Ethnicity and Health Disparities in Alcohol Research

Virginia Commonwealth University

VCU Scholars Compass

Social Work Publications

School of Social Work

2010

Ethnicity and Health Disparities in Alcohol

Research

Karen G. Chartier

Virginia Commonwealth University, kgchartier@vcu.edu

Raul Caetano

University of Texas at Dallas

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http://scholarscompass.vcu.edu/socialwork_pubs

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Published by NIH in Alcohol Res Health. 2010; 33(1-2): 152–160.

This Article is brought to you for free and open access by the School of Social Work at VCU Scholars Compass. It has been accepted for inclusion in Social Work Publications by an authorized administrator of VCU Scholars Compass. For more information, please contactlibcompass@vcu.edu.

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Ethnicity

and Health

Disparities

in

Alcohol Research

KarenChartier,M.S.W.,Ph.D.,andRaulCaetano,M.D.,M.P.H.,Ph.D.

KARENCHARTIER, M.S.W., PH.D., faculty associate, University of Texas School of Public Health, Dallas, Texas RAULCAETANO, M.D., M.P.H., PH.D., regional dean and professor, University of Texas School of Public Health,

dean and professor, University of Texas Southwestern School of Health Professions, Dallas, Texas.

Recentadvancesinalcoholresearchcontinuetobuildourunderstandingofalcoholconsumptionand related consequences for U.S. ethnic minority groups. National surveys show variations across ethnicities indrinking, alcohol usedisorders, alcoholproblems, and treatment use.Higher rates of high­risk drinkingamong ethnic minorities are reported for Native Americans and Hispanics, althoughwithin­ethnicgroupdifferences(e.g.,gender,age­group,andothersubpopulations) alsoare evident for ethnicities. Whites andNative Americans have a greater riskfor alcohol use disorders relative to other ethnic groups. However, once alcohol dependence occurs, Blacks and Hispanics experience higher rates than Whites of recurrent or persistent dependence. Furthermore, the consequencesofdrinking appeartobe moreprofoundfor Native Americans,Hispanics,andBlacks. Disparitiesinalcoholtreatmentutilizationaremost apparentfor Hispanics.Explanationsforthese differences are complex, likely affected by risky drinking behaviors, immigration experiences, racial/ethnic discrimination, economic andneighborhood disadvantage, and variations in alcohol­ metabolizing genes. Research must maintain a systematic, strong, and growing focus on ethnic minorities. Amore complete understanding of these effects for ethnic minority groups is neededto enableresearcherstoface thechallengesofreducing andultimatelyeliminatinghealthdisparitiesin thealcohol field. KEYWORDS: Alcohol treatment; Alcohol use disorders (AUD); Drinking behavior; Ethnicity and alcohol consumption; Health disparities; Medical consequences of alcohol consumption; Risky drinking; Social and cultural factors

ethnicgroupdisparitiesinalcohol consumption,disorders,consequences, andtreatmentuse,aswellasfactors thatmayaccountforthedisproportion­ ateimpactofalcoholonsomeethnic groups.AlcoholresearchintheUnited Statespaidfragmentedattentiontothe implicationsofraceandethnicityprior to1984,withearlyalcoholsurveys focusingprimarilyondrinkingforindi­ vidualsofEuropeandescent(Caetano 1984;Dawson1998).In1984,the firstnationalalcoholsurveywithan emphasisonBlacksandHispanics,at thattimealreadythetwolargestethnic minoritygroupsintheU.S.population, wasconducted(Caetanoetal.1998). Theimportanceofconductingalcohol researchamongethnicgroupswas underscoredbysubsequentstudies identifyingdifferentpatternsofalcohol

T

consumptionanddisproportionate consequencesfromalcoholuseamong ethnicgroups(forareviewseeCaetano etal.1998;GalvanandCaetano2003). Morerecentnationalsurveys,including the1991–1992NationalLongitudinal AlcoholEpidemiologicSurvey(NLAES) andthe2001–2002National

EpidemiologicSurveyonAlcoholand RelatedConditions(NESARC),both conductedbytheNationalInstituteon AlcoholAbuseandAlcoholism(NIAAA), oversampledBlacksandHispanics, facilitatingadditionalresearchinthis area.Overthepastdecade,progress continuestobemadeindocumenting thevariabilityinalcoholconsumption andrelatedconsequencesforU.S. ethnicgroups.

