Scientific researchers like W. Madsen, D. Cahalan, and S. Bacon rightly insist that to gather meaningful and comparable data one must have an operational, quantifiable definition that guarantees consistency as to which cases are counted as alcoholics and which are not. But clinicians and field workers often find it advantageous to ignore such precision and not to allow themselves to get trapped into games of labeling or arguments about whether a client is or is not an alcoholic. There is a general tendency to use the term alcoholic when loss of control and dependence are stressed, and problem drinker when the emphasis is on consequences. There is no standard or sacrosanct terminology here. One could argue the pros and cons of even dropping the term alcoholic entirely:

Con. In view of the great progress that has been made in the last few decades to eliminate the social stigma attached to alcoholism, it would seem a strategic mistake to reverse the trend. Dropping the term would cause the alcoholism movement, after having espoused the term, to lose face before the medical profession, the courts, and the insurance companies. There would be a loss in continuity of research. It might feed the denial system of some alcoholics, encouraging them to delude themselves into attempts at social drinking. It would take the focus off alcohol as our major drug: The alcoholic beverage industry would be delighted to have NCADD change its name to "National Council on Chemical Dependency." A major loss would be the sense of identity that people feel within the fellowship of Alcoholics Anonymous.

Pro. Yet dropping the term would have its advantages. In spite of progress, alcoholism is still odious in the minds of many. Some wish to name it Jellinek's disease, as we now call leprosy Hansen's disease. The stereotype of the skidroad derelict or the "fallen woman" prostitute and the suggestion of insanity still cling to the word, making early detection more difficult and fostering a defeatism or sense of hopelessness not warranted by current success rates in rehabilitation.

For alcoholics in the denial stage the term raises their defenses, and many an initial interview goes smoother if there is no attempt to hang the label "alcoholic" on a new client but just an effort to explore calmly together whether drink is causing some problems. If the client later wishes to label himself, perhaps in an AA meeting, the victory was well worth the tactic. (AA members working in the field too often take for granted the ease with which the word is used among them now and forget how defensive they were in the denial phase, or how painful it was the first time to say "I am an alcoholic.")

Dropping the term might make it easier to sell a program to industry and might lessen the denial or defensiveness of the spouse and family by making them less self-conscious. Alcohol education would be easier and more positive, with less scare tactics centered around alcoholism. Traffic problems and court referrals might be handled more easily if alcoholism were brought into the picture under a different name.

The change might even stimulate a fresh, innovative approach to research. Alcoholism is not a single disease entity like TB or malaria, and cross-cultural differences further confuse the issue. Data might be more objectively gathered from emergency hospitals and police stations if not contaminated by subjective perceptions of alcoholism, as in one study where the physician missed the diagnosis half the time if the patient was well-dressed and not unkempt. Last and perhaps most important, the connotations of the term alcoholic prevent many women from being properly diagnosed, which not only yields misleading statistics but keeps those women from getting the help they need.

What to do? As in many aspects of this field, there is no clear answer. We reject outright the term substance abuse, because it suggests behavioral choice rather than compulsive disease. This is not just "political correctness" but avoids putting those recovering from a disease in the same category with child abusers or sexual abusers. Both DSM-IV and the title of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) distinguish between abuse and alcoholism. Chemical dependency is better, but like "substance" it detracts from the fact that alcohol is our biggest drug problem. We prefer alcohol and other drug addiction.

Extent of Alcohol Problems

(For fuller discussion of this topic see Royce, Alcohol Problems and Alcoholism, Chapter 2 and references therein.)

Alcohol causes more significant problems than all other drugs combined. Alcohol kills over five times more people each year than all illegal drugs together (JAMA, 1993, 270: 2207-12). We now know that a great number of deaths once attributed to accidents and to physical illnesses such as heart or liver failure, acute pancreatitis, internal hemorrhaging, and the like should really be counted as alcohol deaths. And there is clear evidence that alcohol contributes to the causality of cancer. Yet even reasonably well-informed people do not realize the extent to which alcohol use and misuse pervade every aspect of American life: social, economic, political, medical, legal, historical, moral, and emotional. Smoking is now considered our number-one cause of death, but smoking rarely causes one to cross the highway center line to wipe out a carload of innocent people, or a man to beat up his wife. So alcohol can still be ranked as our number one public health problem drug.

