Carly Johnco and Brian Draper
Alcohol use has long been linked with cultural expression, whether it is its symbolic use during a religious ceremony such as a Christian liturgy, the ritual toasting of a newly married couple at the wedding reception, the wine routinely served at the opening night of an art exhibition or its social use as a marker of time and mood (Anderson and Baumberg, 2006 ). Culture is defined in the Oxford Dictionary as “the ideas, customs, and social behaviour of a particular people or society”. In this chapter we will consider various aspects of cultural expression including ethnicity, socio-economic issues, employment, education, religion, living arrangements and issues faced by minority groups and indigenous people. We will consider how differences in alcohol use across different ethnic and cultural groups may influence health consequences of alcohol use, including alcohol-related brain damage.
Ethnicity
There is marked variability in levels of consumption between countries, with high levels of abstention in those countries in North Africa and South Asia with large Muslim populations (World Health Organization, 2011 ). High-risk drinking and alcohol-related harm is particularly prominent in the Russian Federation and Latin America. Even within Europe, the highest drinking region of the world, there is marked variability of alcohol consumption between countries ranging from Turkey, where in 2004 the per capita consumption was less than 5 litres per year, to Hungary where it was closer to 20 litres per year. These national consumption patterns are not static and in Europe since the 1970s a harmonization has been recorded with the traditionally high consumption in southern European countries diminishing and the lower consumption patterns of northern Europe increasing. There is also evidence of national variability in the way people drink: the type of alcohol, the drinking context (for example, with meals or in public) and the frequency (Anderson and Baumberg, 2006 ).
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Genetic variations in the way individuals respond to alcohol can contribute to what might appear to be ethnic differences. For some populations, genetic vulner- ability means low tolerance to alcohol and the inability to process it (International Center for Alcohol Policies, 2001 ). Some East Asians have heightened sensitivity to alcohol due to impairment of alcohol metabolism caused by a non-functional form of the enzyme alcohol dehydrogenase. Although this results in an acute reaction to even small amounts of alcohol, it might confer a protective effect for other alcohol- related harms by limiting alcohol consumption (International Center for Alcohol Policies, 2001 ). The sensitivity characterizes 25 to 40 per cent of the Japanese population, nearly 25 per cent of Han Chinese and between 15 and 30 per cent of Koreans (Maezawa et al ., 1995 ; Shen et al ., 1997 ). For other populations genetic vulnerability is an increased risk for alcohol abuse or dependence (International Center for Alcohol Policies, 2001 ).
Minority groups
It is important to consider the impact of minority group status, including indigenous populations and immigrants, on alcohol-use behaviors. There are a range of cultural influences present in these groups that are likely to impact on their alcohol-use behaviors, along with negative health and cognitive outcomes.
Indigenous people
Before European colonization, most areas of the world, with the exception of parts of the Pacific and North America, had indigenous versions of alcoholic drinks.
These were quite varied in their composition, preparation and primary use, which included nutrition and medicinal purposes as well as alcohol’s psychoactive proper- ties (Dietler, 2006 ). The pre-colonial role of alcohol in indigenous societies was diverse, encompassing political, economic and religious dimensions. Modes of serving, consumption, expected drinking behavior and styles of inebriation were quite varied from culture to culture (Dietler, 2006 ).
European contact and colonization brought changes to the social, political and economic context of alcohol use in indigenous societies (Dietler, 2006 ; Westermeyer, 1996 ). For example, the social context of drinking in the Americas changed to include
“frontier drinking”, which was secular, individualistic, male-centered and often asso- ciated with bravado or confrontation as opposed to the more family-oriented drinking that tended to occur in groups and in religious rituals (Westermeyer, 1996 ). In West Africa, the importance of alcohol in the political economy is highlighted by the role of distilled spirits as a commodity and currency in establishing exchange relationships in the Atlantic slave trade (Dietler, 2006 ). Similarly, rum was used as currency in the early years of the convict settlement in Australia (Saggers and Gray, 1998 ).
There was no pre-European-contact use of alcohol by Indigenous Canadians and New Zealand Maori and limited use by Australian Aboriginal people; early post-contact reports from each country emphasized that the indigenous people had
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to be encouraged to drink alcohol (Saggers and Gray, 1998 ). However, once some of the indigenous people in these countries had acquired the taste for alcohol, patterns of consumption resembled that seen in the European colonists, with a mix of excessive use and abstinence (Saggers and Gray, 1998 ).