Thisreviewofselectedpublished datadescribestheepidemiologyof alcoholuseandrelatedbehaviorsboth acrossandwithinU.S.ethnicgroups.

Theauthorsfocusedonresearch manuscriptspublishedwithinthe past10years.Nationaldatasources wereusedwheneverpossible.To complementpublishedliterature, nationalsurveydataavailablefrom NIAAA,theSubstanceAbuseand MentalHealthServicesAdministration (SAMHSA),andtheCentersfor DiseaseControlandPrevention (CDC)wereused.

DisparitiesinAlcoholResearch

Alcohol

Consumption

Nationalsurveysshowdifferencesin alcoholconsumptionacrossethnic groups,includingpatternsofdrinking associatedwithgreaterriskforthe adverseeffectsofalcohol(e.g.,binge drinking,definedasfiveormoredrinks onthesameoccasion).Accordingto past­30­dayestimatesofdrinkingpro­ videdbythe2007NationalSurvey onDrugUseandHealth(NSDUH) (SAMHSA2008c),anyalcoholusein adults(i.e.,ages18orolder)ismost prevalentforWhites(59.8percent), lowestforAsianAmericans(38.0percent), andsimilarforNativeAmericans(i.e., AmericanIndiansandAlaskaNatives; 47.8percent),Hispanics(46.3percent), andBlacks(43.8percent).Native Americanshavethehighestprevalence (12.1percent)ofheavydrinking(i.e., fiveormoredrinksonthesameocca­ sionfor5ormoreofthepast30days; followedbyWhites(8.3percent)and Hispanics(6.1percent).Alargerper­ centageofNativeAmericans(29.6 percent)alsoarebingedrinkers,with somewhatlowerpercentagesfor Whites(25.9percent),Hispanics(25.6 percent),andBlacks(21.4percent). Relativetootherethnicgroups,thepro­ portionofAsianAmericans(2.7percent) andBlacks(4.7percent)whoareheavy drinkersandAsianAmericans(13.3 percent)whoarebingedrinkersislow.

Estimatesofcurrentandheavy drinkingforadultsbygenderwithin eachethnicgroupareprovidedbythe 2001–2002NESARC(seeTable1) (NIAAA2006).Thesedatashowthat currentdrinkingismostprevalent amongWhiteandHispanicmenand lowestforAsian­Americanwomen. Heavydrinkingisdefinedbyboth weeklyanddailydrinkinglimits(i.e., consuming5ormorestandarddrinks perday[or15ormoreperweek]for menand4ormoredrinksperday [or8ormoreperweek]forwomen) (NIAAA2006).NativeAmericansof bothgendershavethehighestpreva­ lenceofweeklyheavydrinking,whereas Hispanicmenhavethehighestpreva­ lenceofdailyheavydrinking.Rates ofweeklyheavydrinkingarelowestfor Asian­AmericanandHispanicwomen, andratesofdailyheavydrinkingare lowestamongAsian­Americanand Blackwomen.Dawsonetal.(2004) reportedfewchangesinthepercentages ofU.S.adultswhoexceedrecommend­ eddrinkinglimitsfrom1991–1992 to2001–2002.AmongWhites,there wasanincreaseintheproportionof adultsexceedingweeklydrinkinglimits andadecreaseinproportionexceed­ ingdailydrinkinglimits.Bothdaily andweeklyheavydrinkingremained stableforotherethnicgroups.

Alcoholconsumptionalsohasbeen showntovarybyethnicgroupduring

adolescenceandyoungadulthood. Accordingtothe2007NSDUH,the prevalenceratesof30­dayalcoholuse andbingedrinkinginpeopleaged 12–17yearswerehighestforWhites (alcoholuse:18.2percent;binge drinking:11.5percent),followedby Hispanics(15.2percent;9.3percent) andthenBlacks(10.1percent;4.3 percent)andAsians(8.1percent; 5.2percent)(Chenetal.2009).In asampleofyoungadultsfromthe NESARC,ages18–24,Whitesand NativeAmericanshadhighpreva­ lenceratesofcurrentdrinking(77.1 and70.7percent,respectively)and exceedingtherecommendeddaily (52.5and53.0percent)andweekly (17.3and27.4percent)drinkinglimits (Chenetal.2004,2005).Comparatively, Blacks,Hispanics,andAsianshad lowerratesofdrinking(i.e.,current drinking:59.1–60.4percent;exceed­ ingdailylimits:29.0–37.3percent; exceedingweeklylimits:8.5–10.5 percent).

