drinkers or alcoholics, as indeed certain alcoholics alternate between these two extremes.
In another important correlational study, Lipton (1994) found with a southern California population a strong U-shaped relationship between alcohol consumption and depression in the presence of chronic strain combined with negative experiences, replicating a similar finding by Neff and Husaini (1982) in rural Tennessee. Although these studies did not control for the possibility that some abstainers had stopped drinking because of a preexisting health or drinking problem, Lipton found that overall results were unaffected when controlling for self-reported physical health. Moreover, relatively few of the large proportion of abstainers (66%) in Neff and Husaini's study were likely former problem drinkers, showing that moderate drinkers can have a psychosocial advantage over abstainers even where abstinence is a norm. Studies using other populations and methods also have found superior mental health among moderate drinkers (Liu, Waterbor, & Soong, 1996; Winefield, Goldney, Winefield, & Tiggeman, 1992).
Notwithstanding the dearth of prospective or better-controlled community studies, there is substantial evidence that moderate drinking is an indicator and perhaps a cause of good mental health. The U-shaped curves found in studies in which some controls were applied or where age considerations ruled out any substantial proportion of former problem drinkers increase the credibility of these findings, suggesting a parallel with physical health outcomes.
The role of alcohol in facilitating group interactions and enhancing the capacity of individuals to relate to others is a major theme of anthropological research and self-report studies.
Ethnographic research. The centrality of sociability as a factor in alcohol use is a primary result of ethnographic research, as summed up by Heath (1995: p. 352):
Drinking is fundamentally a social activity, and sociability is unquestionably the reason for drinking that is most cited in all of the countries that are described here. The same is true in almost all of the populations that have been studied by anthropologists around the world... We are told that alcohol is "indispensable" for sociability (China, Denmark, Egypt). It is an integral part of "mateship" (male bonding) in Australia, Canada, and New Zealand; and the "regulars" are known and appreciated in pubs in Germany, Italy, and New Zealand. Drinking is "important to community solidarity" in Guatemala and among many of the tribal populations in India; it is said to be integral in relating to friends and general social participation in Spain and Mexico....
Self-report studies. In population surveys (Lowe, 1994b; Roizen, 1983) as well as smaller-scale diary studies (de Castro, 1990; Wilks & Callan, 1990), sociability and friendliness typically are cited as primary motives for and consequences of drinking. In a 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 & Irgens-Jensen, 1990, p. 652).
Experimental studies of sociability. In Pliner and Cappell's (1974) experiment showing that mood-enhancing effects of alcohol are amplified in a group setting, the independent variable was the social environment, not alcohol consumption. Smith, Kendrick, and Maben (1992) demonstrated that people both feel and are perceived as more sociable when they drink, alcohol consumption here being the independent variable. In this experiment, subjects who were given vodka and juice showed greater sociability; those given juice alone did not. Nonetheless, in other settings alcohol reveals a learned association with sociability, so that nonalcoholic drinks that drinkers believe to contain alcohol produce greater sociability (Darkes & Goldman, 1993; Leigh, 1999).
Experimental studies assessing alcohol's effectiveness in reducing "social anxiety" (e.g., Bruch et al., 1992) have yielded the kinds of complex, highly inconsistent findings that characterize the stress-reduction literature generally. This has been especially true with respect to the differential effects of actual alcohol consumption as well as alcohol-related expectancies on men and women (Abrams & Wilson, 1979; de Boer, Schippers, & van der Staak, 1993, 1994; Wilson & Abrams, 1977). The inconsistencies in this line of research may be traceable in part to cultural differences - for example, drinking leads to social anxiety in American women not experienced by Dutch women. Related complex patterns concern self-disclosure by gender as influenced by alcohol expectancies and consumption (Caudill, Wilson, & Abrams, 1987; Hull, Levenson, Young, & Sher, 1983; Schippers, de Boer, & van der Staak, 1997), although in general garrulousness does increase with moderate alcohol consumption (Babor, Berglas, Mendelson, Ellingboe, & Miller, 1983; Higgins & Stitzer, 1988; Stitzer, Griffiths, Bigelow, & Liebson, 1981).