The decimation of indigenous populations by introduced diseases and violence over land possession resulted in many indigenous people becoming dispossessed fringe dwellers who consumed alcohol to excess. This prompted colonial jurisdic- tions to impose controls on indigenous alcohol use due to fears of outbreaks of violence and concerns about the health of indigenous people (Saggers and Gray, 1998 ). From the mid-19th century these controls included prohibition of the sale of alcohol to indigenous people in various parts of the USA, Canada, Australia and New Zealand and in some jurisdictions prohibition remained in force until the mid-20th century (Saggers and Gray, 1998 ; Westermeyer, 1996 ). Overall, prohibition was ineffective and had other negative consequences as it led to increased surveil- lance, exclusion from social spaces such as hotels and the development of riskier drinking patterns such as high-alcohol drinks without food (Wilson et al ., 2010 ).
One of the myths about alcohol use in indigenous people is that they drink more alcohol and in a different pattern to their European counterparts, a view not sup- ported by the evidence (May, 2005 ; Saggers and Gray, 1998 ; Westermeyer, 1996 ).
Indeed, there is marked variation in alcohol use in indigenous groups within coun- tries (Whitesell et al ., 2012 ), with factors reinforcing use including low access to financial security, jobs and relationships (Spillane, Smith and Kahler, 2013 ). Another myth is that indigenous people have a biological vulnerability to alcohol hepatic metabolism and are thus prone to alcohol-use disorders (May, 2005 ; Saggers and Gray, 1998 ). For example, while there is evidence that some Native American popu- lations have variants of the alcohol-metabolizing enzymes alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH), the findings do not explain the high prevalence of harmful alcohol use (Ehlers, 2007 ). Yet there is evidence that alcohol- use disorders are more prevalent in indigenous people than in non-indigenous people in countries worldwide.
Psychosocial issues that have been identified as contributing to harmful alcohol consumption by contemporary indigenous peoples include land rights, with past dispossession of traditional lands and associated moves to reservations where different tribal groups were forced to cohabit; experiences of trauma, social exclusion, poor education, poverty and racism; and family disruption including the legally endorsed forced removal of children from parents (May, 2005 ; Saggers and Gray, 1998 ; Szlemko, Wood and Thurman, 2006 ; Westermeyer, 1996 ). For example, children of the Australian Aboriginal “stolen generation” have twice the risk of harmful alcohol and drug use compared with children of Aboriginals who were not separated from their parents (Zubrick et al ., 2004 ). This combination of contemporary and historical experiences has resulted in alcohol being used by some indigenous people as a way of coping with often forced abandonment and loss of traditional lifestyles.
In Australia it is estimated that the prevalence of harmful alcohol use in Indigenous Australians is approximately double that reported in the general population
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(Wilson et al ., 2010 ). Alcohol harm is responsible for 5.4 per cent of the total disease burden and 6.7 per cent of deaths in Indigenous Australians compared with only 2.3 per cent total disease burden and 0.8 per cent of deaths in the general popula- tion (Calabria et al ., 2010 ). New Zealand Maori have about a 50 per cent higher rate of alcohol abuse/dependence than non-Maori (Marie, Fergusson and Boden, 2012 ). Over 85 per cent of Venezuelan Native American males and 7.5 to 17.5 per cent of females have been reported to have “problem drinking” (Seale et al ., 2002 ; 2010 ). In the USA, alcohol-attributable deaths among American Indians and Alaska Natives is estimated to be double that of the general population (Centers for Disease Control and Prevention, 2008 ).
The extent to which the high prevalence of harmful alcohol use in indigenous populations translates into alcohol-related brain damage (ARBD) is unclear.
Anecdotal reports speak of high rates of ARBD (e.g., Pollitt, 1997 ; Wilson, 2001 );
however, most reports of alcohol-related harm in indigenous people do not include a specific category of brain damage (e.g., Calabria et al ., 2010 ; Saggers and Gray, 1998 ) or only allude to it in a cursory fashion (e.g., Westermeyer, 1996 ; Wilson et al ., 2010 ). Older studies indicate possible concerns. A forensic neuropathology study reported that the incidence of Wernicke’s Encephalopathy was approximately five times higher in Australian Aboriginal people than in the general population (Harper, 1983 ). There are few studies of dementia in indigenous people but two older meth- odologically flawed studies reported high rates of alcohol-related dementia. From a small sample of 192 community-dwelling Canadian Cree subjects, Hendrie and colleagues ( 1993 ) identified eight with dementia of whom two (25 per cent) had alcohol-related dementia. A study from north Queensland in Australia reported that alcohol-related dementia/Korsakoff ’s Syndrome was the main cause of dementia in a small sample of 133 Indigenous Australians aged 65 years and over (Zann, 1994 ). In the latter study most of the sample was living in residential care and their diagnoses were obtained from hospital records and/or a cognitive screening instrument unvalidated in the population.