Differenttrajectoriesofdrinking havebeenidentifiedbyethnicgroup. AccordingtotheNESARC,more NativeAmericans(16.43percent) andfewerBlacks(5.52percent)and Asians(6.03percent)reportanearly onsetofdrinking(i.e.,beforeage15) thanWhites(7.07percent)and Hispanics(7.93percent)(NIAAA 2006).Therateofdrinkingonset

Table DrinkingStatusandHeavyDrinkingforU.S.EthnicGroupsbyGender,2001–2002

U.S.Population AmongCurrentDrinkers

Ethnic CurrentDrinkers WeeklyHeavyDrinking DailyHeavyDrinking Group Male Female Male Female Male Female

White* 74.27 65.10 18.51 13.85 30.74 23.73 (0.73) (0.79) (0.55) (0.47) (0.63) (0.59) Black* 62.62 45.92 19.88 12.67 25.81 19.02 (1.25) (1.01) (1.10) (0.96) (1.42) (1.02) NativeAmerican* 65.48 51.66 21.63 22.19 29.34 27.20 (3.50) (3.23) (3.52) (3.75) (3.32) (3.77) Asian*† 61.51 36.11 10.83 8.24 18.84 19.77 (2.58) (2.67) (1.79) (1.90) (2.30) (2.27) Hispanic 69.99 49.52 13.76 8.81 40.48 24.19 (1.20) (1.51) (1.04) (0.92) (1.62) (1.18)

NOTE:Dataarepercentage(standarderror);*Non­Hispanic.†IncludesPacificIslanders.

SOURCE:NationalInstituteonAlcoholAbuseandAlcoholism.AlcoholuseandalcoholusedisordersintheUnitedStates:Mainfindingsfromthe2001–2002NationalEpidemiologicSurveyon AlcoholandRelatedConditions(NESARC).Bethesda,MD,NationalInstitutesofHealth,2006.

allethnicgroupsandlowestforBlack femalesubjectsat3.91percent. MuthenandMuthen(2000)reported strongeffectsforethnicityonthe developmentofdrinkingbehaviors fromages18to37whencomparing Blacks,Hispanics,andnon­Blackand non­Hispanics.Minorityethnicgroup statuswasasignificantprotectivefac­ torforheavydrinkinguntilage32, afterwhichlevelsofheavydrinkingfor thethreeethnicgroupsweresimilar.

Studiesalsohavebeguntotakeinto considerationthevariabilityinalcohol consumptionthatexistswithinethnic groups(i.e.,White,Black,Hispanic, andAsian)(Dawson1998).Forexam­ ple,Bealsetal.(2003),comparing twoculturallyandgeographically distinctAmericanIndiantribes,showed thatcurrentdrinkingratesamong thoseaged15–54years(41.8to66.6 percentformen;11.5to53.0percent forwomen)werelowerforSouthwest IndiansrelativetoNorthernPlains IndiansandtotheU.S.population. InfourNortherntribes,malesubjects drankmorethanfemalesubjects,with anaverageof4.7versus2.1drinking daysand5.7versus3.1drinksperday inthepastmonth(MayandGossage 2001).Despiteoveralllowratesof alcoholconsumptionforAsians/Pacific IslandersintheU.S.population,some subpopulationswithinthisgroup showalarminglyhighratesofdrink­ ing.Inparticular,prevalenceratesof 30­daybingeandheavyalcoholuse forPacificIslandergroups(ages18or older;26.8percentand12.6percent, respectively),asreportedbythe2006 NSDUH,weremorethandouble thatofotherAsiangroups(12.5per­ centand2.6percent,respectively) (SAMHSA2008c).

Inaddition,Hispanicnational groupshavedifferentdrinkingpat­ ternsbutsimilarbeveragepreferences (Caetanoetal.2009b).Acrossspecific beveragetypes(i.e.,wine,beer,and liquor),PuertoRican(5.1to11.2 drinks/week)andMexican­American (4.1to7.0drinks/week)mendrink themostandhavethehighestratesof bingedrinking(19.6to35.0percent

drinks/week;4.6to26.7percent)and South/Central­American(3.4to7.9 drinks/week;10.3to32.3percent) men.Amongwomen,PuertoRicans drinkmore(1.8to7.9drinks/week) andreporthigherratesofbinge drinking(17.3to40.2percent)relative toCuban,Mexican,andSouth/Central Americans(0.7to3.4drinks/week; 5.1to17.9percent).Beeristhe preferredbeverageforadultsinall nationalgroupsandismostassociated withheavierdrinkingandbinge drinkingforallHispanicmenand PuertoRicanandMexican­American women.Beveragepreferencesalsohave beenstudiedforBlackmen.Among primarilylow­incomeBlackmen, 41percentofdrinkerspreferredmalt liquorbeer(MLB)and35percent hardliquor,withanMLBpreference linkedtomoredrinkingconsequences andheavierdrinking(Bluthenthalet al.2005;Vilamovskaetal.2009).

