The following originally appeared on The Upshot (copyright 2021, The New York Times Company) and was coauthored by Nambi Ndugga and Austin Frakt. It also appeared on page A4 of the print edition on April 21, 2021.
American deaths from misuse of substances, including alcohol, have increased over the past two decades, but not uniformly across various demographic groups.
Overall rates of alcohol abuse and related deaths have consistently and significantly increased for white non-Hispanic Americans, while Black Americans have experienced a much slower and less significant incline, and some other groups have had declines.
More recently, alcohol use has been up during the pandemic, with one study showing a greater increase in misuse among women than among men.
(For men, recommended limits are four drinks per day and 14 drinks per week, and for women, three drinks per day and seven drinks per week, according to the National Institute on Alcohol Abuse and Alcoholism.)
“Alcohol kills many more people than many may realize,” said Yusuf Ransome, an assistant professor at Yale’s School of Public Health. “It is a major contributor to deaths linked to physical injuries, interpersonal violence, motor vehicle crashes, self-harm and other harmful outcomes.”
One reason for this might be that alcohol is often viewed as socially acceptable. “Alcohol use has been normalized because it is consumed sometimes at family and communal gatherings, casual outings, and that’s the type of drinking that is typically seen or showed within the media,” he said. “We rarely see the long-term health impacts of excessive alcohol use, nor do we show the acute dangers of alcohol misuse and abuse.”
Between 2000 and 2016, according to research published in JAMA, alcohol-related deaths continually increased for white men (2.3 percent per year on average) and white women (4.1 percent), with middle-aged white Americans accounting for the highest increase in deaths. Rapid increases during this period in mortality related to alcohol and drugs like opioids among white Americans — particularly those without a college degree — have been termed “deaths of despair.”
The trend mirrors one experienced by Black Americans living in cities in the 1970s and 1980s. The underlying sources suggested by scholars are similar for the two groups, just shifted in time: social and economic stressors including poverty, stagnant or declining incomes, loss of blue-collar jobs, and disintegration of family units.
For Black Americans, there was the added problem of structural and explicit racism that contributed (and continues to contribute) to reduced economic opportunity and worse mental and physical health outcomes.
Rates of alcohol-related deaths among Black Americans declined somewhat in the early years of the 21st century, though they began to rise once more in 2007 (among women) and 2012 (among men). Nonetheless, the rate of alcohol-related death remains lower than among white Americans.
One factor might be a high sense of community and high levels of religious service attendance within the Black community, which have consistently been associated with both lower and less severe alcohol use. Another possible reason for lower rates of alcohol use among Black Americans is the well-founded sense that the possible downsides are more severe for them compared with other racial and ethnic groups. African-Americans are more likely to be policed and to suffer negative outcomes during their interactions with law enforcement, as evidenced over the past year and historically.
“African-Americans, particularly men and those of lower income, are at a higher risk of more social and legal consequences associated with drinking and other substance use,” said Tamika Zapolski, an associate professor of clinical psychology at Indiana University-Purdue University, Indianapolis. “They are more likely to experience negative health complications and be arrested and convicted.”
For example, one study found that Black (and Hispanic) drinkers are 1.5 times more likely to report adverse social consequences from drinking compared with their white non-Hispanic counterparts. These results support earlier findings of significant racial disparities in alcohol-related consequences. Some studies attribute this to increased policing in lower-income Black neighborhoods.
Native Americans have experienced the highest rates of alcohol-related deaths, which have been on the rise since 2000. According to a JAMA study, Native Americans’ alcohol misuse can be traced to “poverty, family history of alcohol use disorder, availability of alcohol at a younger age,” as well as stress from historical trauma. The death rate in 2016 was 113.2 per 100,000 for Native American men and 58.8 per 100,000 for Native American women.
For other groups per 100,000, the death rate was 4.4 and 1.0 for Asian-American and Pacific Islander men and women; 13.8 and 4.6 for Black men and women; 21.9 and 4.7 for Hispanic American men and women; and 18.2 and 7.6 for white men and women.
While there has been an overall increase in such deaths among Asian-Americans, the trends in alcohol consumption tend to diverge by national origin. Among Asian-American and Pacific Islander populations, U.S.-born individuals have higher rates of alcohol abuse than their first-generation immigrant counterparts, which may be because of cultural assimilation, among other factors.
The enculturation process may have also had an impact on young Hispanic women, who are experiencing an increase in alcohol consumption and have the third-highest rates of female alcohol-related deaths, after Native American and white women.
In the past two decades, women died of alcoholic liver disease on average two to three years earlier than men, even though they generally had longer life expectancies. During the pandemic, they have experienced a 41 percent increase in heavy drinking episodes, a survey study showed. (The C.D.C. definition of binge drinking for women is four or more drinks over two hours.)
“Over the past two decades, underage females were exposed to and suffered the effects of alcohol marketing,” said David Jernigan, professor of health law, policy and management at the Boston University School of Public Health, who has researched the relationship between alcohol marketing and consumption of alcohol.
“Specific products and product categories were created primarily for females: sweeter, fizzier, and marketed as more ‘feminine’ drinks,” he said.
More than boys and young men, girls and young women are drawn to so-called alcopops — flavored, often fruity, alcoholic beverages — fueling their popularity, according to one study. Women absorb more alcohol than men when drinking equivalent amounts because it takes longer for them to metabolize it, so the risk of harm is higher.
“We are seeing the consequences now, with increasing rates of cirrhosis and liver cancer deaths for women being the canary in the coal mine for a range of negative effects,” Professor Jernigan said.