More recent epidemiological studies of cognitive impairment in Indigenous Australians that utilized culturally appropriate methodologies have not found alcohol to be a major cause of dementia (Radford et al ., 2013 ; Smith et al ., 2010 ). One study in a rural Australian substance treatment in-patient population reported that 82 per cent of indigenous subjects and only 28 per cent of non-indigenous subjects were cognitively impaired on the Addenbrooke’s Cognitive Examination – Revised (Allan, Kemp and Golden, 2012 ). The researchers noted that interpretation of these results was limited by the uncertainty of the validity of the screening tool in the indigenous population. It is worth noting, however, that some of the health factors that are associated with increased risk of the Wernicke-Korsakoff Syndrome, such as diabetes and poor nutrition, are prevalent in some indigenous populations and may indicate increased risk (Arpi et al ., 2006 ; Gubhaju et al ., 2013 ; Wijnia et al ., 2012 ).
Cultural sensitivity of the care system also influenced the recognition and treatment of cognitive impairment – for example, due to a lack of culturally appropriate assessment measures, a lack of advocacy, difficulties in service provision in rural
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areas, the need for appropriate cohesion between traditional healing customs and western health care, and the need for language resources (Keightley et al ., 2009 ).
There are potential negative outcomes for cognition resulting from parental alcohol abuse. Foetal Alcohol Syndrome (FAS) is a condition that refers to the teratogenic effects of heavy maternal alcohol consumption upon the developing fetus such as growth retardation, characteristic facial features and central nervous system dysfunction which can include developmental delay, behavioral disorders and intellectual disability (O’Leary, 2004 ). High rates of FAS have been reported in some indigenous populations in Australia, the USA and Canada, being recognized as the main preventable non-genetic cause of intellectual impairment (O’Leary, 2004 ).
There are concerns that findings from a few studies in select indigenous populations known to have high alcohol consumption have been extrapolated to be repre- sentative of indigenous populations as a whole thereby obscuring other factors such as poor education, poverty, unemployment and racism that might be responsible for cognitive outcomes (Hoy, 2012 ). Nevertheless, the potential intergenerational impact of FAS upon indigenous populations is of great concern.
Migration
Various patterns of harmful alcohol use have been described in immigrant populations, which do not simply reflect alcohol use in the country of birth, although little is known specifically about how this may relate to ARBD. Some examples illustrate this. Levels of alcohol consumption in various South Asian immigrant groups in Scotland are lower than in the general population (McKenzie and Haw 2006 ), while age-standardized alcohol-related mortality was comparatively low in immigrants from Pakistan, other parts of the UK and elsewhere in the world (Bhala, Fischbacher and Bhopal, 2010 ). In contrast, immigrants from the former Soviet Union residing in Israel have high rates of alcohol-related disorders (Weiss, 2008 ). A study comparing the alcohol use in Latinos born in the USA with that in recent Latino immigrants pre-immigration and post-immigration found that the post-immigration alcohol use of immigrants was lower than their pre-immigration use and that of US-born Latinos (De La Rosa et al ., 2012 ). In Germany, the drinking behavior of adolescent immigrants from Turkey and the former Soviet Union only partially conformed to expectations and the authors speculated on the role of acculturation in their find- ings (Donath et al ., 2011 ). An examination of alcohol-use disorders in Afghan migrants to Germany found that they were significantly associated with accultura- tion stress and mental distress whether or not alcohol was used prior to migration (Haasen, Sinaa and Reimer, 2008 ). The important role of acculturation in migrants was supported in a nationally representative sample of 952 Asian American adults extracted from the Wave 2 National Epidemiologic Survey of Alcohol and Related Conditions. After controlling for other factors, a positive relationship between ethnic drinking cultures and alcohol outcomes held for most drinking outcomes, with a moderating effect of integration into ethnic cultures as indicated by ethnic language use being found in US-born Asian Americans (Cook, Mulia and Karriker-Jaffe, 2012 ).
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The studies considered here illustrate the complexity of understanding harmful alcohol use in immigrant populations and show little information specifically about ARBD.
Socio-economic status
There is a notable socio-economic gradient in relation to alcohol-related mortality and morbidity (Melchior et al ., 2011 ); however, this relationship is complex and multifaceted. Socio-economic status (SES) and disadvantage can refer to a range of issues, although most commonly it refers to combinations of low levels of education, unemployment and financial hardship. It is also relevant to consider the impact of both individual-level and area-level socio-economic disadvantage on both alcohol- use patterns and negative health outcomes. Hazardous use of alcohol increases the risk of a range of negative health outcomes, including ARBD. While the research on the impact of SES on ARBD is somewhat limited, understanding the impact of SES on hazardous alcohol-use patterns may provide some insight into high-risk groups in the community.
There are a number of different mechanisms proposed to underlie the effect of SES on substance use patterns, including psychological, social and environmental contributions. Investigations into the effect of SES on alcohol use and alcohol-related consequences are complex. There are often conflicting results due to the varying methodologies used. Studies vary in their definitions and classifications of SES, including varying combinations of education, income and employment as proxy indicators. Studies also vary in their measurement of what constitutes problematic drinking behaviors, ranging from frequency and quantity of consumption, to the experience of negative alcohol-related health outcomes.