Alcohol

Use

Disorders

Accordingtothe2001–2002NESARC, past­yearalcoholabuseandalcohol dependenceisprevalentin4.7and3.8 percentoftheU.S.adultpopulation, whilethelifetimeprevalenceofalcohol abuseandalcoholdependenceis17.8 and12.5percent,respectively(Hasin etal.2007).Whiteshavegreaterodds thanBlacks,Hispanics,andAsiansfor eitherapast­yearorlifetimealcohol usedisorder.NativeAmericanshave greateroddsthanWhitesforlifetime alcoholdependencebutsimilarodds forlifetimealcoholabuseandpast­year alcoholabuseanddependence.More specifically,Whites(13.8percent)are morelikelythanBlacks(8.4percent) andHispanics(9.5percent)todevelop alcoholdependenceintheirlifetime (Hasinetal.2007).However,once alcoholdependenceoccurs,Blacks (35.4percent)andHispanics(33.0 percent)haveahigherprevalencethan Whites(22.8percent)ofrecurrentor persistentalcoholdependence (Dawsonetal.2005).

differencesinratesofalcoholuse disorders.The2002–2003National LatinoandAsianAmericanStudy (NLAAS)foundthatadultestimates oflifetimealcoholabuseanddepen­ dencewerehighestamongPuerto Ricans(7.1and5.5percent,respec­ tively),followedbyMexicanAmericans (6.0and4.7percent),“other”Latinos (5.7and3.1percent),andCuban Americans(3.1and2.4percent) (Alegriaetal.2008).Similarly,as examinedbygender,PuertoRican (15.3percent)andMexican­American (15.1percent)menhavehigherrates ofalcoholdependencethanSouth/ Central­American(9.0percent)and Cuban­American(5.3percent)men (Caetanoetal.2008a).Among Hispanicwomen,PuertoRicans(6.4 percent)hadhigherratesrelativeto Mexican(2.1percent),Cuban(1.6 percent),andSouth/CentralAmericans (0.8percent).

Varyingestimatesofalcoholdepen­ dencealsohavebeenobservedamong Asian­Americannationalgroupsand AmericanIndiantribes.Chaeetal. (2008),basedondatafromthe 2002–2003NLAAS,reporteda3.6 percentlifetimeestimateofalcohol disordersamongAsianAmericans. Comparatively,FilipinoAmericans (20.2percent)hadalowerprevalence oflifetimealcoholdisordersthan “other”AsianAmericans(39.3per­ cent)butahigherprevalencethan Chinese(10.3percent)andVietnamese Americans(2.5percent).Additionally, Bealsetal.(2005)found,relativeto NorthernPlainsIndians,thatSouthwest Indiansarelesslikelytoreportpast­ year(4.5versus9.8percent)andlife­ time(9.8versus16.6percent)alcohol dependence,withlowerratesfor womenregardlessoftribeaffiliation. Lifetimeratesofalcoholdependence alsovariedfrom1to56percentfor menand2to30percentforwomen acrosssevengeographicallydiverse AmericanIndiantribesfromtheTen TribesStudy(Kossetal.2003).

Somechangesintheprevalenceof alcoholabuseanddependencefrom 1991–1992to2001–2002havebeen

DisparitiesinAlcoholResearch

reportedforU.S.ethnicgroups(Grant etal.2004).Past­yearalcoholabuse increasedforWhites,Blacks,and HispanicsbutnotforAsiansand NativeAmericans.Further,ratesof past­yearalcoholdependencedecreased forWhitesandHispanics,whereas ratesforBlacks,NativeAmericans, andAsiansremainedstable.Recent researchfindingsalsobasedon1991– 1992and2001–2002datasuggest aseculartrendofincreasedriskfor alcoholdependenceinWhiteand HispanicwomenbutnotBlackwomen (Gruczaetal.2008a).Thischange waspartlyattributedtoasharper decreaseintheageofdrinkingonset forwomencomparedwithmen born1954to1983andwasmost pronouncedforWhitewomenbut lesssoforHispanicwomen(Grucza etal.2008b).