Despite the pervasive use of alcohol in conjunction with leisure activity worldwide (Argyle, 1987), Kunz's (1997) review of research on alcohol and leisure (including the impact of drinking on leisure and the role of active recreation in preventing alcohol abuse) identified methodological problems that make this line of research inconclusive. Earlier, Simpura (1985) had deplored the exclusion of drinking from systematic research on the use of leisure time.
Thus, the connections between drinking and leisure rely largely on ethnographic and self-report data. MacAndrew and Edgerton's (1969) cross-cultural exploration of the "time out" phenomenon established that people are socialized to know what degree of deviation from nondrinking behavior is acceptable, even during culturally sanctioned periods of alcoholic disinhibition. This classic analysis revealed the persistence of social controls even amid apparent license and mayhem. In a more positive light, American sociology has documented the favorable changes in affect and behavior that occur during transitions from work to play (Gusfield, 1987). College students, for example, experience stress reduction from drinking during such transitional periods (weeknights and early Friday evenings), but not in the "play" zones of late Friday or Saturday evenings (Orcutt & Harvey 1991).
Orcutt (1993, p. 390) has summarized the effects of drinking: "disinhibition, relaxation, and sociability signal to self and others the shift from the serious mood of workdays to the more spontaneous and playful mood of evenings and weekends." Drinking that violates these temporal norms (e.g., at work or early in the day) is defined as deviant (Reese & Katovich, 1989). In a telephone survey in the southwestern United States, respondents said they expected alcohol to affect their leisure experiences by: (a) facilitating disengagement from responsibilities and tensions, (b) increasing self-assurance and acceptance, and (c) heightening engagement in immediate experience (Carruthers, 1993). Such expectancies apparently mirror actual drinking experiences and rewards.
Hunt (1990, pp. 243-244) summarized the way alcohol brings people together into social units, large or small, as a major sociological and anthropological theme: "The use of alcohol is seen as a social cement which along with other group activities binds together the members of the community thereby enhancing group solidarity." Studies of alcohol and social cohesion typically focus on public drinking places such as taverns (Single, 1993), whose social norms determine the level of alcohol consumption, whether moderate or heavy (Clark, 1981; Cosper, Okraku, & Neumann, 1987; Single & Pomeroy, 1999; Single & Wortley, 1993; Storm & Cutler, 1981). In Canada, for example, adolescents who drink illegally in bars drink more moderately than those who drink away from adults (Smart, Adlaf, & Walsh, 1996). Observational studies consistently describe ritualized sociability in taverns (Fisher, 1982; Single & Storm, 1985); anthropological research has analyzed the shifting functions and benefits of such public drinking establishments throughout history and across cultures (Heath, 1991).
At the culture-wide level of cohesion, nations such as Greece, Italy, and Spain "have acquired a 'cultural immunity' to alcohol 'problems' based on the ways in which alcohol is interwoven into the matrix of the personal, social, and religious lives of the people of these societies" (Gefou-Madianou, 1992, p. 22). There is vast documentation of the moderating influences on drinking and its socialization in general (Blum & Blum, 1969; Maloff, Becker, Fonaroff, & Rodin, 1982; Peele & Brodsky, 1996), and for American subcultures (Greeley, McCready, & Theisen, 1980) such as the Chinese and other Asian groups (Barnett, 1955; O'Hare, 1995), Jews (Glassner & Berg, 1980), and Italians (vs. Irish Americans; Vaillant, 1983). Contrasting with these are cultures with proscriptive norms (Akers, 1992), where abstinence may not convey the psychosocial disadvantages that it does in cultures where social drinking is the norm (Orcutt, 1991; Peele, 1999b). In addition to moderation or abstinence, however, groups can cohere around excessive drinking, as in weekend binge-drinking in college fraternities (Kuh & Arnold, 1993; Wechsler, Dowdall, Davenport, & Castillo, 1995).
Long-term Cognitive Functioning
Notwithstanding the impairments of cognitive and psychomotor performance from acute exposure to alcohol (Finnigan & Hammersley, 1992), substantial evidence demonstrates that moderate drinkers show a higher level of cognitive functioning than abstainers. This suggests both that those with a higher level of cognitive functioning are more drawn to moderate drinking and also the possibility of a beneficial long-term effect from alcohol. In a correlational study with a nonclinical sample of 18-, 21-, and 24-year-old men and women, Bates and Tracy (1990, p. 247) cited the "large number of significant positive correlations between use intensity and cognitive abilities." The failure of a negative tail to appear in this analysis could be due either to the relatively low levels of drinking in the population or to the likelihood that negative long-term effects would not reveal themselves in such a youthful group.
