I saw an interesting story on the news yesterday and found it was linked to an even earlier report in the Tokyo Times. There is a cultural movement in Japan among the younger generation to abstain from alcoholic beverages or drink only on special occasions. I saw a young woman interviewed and she described her motivation as wanting to spend her money on other things. The report also said that alcohol use in Japan was a ritual for bonding in the workplace. They showed images of work parties with many people drinking as well as a man in a suit passed out on at the edge of a train platform. Survey data was quoted as saying that 90% of Japanese drink alcohol rarely or not at all. The most sobering statistic was that tax revenue from decreased alcohol use was down 30%. That drop caused the government to ask for suggestions about how to get people drinking again. That approach did not get any positive reviews in the man-on-the street interviews including a bartender serving non-alcoholic drinks.
This story was immediately interesting to me for several reasons. First, I have always been puzzled by the American approach to intoxicants. On a cultural basis, they are considered a rite of passage and the best evidence is the data on substance use in college aged students and how it generally decreases over time. Second, there is always a great deal of ambivalence advocating sobriety as a reasonable lifestyle, even though most Americans either don’t drink or drink very little. The American population has a lower level of lifetime abstainers and (expectedly) a higher number of former drinkers per the world average. There is ample rhetoric in popular media and culture to ridicule people who don’t drink and in many cases drug users are idealized. Third, the attitude extends to other drugs. Contrary to pro-cannabis hype, there are very few countries in the world where cannabis is legal much less sold in highly concentrated forms. That same hype promoted the medical use of cannabis even though there is little evidence that it does much. Similar arguments are being made about hallucinogens and in some cases, all scheduled drugs that are currently considered illegal. Fourth, intoxicants are generally heavily marketed to the public. Vodka is a clear example. The New York Times did a famous taste test of vodka comparing various vodkas to the least expensive brand (3). The least expensive brand won the competition. At the time, many much more expensive designer vodkas had emerged from several countries. One of the authors main points is that vodka is sold based on marketing rather than taste. Many essays about vodka describe is as tasteless. Since 2005 there have been endless taste tests, rankings, and other promotions - basically more marketing. More recently several prominent celebrities have promoted their own expensive brands of vodka and tequila. In some cases, the businesses have grown to very large values. All of that based on marketing what is essentially a tasteless, intoxicant that comes with a long list of problems to people who want to drink it for how they see it advertised. Fifth, the issues of tax revenue. Let’s face it – the only good reason to promote intoxicants is to make money.
Most common
intoxicants also reinforce their own use – at least for a significant segment
of the population. That leaves politicians needing to counter that common
knowledge. There are two arguments commonly used to do that. The first is that we will tax the new
intoxicant and that will create all kinds of revenues for services that
taxpayers want. Alcohol, tobacco, and gambling taxes have been around for a
long time and generate billions of dollars per year at the federal level. Since, everyone knows that drugs and alcohol
carry a heavy burden in terms of mortality and morbidity the second argument
goes something like this: “We will create a special fund to help all of the
people adversely affects by these intoxicants (and gambling).” During my career as an addiction
psychiatrist, I saw treatment services basically disappear. They were few functional detox units, few
functional substance use treatment units, and few addiction specialists. There was a small remote gambling addiction residential treatment program –
but it did not match the degree of gambling problem in the state. If adequate finding for substance use
treatment from sin taxes exists – please let me know about it because I have not seen it. Like many products and services in the US,
alcohol, intoxicants, and gambling all end up being promoted by governments at
all levels as a revenue generating activity.
The damage done is rarely discussed.
In the case of alcohol, the damage is unmistakable if you
know friends or family members with the problem. Damaged relationships and
marriages, legal problems and incarceration, and a list of significant medical
complications. The current government
warning (7) on alcohol is:
GOVERNMENT WARNING: (1) According to the
Surgeon General, women should not drink alcoholic beverages during pregnancy
because of the risk of birth defects.
(2) Consumption of alcoholic beverages impairs
your ability to drive a car or operate machinery, and may cause health problems.
May cause health
problems is an understatement. A more appropriate statement would say can
cause health problems up to and including birth defects and intellectual
disability, mental illness, severe cognitive problems, liver disease, pancreatic disease, cancer, hypertension, and
death. Rather than being explicit about the health risks for many years alcoholic
drinks were promoted as heart healthy and increasing HDL or "good" cholesterol. Any
slight advantage disappears when subjects recovering from alcohol use disorders
are eliminated from the control group.
What about consumption figures? The usual way that consumption is compared is
by taking the alcohol content of all of the beverages consumed in a country and
converting it to the equivalent amount of 80 proof ethanol. The per
capita annual consumption can be compared in total volumes or standard drinks. A
standard drink is 1.5 fluid ounces of 80 proof (40%) alcohol or the equivalent
in any one of those drinks is considered a standard drink. In the US 14 grams
or 0.6 ounces of pure alcohol is considered a standard drink. Apart from consumption there are estimates of
what the standard drink threshold might be to cause cirrhosis or pancreatitis.