Alcohol

Consequences

Bingeandheavydrinkingarehigh­risk consumptionpatternsthatcontribute toavarietyofalcohol­relatedsocialand healthproblems(Naimietal.2003; Rehmetal.2003).However,thecon­ sequencesofalcoholconsumptionare moreprofoundinsomeethnicgroups thanothers.High­riskdrinkingcon­ tributestothehigherratesofalcohol­ relatedproblemsforsomeethnic groups(e.g.,NativeAmericans),but thenegativeeffectsofalcoholforethnic minoritiesoftenoccuroverandabove thecontributionofalcoholuse.Most recently,Muliaetal.(2009)showed thatBlackandHispanicadultdrinkers aremorelikelythanWhitedrinkersto reportalcoholdependencesymptoms andsocialconsequencesfromdrinking. Theseethnicgroupdifferenceswere identifiedindrinkersattheno/low levelofheavydrinking,whereasalcohol problemsweresimilarforallgroups atthehighestheavy­drinkinglevel. Furthermore,researchcontinuesto showdifferenttrajectoriesofalcohol problemdevelopmentacrossethnic groups.Particularly,Blacksrelativeto Hispanicsandotherethnicgroups showalowerlevelofalcohol­related problemsduringadolescenceandin

theirmid­twentiesbutahigherlevel bytheirmid­thirties(Muthenand Muthen2000;Wagneretal.2002).

Social

Consequences

Drivingundertheinfluence(DUI)is animportantalcohol­relatedproblem, whichalsoisassociatedwithethnicity. Amongethnicgroups,WhitesandNative Americanshavethehighestratesof DUIinnationalsurveys.Basedonadult datafromthe2007NSDUH,15.6 percentofWhitesand13.3percent ofNativeAmericansreportpast­year DUI,whereasrelativelylowerrates arereportedbyBlacks(10.0percent), Hispanics(9.3percent),andAsians (7.0percent)(SAMHSA2008b).DUI estimatesusingthe1991–1992NLAES and2001–2002NESARCwerealso higherforWhites(6.4to5.0percent) andNativeAmericans(4.2to5.9 percent),despiteoverallreductions inDUIforWhitesduringthistime period(Chouetal.2005).Past­year DUIalsodeclinedforHispanicmen from5.4to3.5percent,butHispanic youngwomenages18–29yearsemerged asanewriskgroupforDUI(0.6to2.0 percent).AmongHispanicnational groups,Caetanoetal.(2008b)reported thehighestratesoflifetimeDUIfor Mexican­American(21.0percent)and South/Central­American(19.9percent) menandMexican­Americanwomen (9.7percent).Asasidenote,itis importanttobecautiouswhencom­ paringtheseratesacrossstudies,asthey arederivedfromdifferentmeasuresof DUI(i.e.,everdrivingundertheinflu­ enceofalcohol[NSDUH];driving afterhavingtoomuchtodrinkmore thanonce[NESARC];drivingafter drinkingenoughthatyouwouldbein troubleifstoppedbypolice[Hispanic nationalgroupsstudy]).

Additionalresearchshowsthatethnic groupsaredifferentiallyaffectedby alcohol­attributedviolence,including intimatepartnerviolence(IPV). Generalratesofmale­to­femaleand female­to­malepartnerviolenceare highestamongBlackcouples(23and 30percent),followedbyHispanic (17to21percent)andWhite(12

and16percent)couples(Caetano etal.2000).Schaferetal.(2004) reportedstrongereffectsforalcohol problemsinpredictingIPVforBlack couplescomparedwithHispanicand Whitecouples.Alcoholappearsto playanimportantroleinIPV, althoughitisdifficulttoestablisha directcausallink.Caetanoetal.(2001) reportedthat30to40percentof menand27to34percentofwomen whoperpetrateIPVaredrinkingat thetimeoftheevent.Alcoholalso contributestoviolencevictimization amongAmericanIndians(Yuanetal. 2006).Severalstudiesindicatethat NativeAmericansareatgreaterrisk foralcohol­relatedtrauma(e.g.,IPV, rape,andassault)comparedwith otherU.S.ethnicgroups(Oetzel andDuran2004;WahabandOlson 2004).Conversely,IPVamongAsian AmericansrelativetotheU.S.popu­ lationislow(Changetal.2009).

