The Curious Sober Movement

 

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.

Note the differences in excise tax collected on each group of beverages based on the fact that alcohol content is the basis of taxes and also that the 2.5% tax on gross sales generates substantial revenue.

The most recent budget for the state of Minnesota was $53.7B compared with alcohol excise taxes of $187M or about 0.35%.   For comparison Japan generated $8.1 in alcohol tax in 2021 – 1.7% of overall tax revenue.

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

The Most Important Decision In Your Life......

See Complete Reference Below

I thought a while about how to write this.   There are a lot of opinions out there about how a decision like this one should be philosophical or religious.  After practicing psychiatry for over 30 years I have to come down on the side of practical.  The most practical decision I think that anybody can make is to stop using intoxicants, at least to the point of intoxication.  I don't really care what your current intoxicant is.  It could be alcohol or cannabis or heroin.  Deciding to stop it will only improve your life and the lives of your family and friends for any number of reasons.  At this point I am a witness to the thousands of people who have stopped and seen those improvements.  I am also a witness to the unfortunate thousands of people who did not stop and ended up dead, incarcerated, homeless, chronically mentally ill, in nursing homes, or leading miserable lives.  I am not naive enough to think that my little argument here is going to make that much of a difference and will elaborate on that in the paragraphs that follow.

One counter issue that I want to address as early as possible because it is often used to short circuit arguments against intoxicants is what I consider an American pro-intoxicants argument.  It certainly can exist in other cultures, but I am restricting my comments to Americans because of the pervasive attitudes about intoxicants.  The most obvious attitude is alcohol and drug use as a rite of passage to adulthood.  This is a well documented phenomenon rationalized at several levels.  Common examples include: "If one is old enough to vote or go to war they are old enough to drink."  There is abundant current evidence that 18-21 year olds if anything are exposing brains that are neurodevelopmentally immature to the effects of alcohol and street drugs - often at toxic levels.  Rational arguments against exposure are not likely to have much of an impact on a population segment in the throes of the invulnerability of youth.  Even apart from the brain based argument, the driving and risk taking behavior of this group is well documented.  Adding intoxicants to the mix is not likely to alter those decisions in a positive way.

An extension of the rite of passage argument is the rights argument as in "Alcohol and tobacco are legal substances and therefore I have a right to use them."  There is no doubt that is true, but the right is limited.  Only people of a certain age can use these compounds and in the case of intoxicants that can affect public safety - their use is even more limited.  People who I have seen invoke the rights argument are generally not talking about limited rights.  The modern version of the rights argument is that "no one should have the right to tell me what I can put in my body.  On that basis all drugs should be legal and easily accessible".  A complementary argument is: "Alcohol and tobacco kill more people every year than (fill in favorite intoxicant here) and therefore I should be able to use it."  Another complementary argument that often gets more support is: "The War on Drugs is a complete failure.  All drugs should be legal and that way we can tax it and make a profit from it.  We can put the cartels out of business."  The rights argument frames an idyllic drug consuming society immune to the medical problems of acute intoxication and addiction as well as all of the associated social and legal problems.  Extreme arguments like this suggest to me that they are driven in part by desperation.  Of course intoxicants need to be regulated - we already have ample evidence of what happens when they are not.  The basic problem that they reinforce their own use at increasing levels cannot be ignored.  Tax on intoxicants is generally an unreliable revenue source when the total cost to the taxpayers for that intoxicant and the fact that revenue is diverted away from covering those costs.
  
A second cultural phenomenon is the use of intoxicants for celebrations.  Weddings, funerals, and various parties often result in the excessive consumption of alcohol. I attended a funeral where the clergyman addressed half of the audience and suggested that an AA meeting might be in order afterwards.  The deceased was probably a victim of excessive alcohol use.  Although alcohol remains predominant in many of these settings, since the 1970s second and third intoxicants are also common.  The relevant consideration is whether these celebrations can occur without the intoxicants.  Interestingly, that decision may come down to the cost of having an "open bar" versus less expensive alcohol on tap. 

A third consideration is the subculture of extreme use.  Many states are notorious for per capita alcohol consumption, binge drinking, and driving after drinking too much.  I don't think that the problem has been well studied, but growing up in a heavy drinking or using culture exposes anyone to early use and reinforcement that are both precursors to problematic use. 

There are several arguments in the popular media that seek to minimize the potential impact of drugs on your life.  Think about the counterarguments:



1.  If I don't have a diagnosis of alcoholism or drug addiction my pattern of using intoxicants is not a problem:

The most absurd presentation of this argument was the idea that a significant number of binge drinkers do not meet diagnostic criteria for alcohol use disorder.  I can't count the number of people who I know that have had their lives ruined or ended by a single drinking binge.  Many high schools in the US started a senior party strategy because so many students were killed around the time of graduation parties due to acute alcohol intoxication.  The drivers in these cases were not alcoholics.  They were high school seniors many of whom had limited exposure to alcohol before the fatal accident.  Binge drinking and acute intoxication is associated with a long line of accidental deaths, alcohol poisoning deaths, suicides, homicides, intimate partner violence, rapes, and other crimes.  All preventable by not binge drinking or more importantly getting intoxicated in the first place.  The same pattern follows every other intoxicant.  If you put yourself in a mentally compromised state in practically any setting - bad things will happen whether you have been diagnosed with a substance use disorder or not.

2.  Alcohol is a heart healthy beverage:

The CDC and the American Heart Association both recommend moderate intakes of alcohol and they define that as one standard drink of alcohol per day for women and one or two standard drinks for men.  This is based on data that shows that these amounts of alcohol may confer reduced risk for heart disease but that higher amounts increase risk.