Comparing levels of alcohol consumption between the US,
Japan, and Russia those numbers are 10.5, 10.09, and 9.97 liters per year.
These are population averages and there is typically great variability between
various populations and historically – even within the same population over
time. There is also a graphic that I
made a few years ago (see header of this post) that takes a look at comparisons across several
types of drinking relative to the average consumption of the world.
What is curious sober movement? There seems to be very little written about it and essentially nothing in the scientific literature. That may be why the headlines all involve decreased tax revenues from decreased drinking. Historically there have been sobriety movements in the past. The most well known one in the United States was the Temperance Movement. It seems that a basic mistake of these movements is proselytizing and trying to influence politicians. The resulting Prohibition Era in the US is widely cited by drug legalization advocates as a failure, even though it was a law that could never be enforced and there were clear cut benefits for those who had no choice but to abstain. The current pandemic highlights how limits on established behaviors including measures designed to limit infection and loss of life are immediately politicized and the resulting chaos results in a loss of any benefit. Some people would rather threaten public health officials rather than simply wear a mask. In the area of intoxicants, I am sure any measure to prohibit the sale of alcohol would result in similar reactions today. The legalization of cannabis has been sold to the public and politicians and once that is out of the gate – there is no turning back even though there is early evidence that it will be another blight on the land.
Whatever curious sober is – I hope it has traction in the United States. The travelling medicine show here never seems to stop. We have a massive drug and alcohol problem here and everybody should know it and more importantly act like it. The single best way to stop it – is not by providing treatment for addiction. The single best way to stop it is to not pick up a drink or a cigarette or any other intoxicant in the first place. In the public health field that is called primary prevention. All of the intoxicant promoters joke about the "Just say no to drugs" public service messages. Of course they would. Nobody ever talks about the fact that the best life you can live is a sober life.
The young people in Japan are discovering that.
George Dawson, MD, DFAPA
Supplementary 1: Vodka Pricing, Cost, and Profit
I decided to make a graphic to show the raw material cost and various taxes on a 750 ml bottle of 80 proof vodka to illustrate how much profit can be made from marketing intoxicants in various ways. The raw material cost in this case is very low since beverage alcohol is distilled and sold by agribusinesses in large volumes. There is apparently only one manufacturer in the US that does their own distilling. For most the manufacturing process consists primarily of filtering and adding various flavors. The tax references are at the bottom of the page using Minnesota Department of Revenue guidelines. There is conflicting information on sales tax but the Dept of Revenue said that it is charged so I included it in the graphic. In Minnesota there is also an excise tax and a separate 2.5% tax on gross liquor sales. Minnesota has taxes like the the MinnesotaCare Provider Tax on health care services that is currently at 1.6%. In theory it can be passed through to the customer/patient but it is selective since reimbursement rates are set without it. I would see this 2.5% tax as being similar and it would be included in the pricing. (click to enlarge graphic)
For tax comparisons, here is a table from reference 3 about the tax revenues generated from the last year available.
References:
1: Why Japanese
government is encouraging drinking. CBS
Morning News. December 31, 2022 https://www.cbsnews.com/video/why-japanese-government-is-encouraging-drinking/
2: A 'sober-curious'
generation leaves Japan with a hangover.
Should an arm of the government be encouraging people to drink, even in
moderation? Japan Times. August 24,
2022 https://www.japantimes.co.jp/opinion/2022/08/24/commentary/world-commentary/liquor-taxes/
3: Asimov A. A Humble Old Label Ices Its Rivals. New York Times. January 26, 2005.
4: Lachenmeier DW,
Kanteres F, Rehm J. Is it possible to distinguish vodka by taste? Comment on
structurability: a collective measure of the structural differences in vodkas.
Journal of agricultural and food chemistry. 2011 Jan 12;59(1):464-5.
5: Hu N, Wu D, Cross
K, Burikov S, Dolenko T, Patsaeva S, Schaefer DW. Structurability: A collective
measure of the structural differences in vodkas. Journal of agricultural and
food chemistry. 2010 Jun 23;58(12):7394-401.
6: World Health
Organization (WHO). The Global Health
Observatory. Global Information System on Alcohol and Health. Levels of Consumption. https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/levels-of-consumption Accessed on 01/04/2023
7: PART 16 -
ALCOHOLIC BEVERAGE HEALTH WARNING STATEMENT.
§ 16.21 Mandatory label information.
Link
8: AMERICA'S INSATIABLE DEMAND FOR DRUGS. COMMITTEE ON HOMELAND SECURITY AND
GOVERNMENTAL AFFAIRS. UNITED STATES
SENATE. ONE HUNDRED FOURTEENTH CONGRESS. April 13, 2016 Link