Medical

consequences

Bothmorbidityandmortalityareareas ofdisparityacrossethnicgroups.Liver cirrhosisisonealcohol­attributeddis­ easethathasmoresevereconsequences forsomeethnicgroups.Hispanicsand Blackshavegreaterriskfordeveloping liverdiseasecomparedwithWhites (Floresetal.2008),andHispanicmen havethehighestrateoflivercirrhosis mortality(Stinsonetal.2001;Yoon andYi2008).Additionally,ratesof alcohol­relatedesophagealcancerand pancreaticdiseasearehigherforBlack menthanWhitemen(Polednak2007; Yangetal.2008),whereasfetalalcohol syndromeandfetalalcoholspectrum disordersaremoreprevalentinBlacks andNativeAmericans(Russoetal. 2004).From2001to2005,alcohol­ attributeddeathsaccountedfor11.7 percentofallNativeAmericandeaths, morethantwicetheratesofthegeneral U.S.population(CDC2008).

Likewise,NativeAmericansareover­ representedinnationalestimatesof alcohol­relatedmotorvehicledeaths andalcohol­involvedsuicides(CDC 2009a, b).Furthermore,alcoholcon­ sumptionmaybemoredetrimentalat

intermsofmortality.Semposetal. (2003)foundnoprotectivehealth effectformoderatedrinkinginBlacks, aspreviouslyreportedinWhites.

Alcohol

Treatment

Utilization

Thehigherlevelofriskydrinkingfor NativeAmericansandHispanicmen andtheincreasedoccurrenceofalcohol consequencesforNativeAmericans, Hispanics,andBlacksmayindicatea greaterneedforalcoholtreatmentin thesepopulations.Notsurprisingly, NativeAmericanshavethehighest prevalenceofalcoholtreatmentneed (i.e.,classifiedbymeetingoneofthree criteriainthepastyear,including alcoholdependence,alcoholabuse,or receivingspecialtyalcoholtreatment; 12.2percent),basedondataforadults fromthe2007NSDUH(SAMHSA 2008a),withlowerratesforWhites (8.4percent),Blacks(7.6percent), Hispanics(7.4percent),andAsians (4.5percent).ForNativeAmerican men,Bealsetal.(2005)reportedmore helpseekingfromspecialtyalcoholor drugtreatmentprovidersrelativeto theU.S.population,buttherewereno differencesforwomen.Comparatively, AlaskaNativesreportlessuseofpsychi­ atrists,medicaldoctors,andpsycholo­ gistsforalcoholproblemsthanWhites, Blacks,andHispanics(Hesselbrocket al.2003).However,thedifferencesin alcoholservicesforAlaskaNativesmay representaloweravailabilityofsome professionalsinAlaska.

Additionally,datafromthe2007 NSDUH(SAMHSA2008a)suggest agreaterunmetneedforalcohol treatmentforsomeethnicgroups. Asians(0.1percent)andHispanics (5.5percent)withaneedforalcohol treatmentwerelesslikelytoreceive specialtyalcoholtreatment(i.e.,alcohol anddrugrehabilitationprogram, hospitalormentalhealthcenter) comparedwithWhites(8.0percent) andBlacks(14.0percent).Schmidt etal.(2007)alsoreportedlessspecialty alcoholordrugprogramusefor

physicianforalcoholproblemsandto attendAlcoholicsAnonymous(AA). Further,andmorealarming,Blacks andHispanicswithhigherseverity alcoholproblemswerelesslikelyto useanytreatmentservicescompared withWhiteswhohavesimilarseverity ofalcoholproblems.Utilizationrates foralcoholtreatmentmayreflect underlyingethnicgroupdifferences intheeconomicandlogisticresources thataffecttreatmentuse.Zemoreet al.(2009)showedgreaterbarriersto treatmentuseforSpanish­speaking (versusEnglish­speaking)Hispanics. Schmidtetal.(2007)identified concernsaboutpayingfor,finding services,andobtainingchildcareas barriersforHispanicsinobtaining treatment.Differentratesofhealth insurancecoverageacrossethnicgroups mayserveasabarriertoutilization forsometreatmentservices(e.g., careprovidedbyaprivatephysician). However,governmentfundingfor alcoholtreatmentprogramsalsomay lessentheaffectofinsurancecoverage onethnicgroupdifferencesintreatment utilization.Weisneretal.(2002) showedthatBlacksweremorelikely thanWhitestobeinaspecialtyalcohol treatmentprogramregardlessof insurancestatus,whereasHispanics withhealthinsurancewerelesslikely toenteratreatmentprogram.