A number of prospective and general-population studies reveal either no relationship in the elderly between cognitive ability and alcohol consumption (Dent et al., 1997; Hebert et al., 1993) or more often a curvilinear (Christian et al., 1995; Iliffe et al., 1991; Launer, Feskens, Kalmijn, & Kromhout, 1996) or a positive (Dufouil, Ducimetiere & Alperovitch, 1997) relationship. Several recent studies with older populations are worth noting. Orgogozo et al.'s (1997) prospective study of a French population yielded a curvilinear relationship between wine consumption and risk for dementia or Alzheimer's disease for both men and women. Hendrie, Goa, Hall, Hui, and Unverzagt (1996) found light drinking to be associated with better cognitive functioning and daily activity in one of the largest community studies among inner-city Black Americans. The study combined both genders and controlled for a range of variables found also to influence the dependent measures. The tested measures included a total cognitive function score, a measure of memory, and an activities-of-daily-living score. Findings obtained in varied populations and for different measures of cognitive functioning lean towards the interpretation that people benefit from drinking moderately in the long term, rather than only that healthier, better-functioning people have more opportunities and desire to drink moderately. Nonetheless, additional prospective studies are needed to strengthen the case that, as with cardiovascular and mortality outcomes, alcohol has such a directly beneficial effect.
Studies of the effects of alcohol use on creativity have had mixed results (Lapp, Collins, & Izzo, 1994; Lowe, 1996a; Ludwig, 1990), which may be a function of cultural differences as well as the difficulty of developing adequate research paradigms for this complex phenomenon. Alcohol may facilitate the incubation phase of creativity while obstructing complex intellectual processing (Gustafson & Norlander, 1994; Norlander & Gustafson, 1996), may help inhibited subjects (Lowe, 1994a), can reduce writer's block (Brunke & Gilbert, 1992), and can be used for self-stimulation (Koski-Jannes, 1985). In two well-designed experimental studies, Lang, Verret, and Watt (1984) found that alcohol consumption did not actually affect creative performance (although subjects who had drunk judged their work more favorably), while Lapp et al. found that drinking had a substantial placebo effect on creativity, but no pharmacological effect.
Work performance, as measured by income, shows a clear advantage for moderate drinkers in several correlational studies done to date. In a study using U.S. survey data (with former drinkers separated for analysis), moderate drinkers (2.0-3.5 drinks/day) had the highest earnings (Heien, 1996). French and Zarkin (1995, p. 319), in a questionnaire survey of randomly selected employees at four U.S. work sites, found that "controlling for other variables and conditional on working, moderate alcohol users have higher wages [peaking at 1.7-2.4 drinks/day] than abstainers and heavy drinkers...." The parallel to the U-shaped relationship found with drinking and heart disease is striking, although this research is correlational rather than prospective. Possible explanations for the successful work performance of moderate drinkers include both better physical health and psychosocial adjustment.
Benefits at both ends of the life span
Heavy, problematic drinking is a hazard of youth (Helzer, Burnam, & McEvoy, 1991). In the United States, concern over concentrated heavy drinking among teenagers and young adults has lately focused on collegiate "binge drinking" (Wechsler, Davenport, Dowdall, Moeykens, & Castillo, 1994, Wechsler et al., 1995). Yet some consider this application of a term that heretofore signified explosive, loss-of-control drinking by alcoholics to be inaccurate and alarmist (Gose, 1997). In Canada, underaged drinkers on the whole are no more likely to be heavy or problem drinkers than are legal drinkers (Smart, et al., 1996). Other research indicates that young people who experiment with alcohol may be better adjusted than those who abstain or drink excessively. In Norway, young males who first got drunk in middle adolescence had fewer psychological problems than those who did so earlier or later (Pape & Hammer, 1996). Likewise, in the United States, Nezlek, Pilkington, and Bilbro (1994) found that college students who reported a "moderate" frequency of binge-drinking episodes had more - and more intimate - social interaction than those who reported a greater frequency or none at all. In other words, those who drink normatively (allowing for the risks of such behavior for inexperienced drinkers) are integrated more fully socially and psychologically. As a context for interpreting these data, cultures that successfully inculcate moderate drinking practices (such as the Jewish and Chinese) matter-of-factly accept youthful drinking as an opportunity for learning accepted social behavior - a model of socialization recommended by Lowe and Foxcroft (1993).