Estimating Is Difficult. Lengthy treatises " to some more boring than the statistics themselves " have been written about the problems involved in trying to compile accurate figures on alcoholism. Vagueness of definition and a lack of standard criteria for alcoholism are complicated by our society's emotional attitudes toward the misuse of alcohol and consequent tendencies to gloss over it. Some apparent increases in the estimates of the numbers of alcoholics are no doubt merely a reflection of better methods of case finding and reporting, along with the new willingness to face alcohol problems openly and without disguise, especially among women.

Estimates of the extent of alcohol abuse based on arrests and court convictions can be misleadingly low. Arresting officers will often settle for lesser charges, such as reckless driving, because there is a better chance of proving the charge in court. More severe penalties tend to predispose a jury toward acquittal. In 1984 three groups of Midwest pathologists claimed that their autopsies showed 91 percent of auto deaths were alcohol-related.

Often neglected in such discussions are the figures from the National Safety Council and other sources on the role of alcohol in death and injury other than by automobile. Other types of alcohol-related accidents should not be ignored: home, boat, fire, drownings, suicides, and a high percentage of fatal crashes in airplanes other than commercial or military. Thus one-third of industrial and home accidents, 25 percent of ski accidents, 19 percent of bicycle accidents, and an estimated 75 percent of boat and small plane deaths and injuries occur after drinking. Commercial pilots are rigidly monitored, but the Federal Aviation Administration (FAA) has no effective means of checking private planes. People who are used to boats and are around them all the time don't fall off and drown in the wee hours because they have been drinking milk all Saturday night. Not drunk nor an alcoholic, the man who has a few beers before climbing the ladder to paint his house may dull his sense of balance just enough to cause a broken neck, but it will not be reported as alcohol-related.

Rates on per capita consumption of alcohol do not necessarily reveal rates of alcoholism. Orthodox Jews, Greeks, and wine-drinking southern Italians have low rates of alcoholism (not zero, as is mistakenly thought) but relatively high rates of alcohol consumption. Some Scandinavian and other northern countries have high rates of alcoholism without overall per capita consumption of alcohol ranking equally high. High consumption rates for convention and vacation cities do not necessarily mean high alcoholism rates for the local citizens.

Another irritation is that statistics on rates of alcoholism among adults do not use a uniform age base. Some figures are based on all people over twenty-one, others on those over twenty, and some on those over eighteen or even fifteen " making comparisons difficult. Lastly, since research takes time to compile and this is a rapidly changing field, the latest figures are bound to be obsolete before the ink is dry.

Methods of Estimating. One method of estimating the percentage of alcoholics in a given population was the formula developed by E. M. Jellinek (Haggard and Jellinek, 1942) based on deaths from cirrhosis of the liver. Jellinek (1959) himself repudiated the formula. Polling physicians, social workers, and clergymen regarding the prevalence of alcoholism in their clientele may not be very reliable, but it is useful to uncover those who do not get counted in data from agencies explicitly designated as serving alcoholics. Sociological surveys of drinking practices and alcohol problems, using methods like those of Cahalan, Room, and associates, are perhaps the most realistic approach. Community surveys, especially longitudinal studies that follow a group over a long period of time (e.g., Fillmore, 1988; Vaillant, 1983), are the most expensive but the best source of data when properly designed and administered. Even here, getting a representative cross-section for one's sample and standardizing criteria for comparison with other groups present nearly insurmountable problems, while adequate follow-up may require dogged (and expensive) detective work.

With all the above cautions in mind, we shall summarize the literature to substantiate our assertion that alcohol is a large factor in American life and a major cause of problems. For the reasons given, very few statistics here are more than estimates, but the expertise of social scientists is such that they are on guard against pitfalls and skilled in acquiring the most accurate data possible. It is better to lean toward the conservative side, lest we lose credibility. We must resist the temptation to inflate figures in order to impress either the public or legislators, though this becomes a crucial issue when funds are being allotted. Youngsters especially may not believe us on anything if they catch us in even one exaggerated statement.