Lowerratesoftreatmentcompletion forBlacksandHispanicsthanWhites pointtoanotherpossibledisparityin alcoholtreatment(Bluthenthaletal. 2007).However,thosethatcomplete treatmentappeartobenefitequally regardlessoftheirethnicgroup (BrowerandCarey2003;Tonigan 2003).Evenso,differenttreatment modalitiesandprovidercharacteristics maybemorebeneficialthanothers foreachethnicgroup.Arroyoetal. (2003)reportedthatWhitesin12­ stepfacilitation(TSF)therapyhad betterdrinkingoutcomesthandid Whitesinothertypesoftreatmentor HispanicsinTSFtherapy.Hispanics showlessAAattendancebothduring andaftertreatment(Arroyoetal. 1998;Toniganetal.2002),aswellas

betweenpatientandprovider(Field andCaetano2010).Basedonprelim­ inarydata,AmericanIndiansalso reportbetterdrinkingoutcomesin motivationalenhancementtherapy comparedwithothertreatments (Villanuevaetal.2007).Together, theseandotherstudiessuggestthat culturallytailoredalcoholtreatment programsarelikelysolutionsfor addressingdisparitiesinalcoholtreat­ mentforethnicminoritygroups (Schmidtetal.2006).

Predicting

Ethnic

Disparities

in

Alcohol

Studieshavesoughttoexplainthe differencesinalcoholconsequences amongethnicgroups.Oneexplanation isthehigherratesofriskydrinking forsomeminorityethnicgroups(e.g., HispanicsandNativeAmericans). However,otherstudiesfindthatethnic differencesindrinkingalonedonot fullyexplainalcohol­relateddisparities (Herd1994;Jones­Webbetal.1997; Muliaetal.2009),requiringtheexam­ inationofotherpossiblefactors.

Social

and

Cultural

Factors

Ethnicdisparitiesinalcoholproblems maybeexplainedbysocialandcultural factors.Currentresearchhas,forexample, focusedontheinfluenceofaccultura­ tion,socialandeconomicdisadvantage, andalcoholavailabilityinpredicting alcoholproblems.Asaproxyforaccul­ turation,beingbornintheU.S.has beenidentifiedasariskfactorforalcohol dependenceinHispanics,particularly whencomparingforeignandU.S.­ bornMexicanAmericans(Alegriaetal. 2008;Caetanoetal.2009a).Among Hispanics,higheracculturationisasso­ ciatedwithagreaterriskforalcohol abuse(Caetanoetal.2009a),aswell asheavyepisodicdrinkingforwomen (Caetanoetal.2008c).Inaddition, socialdisadvantage,asdefinedby racial/ethnicstigma,maycontributeto

DisparitiesinAlcoholResearch

ethnicdisparitiesinalcoholproblems forHispanicsandBlacks(Muliaetal. 2008,2009).InAsianAmericans,Chae etal.(2008)reportedgreaterriskfor alcoholdependenceforindividuals reportingexperiencesofunfairtreatment andforindividualswithlowethnic identificationwhoexperienceracial/ ethnicdiscrimination.

Further,forBlacks,aneffectfor economicdisadvantageonalcohol disparitieshasbeenreported.Building onearlierresearch(Jones­Webbetal. 1995,1997),Jacobsonetal.(2007a,

b)showedthatbothindividual­ and neighborhood­leveleconomicdisad­ vantagepredictedaloweralcohol treatmentcompletionforBlacks. Aswell,Cunradietal.(2000)identi­ fiedresidenceinanimpoverished neighborhoodasariskfactorfor male­to­femalepartnerviolenceand female­to­malepartnerviolence amongBlackcouples.Otherneigh­ borhood­levelfactorsalsomaycon­ tributetoalcohol­relateddisparities amongethnicgroups(e.g.,alcohol availability).Inurbanareasinthe UnitedStates,ethnicminoritygroups experienceahigherdensityofalcohol outletscomparedwithWhites(Alaniz 1998;Romleyetal.2007),and greateralcoholoutletdensityhas beenshowntopredictincreasedrates ofalcohol­relatedviolenceandmor­ bidity,includingIPV,violentassaults, sexuallytransmittedinfections,and liverproblems(Gruenewaldetal. 2006;McKinneyetal.2009;Theall etal.2009).Conversely,restricted alcoholavailabilityasenforcedby alcoholprohibitionandpolicein AlaskaNativevillagesisassociatedwith lowerratesofassaultandotherinjuries (WoodandGruenewald2006).