As a rule, the elderly are moderate, social drinkers (Adams, 1996; Alexander & Duff, 1988; Busby, Campbell, Borrie, & Spears, 1988; Hanson, 1994; Meyers, Hingson, Mucatel, Heeren, & Goldman, 1985/1986) with fewer drinking problems than other age groups (Hilton & Clark, 1991), the exceptions being mainly among isolated individuals (Hanson, 1994). Stall (1986) found that formerly heavy drinkers typically reduce consumption with age in response to reduced tolerance for alcohol and finances. Moreover, for older Americans, like other adult populations, moderate drinking has life-prolonging effects (Mertens et al., 1996; Scherr et al., 1992; Simons, Friedlander, McCallum, & Simons, 1996; Thun et al., 1997).
In addition, research has indicated that elderly drinkers enjoy psychosocial and therapeutic benefits due to drinking (e.g., Black, 1969; Chien, 1971; Mishara & Kastenbaum, 1974; Volpe & Kastenbaum, 1967). Mishara and Kastenbaum (1980) summarized research showing that patients on geriatric units and in nursing homes given beer or wine daily relative to control groups increased social interaction and participation in the milieu and showed improved orientation, morale, general functioning, and cognitive capacity and reduced need for sleeping medications. Analogous findings were obtained among the noninstitutionalized elderly. Dufour, Archer, and Gordis (1992) called these results promising, relying on a study by Mishara, Kastenbaum, Baker, and Patterson (1975) that continued to find the identified benefits and utilized stricter methodological controls than in other research. A recent study reiterated many of these results with elderly drinkers. Examining reports "that retirement communities have a particularly high prevalence of heavy drinking," Adams (1996, p. 1082) found instead in three retirement communities that, although "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."
The disparate research reviewed here broadens the universe of relationships with alcohol consumption beyond health outcomes to psychological adjustment, social integration, productivity, and effective functioning. To a greater degree than either abstainers or heavy drinkers, moderate drinkers experience these indicators of psychological and social well-being. These relationships appear with sufficient frequency across different populations, study variables, and methods of investigation to suggest an underlying pattern analogous to and interlinked with the well-established U- or J-shaped relationship between alcohol consumption and increased health benefits and longevity.
The challenge in interpreting such robust yet diverse and complex findings is to say anything meaningful about directions of causality, since ethnographic, self-report, correlational, prospective, and experimental studies justify the assignment of different degrees of predictive power to alcohol consumption as a causal variable. We envision a complex model by which the observed benefits of moderate drinking do not flow directly from the pharmacology of alcohol, but are created through positive drinking habits as experienced and interpreted in a context conditioned by culture, social environment, and expectation (Harburg, Gleiberman, DiFranceisco, & Peele, 1994). In this complex causal nexus, alcohol is not the sole cause of the cardiovascular and other health benefits associated with it (Peele, 1997; Skog, 1995), but it is likely that moderate alcohol consumption does have independent causal significance in the creation of its psychosocial concomitants.
For now, we can say with some confidence that moderate alcohol consumption is part of a cluster of interrelated factors that we identify provisionally as follows: life orientation (motives, values, resources, decision making); drinking patterns and levels; other health-related behaviors; physical health; psychosocial well-being; productivity and economic success. More basically, individuals with a positive, health-seeking orientation to life use alcohol within a larger framework of self-regulation and pleasure (Grossarth-Maticek & Eysenck, 1995; Grossarth-Maticek, Eysenck, & Boyle, 1995). Healthful drinking is thus a part of an orientation that includes a range of productive and healthful behaviors that in combination generate positive sensations, health outcomes, and additional reinforcement including social support and cohesion.
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