There is evidence of area-level impact on alcohol use with residents of similar geographical areas showing similar patterns of consumption (Karriker-Jaffe, 2011 ), and higher rates of problematic alcohol use in areas of socio-economic disadvan- tage (Jones-Webb et al ., 1997 ; Stimpson et al ., 2007 ; Waitzman and Smith, 1998 ).
While neighborhood disadvantage seems to play a role in increased use, perhaps through problematic social norms, high alcohol consumption is also seen in neighborhoods where there is high income inequality (Cutright and Fernquist, 2010 ), possibly indicating a role of upward social comparisons in increasing dis- satisfaction and substance use. There is a clustering of negative alcohol-related outcomes in areas of socio-economic deprivation, including increased rates of ARBD (Chiang, 2002 ; MacRae and Cox, 2003 ) and higher rates of FAS (Abel, 1995 ). The impact of SES on alcohol use is evident in developed as well as less developed nations, including India and Sri Lanka (De Silva, Samarasinghe and Hanwella, 2011 ; Pillai et al ., 2013 ), where higher proportions of income is spent on alcohol in lower-income households compared with higher SES groups (De Silva, Samarasinghe and Hanwella, 2011 ). While area-level disadvantage does seem to have a role in alcohol use and outcomes, the effect is likely to be indirect, and often disappears when adjusting for individual-level mediating factors (Karriker-Jaffe, 2011 ).
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Given the variability in measurement of individual-level SES and alcohol-use patterns it is unsurprising that the findings are complex. There are reasonably consistent findings between poorer SES and increased hazardous alcohol use and consequences. Some findings indicate that those with higher SES tend to have higher alcohol consumption, especially in relation to binge drinking patterns (Casswell, Pledger and Hooper, 2003 ; Chuang et al ., 2005 ; Huckle, You and Casswell, 2010 ; Keyes and Hasin, 2008 ; Melotti et al ., 2013 ; Sanchez et al ., 2013 ). The socio- economic gradient is often more prominent when examining more extreme aspects of hazardous alcohol use, such as frequent hangovers, periods of alcohol-related unconsciousness, alcohol-specific hospitalizations and death (Paljarvi et al ., 2013 ).
Surrogate alcohol consumption (consumption of alcoholic substances not intended to be drunk, such as mouthwash or cleaning products with ethanol) is an especially dangerous form of alcohol abuse that is frequently seen in low SES populations (Tomkins et al ., 2007 ). Low SES appears to impact alcohol use in one of two directions, increasing the likelihood that a person would either abstain from alcohol use or have an alcohol-related problem (Bloomfield et al ., 2006 ; Casswell, Pledger and Hooper, 2003 ). It is likely that the complexity of this finding is partially due to the disparities between these two groups. Overall, findings do suggest increased rates of alcohol-related harm in those with poorer SES, including mortality, cirrhosis and hospitalizations (Bloomfield et al ., 2006 ; Harrison and Gardiner, 1999 ; Makela, Keskimaki and Koskinen, 2003 ), along with greater impact of alcohol use on cog- nitive abilities in low SES groups which may be due to lower cognitive reserve (Sabia et al ., 2011 ). It has been argued that those with lower SES may have increased negative outcomes related to their alcohol use due to factors that limit use of or access to protective health behaviors, such as health care, housing and nutrition, rather than necessarily due to heavier consumption (Huckle, You and Casswell, 2010 ; Makela and Paljarvi, 2008 ). Poverty is also a factor. In Sri Lanka, despite spending less on alcohol than those with higher incomes, the poor are likely to spend a higher proportion of their disposable income on alcohol (De Silva, Samarasinghe and Hanwella, 2011 ). The impact of other health behaviors is likely to exacerbate the negative impact of alcohol use among those experiencing socio- economic disadvantage. Examples include poor nutrition, which increases the risk of ARBD, and smoking, which is independently associated with dementia (Almeida et al ., 2002 ; Arpi et al ., 2006 ; Murphy et al ., 2012 ). Findings in relation to the socio- economic gradient on alcohol-use outcomes often suggest a different pattern for men and women (Batty et al ., 2012 ; Bloomfield et al ., 2006 ). Lower SES is often associated with higher risk of heavy use and abuse in men, but was associated with lower use and abuse patterns in women (Batty et al ., 2012 ; Bloomfield et al ., 2006 ; van Oers et al ., 1999 ). In the context of understanding the abstinence and abuse groups found in studies of low SES populations, it may be that women who are caring for children tend to be represented more in the abstinence groups, while men commonly fall into the hazardous-use groups. Unemployment was found to be the highest risk factor for hazardous drinking in men, while being on a disability pension increased the risk for women (Paljarvi et al ., 2013 ). The role of gender in drinking