Biological

Factors

Biologicalexplanationsalsohavebeen researched,includingtheeffectof alcohol­metabolizinggenesondrinking behaviorsandthehealtheffectsof alcoholconsumption(Zakhari2006). Mostoftencitedistheprotectiveeffect oftheALDH2*2alleleforalcohol dependenceinAsians,whichisassoci­

atedwithfacialflushingandotheraver­ sivesymptomstoalcohol.However, otherpopulationsalsohavebeenexam­ inedfortherelationshipofalcohol­ metabolizinggenestoalcoholuseand dependence.InMexicanAmericans, forexample,theADH1C*2,ADH1B*1, andCYP2E1c2allelesareassociated withanincreasedriskforalcohol dependence(Konishietal.2003,2004), whereasinBlacksandSouthwestIndians theADH1B*3alleleisprotective againstalcoholismandalcohol­related birthdefects(Ehlers2007;Scottand Taylor2007).TheADH1B*1and ADH1C*2allelesinAsiansandthe ADH1B*1inWhitesalsopredict alcoholism(Zintzarasetal.2006).

Conclusions

Ithasbeennearly10yearssinceNIAAA’s “calltoarms”toaddressalcohol­related healthdisparities(Russoetal.2004). Recentadvancesinalcoholresearch continuetobuildourunderstanding ofalcoholconsumptionandproblems amongU.S.ethnicgroups.Native Americans,Hispanics,andBlacks remaindisproportionallyimpactedby drinkingcomparedwithotherethnic groups.However,studiesthathighlight within­ethnicgroupdifferencesandthe social,cultural,andbiologicalfactors associatedwithalcohol­relateddisparities helpustounderstandmoreprecisely whoisatrisk.Despitethisprogress, thecurrentpictureforethnicgroups, relatedtoalcoholconsumption,disorders, andrelatedconsequencesisstillfrag­ mented.Thereisnooneplacetolook foracompleteaccountofalcohol researchonallethnicgroupsinspite ofnewlargesurveysconductedby Federalinstitutionsandacademic investigators,andcomparisonsbetween existingstudiesaremadedifficultby theuseofdifferentsurveymethods (e.g.,measuresandstudysamples). Moreresearchexaminingsubpopula­ tionswithineachethnicgroupalsois needed.Thereshouldbesomecaution ininterpretingbetween­ethnic­group differencesinalcoholuseandrelated behaviorsuntilwithin­groupdifferences aremorethoroughlyinvestigated.

Currentresearchindicatesthatovergen­ eralizationsaboutAsiansdrinkingless thanotherethnicgroupsmaynotapply toPacificIslanders,andriskydrinking forHispanicmenandNativeAmericans maybelessapplicabletoCuban­ AmericanmenandSouthwestIndians.

Largenationalsurveysalsoprovide limiteddataforexaminingexplanatory factorsforalcoholdisparitiesmuch beyondsocialdemographicvariables, oftenlimitingthisresearchtosmaller lessrepresentativesamples.Both drinkingandthedevelopmentof alcohol­relatedproblemsarecomplex eventswithmultiplecauses.U.S.ethnic minorities,therefore,havetocontend withahostoffactorswiththepotential tohaveadverseeffectsonthesebehav­ iors.Immigrantgroupsmustgo throughaprocessofacculturationto U.S.societythatcanleadtoincreased personalstressandtensionwithin families.TogetherwithBlacksand NativeAmericans,thesegroupsalso canfacesocioeconomicdisadvantage andpotentialracial/ethnicdiscrimina­ tion.Thesetwolatterfactorsinturn oftenareassociatedwith,forexample, poorjobopportunities,residential segregation,lifeinunsafeneighbor­ hoods,overexposuretoalcoholadver­ tising,policeprofilingandbrutality, andlackofaccesstoadequatehealth care.Tofacethechallengesassociated withreducingandultimatelyelimi­ natinghealthdisparitiesinthealcohol field,researchmustmaintainasys­ tematic,strong,andgrowingfocuson ethnicminorities.Amorecomplete understandingoftheseeffectsforethnic minoritygroupsisneededtoenable researcherstodevelopbetterand moretargetedstrategiesforpreventing andtreatingalcoholdisordersand relatedconsequences. ■

Financial

Disclosure

Theauthorsdeclarethattheyhaveno competingfinancialinterest.

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