3.  Intoxicants can be good for your health - some are natural medicines:

The great natural argument leaves a lot to be desired. It's like listening to that guy in a bar tell you that his doctor told him he could drink as much wine as he wanted because it was a natural beverage and then realizing that he is standing in a puddle of his own urine. Peak alcohol consumption in the US occurred at time when it was considered a medication in the early part of the 19th century.  The current best example is cannabis, a substance that has been around for at least 10 centuries and suddenly it is a miracle cure for everything.  The obvious question is why that wasn't noticed in that last 1,000 years. 

4.  Alcohol and drug use disorders are not diseases - it is a question of choice and therefore I have nothing to worry about:

Despite what you may read on some online blog, in opinion polls most people consider alcoholism and addictions to be diseases.  Almost everyone has had some contact with people who have these problems and they see that the usual negative consequences that cause most people to correct their behavior - have no effect on the addicted.  There is no or at least limited capacity for self correction.

5.  I am a libertarian and I believe that all intoxicants and drugs should be legal - I should be the only person deciding what goes into my body:

A familiar argument that ignores human history. The reason that there are controls on addictive drugs is because a significant part of the population will use them in an uncontrolled manner and that generally leads to a chaotic society with all of the costs of that chaos. The more free access there is - the more addiction and chaos.

This argument implies that everyone is the best judge of "what I put in my body" based on political beliefs. There is no evidence that is true.

6.  I am an adult and if I want to have a drink - I will have a drink:

That is a minor variation of the libertarian argument for non-libertarians.  It is basically a truism - yes of course unless you are prohibited by law (and some people are) you can have a drink.  Doing something basically because you can strikes me as a shallow argument. Looking at what happened during Prohibition, I think it is safe to say that the right to drink was preserved by a relatively vocal minority of people who want to drink.  They want to drink for the previously cited cultural reasons and in fact there were some famous exceptions to Prohibition that were based on purported religious ceremony and requirements for alcohol. 

A similar argument is that if a person wants to feel high "there is nothing wrong with that."  At a superficial level and strictly speaking that is true as long as the level of intoxication doesn't lead to medical, safety, or interpersonal problems. The larger question is whether there is something better to do. Let's define better as another recreation that leaves you better off than using intoxicants.  In that case walking around the block is better than getting stoned.

7.  It is part of my creative process:  

There are reviews and books written about how creative people have used drugs and alcohol to enhance their creative process.  These works are by their nature anecdotal.  I am unaware of any controlled sober group and their creative process but it is likely that they exist in large numbers.

8. I am self -medicating and need it to treat insomnia, anxiety, depression, and/or pain:

Self medication implies that intoxicants are actual treatments for these problems. If you talk to any person who uses this strategy - the amount of relief lasts for a few hours.  People tell me: "Look doc - if you can't get rid of this anxiety - I know how to get rid of it for a few hours."  Using alcohol, street drugs, or diverted prescription medications is usually a recipe for worsening symptoms and tolerance.  In that setting people often have the idea that more drugs will bring back the few hours of relief and there are always examples of associated catastrophes in the news. 

9.  The political argument that by allowing universal access to drugs - the cartels will be out out of business - 

Very common to hear that all drugs should be legalized and hear this argument in the next breath.  Most of the people making this argument seem naive to fact that black markets still exist with legal intoxicants.  In the WHO Global status report on alcohol and health 2014, 24.8% of the alcohol consumed was outside of government control.  In the US, it was 0.5 liters of a total of 9.2 liters per capita.  For tobacco the black market is somewhere between 8.5 and 21% of sales. In Colorado there is currently mixed concern about the possibility that drug traffickers are in plain sight, continuing to grow cannabis in remote areas and transport to other states, but reliable information is not available. In the case of heroin, the current impetus for its use is that it is 25% the cost of diverted pharmaceutical opioids.  In the worst case scenario of legalized opioids with no control is it realistic to consider governments regulating heroin at that low cost to consumers?  If not it is a recipe for continued uncontrolled black markets. 

10.  The "You are an prohibitionist" counterargument:

Whenever I present any of my arguments for avoiding intoxicants in the list above, there is the inevitably that some very angry guy accuses me of being a prohibitionist.  I don't know how much weight that ad hominem carries but I always find it amusing. If prohibition worked, I would not need to make these arguments.  My blog is one of the few places where you can see a graphic of how things went during prohibition and it obviously wasn't good.
 
Believe me - you can go through life without ever taking a drink, smoking a joint, snorting cocaine, or injecting heroin and not miss it.  The best case scenario is that it adds nothing to your quality of life.  It is also tempting to think that you have plenty of time to quit later.  With that plan many people either never quit or realize when they are 40 years old that they have been in a fog for 20 years.  Addictions sneak up on you and steal what should be your most productive years.

In fact none of the people with addictions who I talk to ever started out believing that one day they would end up with an alcohol or drug use problem.  Recognizing all of the defective arguments listed above is a good first step.  The most important ability to prevent addictions is self correcting abstinence.  If you wake up one day and realize you dodged a bullet when you were intoxicated, think long and hard about avoiding that situation again.

If you can't - you may have a serious problem.


George Dawson, MD, DFAPA



Supplementary:

Graphic at the top is from:

Lavallee RA, Yi H.  Surveillance Report #92: Apparent per capita alcohol consumption: national, state, and regional trends, 1977-2009.  US Department of Health and Human Services. Public Health Service.  August 2011.  Link.