A PROFILE OF ALCOHOLICS ANONYMOUS No one knows exactly when Alcoholics Anonymous (A.

A) began, but it is believed that the organization was formed around 1935 in Akron, Ohio. The first meetings were attended by a few acquaintances who discovered that they could remain sober by attending services of a local religious group and sharing with other alcoholics their problems and efforts to remain sober. By 1936, weekly A.A. meetings were taking place around the country. Who participates in A.A? currently, its membership is estimated to be well over 5 million individuals worldwide. The sole requirement for participation in A.A is a desire to stop drinking. Originally the organization attracted hardened drinkers who turned to it as a last resort; more recently, however, it has attracted many people who are experiencing drinking problems but whose lives are otherwise intact. Members come from all walks of life, including all socioeconomic levels, races, cultures, sexual preferences, and ages. The philosophy of Alcoholics Anonymous is a commitment to the concept of self-help. Members believe that the person who is best able to reach an alcoholic is a recovered alcoholic. In addition, members are encouraged to immerse themselves in the culture of A.A. to attend 90 meetings in 90 days. At these meetings, A.A members speak about the drinking experiences that prompted them to seek out A.A and what sobriety has meant to them. Time is set aside for prospective members to talk informally with longtime members, so that they may learn and imitate the coping techniques recovered alcoholics have used. Some meetings include only regular A.A members and cover issues of problem drinking. A.A has a firm policy regarding alcohol consumption. It maintains that alcoholism is a disease that can be managed but never cured. Recovery means that an individual must acknowledge that he or she has a disease, that it is incurable, and that alcohol can play no part in future life. Recovery depends completely upon staying sober. Is Alcoholics Anonymous successful in getting people to stop drinking? A.As dropout rate is unknown, and success over the long term has not been carefully chronicled. Moreover, because the organization keeps no membership lists (it is anonymous), it is difficult to evaluate its success. However, A.A it self maintains that two out of three individuals who wish to stop drinking have been able to do so through its program, and one authorized study reported a 75% success rate for the New York A.A chapter. Researchers attempting to understand the effectiveness of A.A programs have pointed to several important elements. A.A is like a conversion experience in which an individual adopts a totally new way of life; such experiences can be powerful in bringing about behavior change. Also, a member who shares his or her experiences comes, through the sharing process, to develop a commitment to other members. The process of giving up alcohol contributes to a sense of emotional maturity and responsibility, forcing the alcoholic to accept responsibility for his or her life. A.A may also provide a sense of meaning and purpose in the individuals life-most chapters have a strong spiritual or religious bent and urge members to commit themselves to a power greater than themselves. The group can also provide affection and satisfying personal relationships and thus help people overcome the isolation that many alcoholics experience. Too, the members provide social reinforcement for each others abstinence. A.A is significant as an organization for several reasons. First, it was one of the earliest self-help programs for individuals suffering from a health problem therefore, it has provided a model for selfhelp organizations whose members have other addictive problems, such as Overeaters Anonymous and Gamblers Anonymous, among many others. Second, in having successfully treated alcoholics for decades, A.A demonstrated that the problem of alcoholism was not as intractable as had been widely assumed.

Moderate drinking (W.R. Miller, 1980; Larimer & Marlatt, 1990). Drinking in moderation has some particular advantages for the problem drinker (Pomerleau, Pertschuk, Adkins, & Brady, 1978). First, moderate drinking represents a more realistic social behavior for the environments that a recovered problem drinker may encounter. Second, traditional therapeutic programs that emphasize total abstinence often have high dropout rates. Programs for problem drinkers that emphasize moderation may be better able to hold on to these participants. One example of a successful approach to controlled drinking was developed by W.R Miller, Taylor, and West (1980). Their program, called Behavioral Self-Control Training (BSCT), focused directly on drinking behavior. It included setting specific goals for the amount of alcohol consumption, selfmonitoring alcohol consumption, training in controlling the rate of alcohol ingestion, selfreinforcement for controlled drinking, functional analysis of drinking behavior, and instructions in alternatives to alcohol abuse. In one study (W.R Miller et al., 1980), BSCT was evaluated against bibliotherapy, in which participants read self-help materials in an effort to control their drinking; the BSCT intervention plus 12 sessions of relaxation, communication, and assertiveness training; and BSCT plus 12 weekly sessions of individually tailored broad-spectrum approaches to problem drinking. Bibliotherapy participants showed more drinking problems than participants in the other three conditions; the other three groups were equivalent in success. The success of BSCT is significant for two reasons. First, it demonstrates that programs of controlled drinking can be successful with at least some problem drinkers. Second, it suggests that these programs neet not be as complex, intensive, and expensive as the typical multimodal, or broadspectrum, approach to alcohol abuse. The more focused treatment produced equivalent succes rates to the multimodal approach and did so in a shorter period of time with less expense. Ultimately, then, these focused approaches to problem drinking may be as successful as the more involved multimodal and broad-spectrum approaches (W. R. Miller et al., 1980).

Drinking and Driving A final alcohol-related problem we will consider concerns vehicular fatalities that result from drunken driving. this aspect of alcohol consumption is probably the one that most mobilizes the general public against alcohol abuse. programs such as MADD (mothers against drunk driving) and SADD (Siblings against drunk driving) have been founded and staffed by the parents, brothers, and sisters of children and adults killed by drunk drivers. Increasingly, the political impact of these and related groups is being felt, as they pressure state and local governments for tougher alcohol control measures and stiffer penalties for convicted drunk drivers. moreover, interpersonal pressure is mounting for hosts and hostesses to assume responsibility for the alcohol consumption of their guests and for friends to intervene when they recognize that their friends are too drunk to drive. but this can be a difficult task for a peer to unertake. how do you know when to tell a friend that he or she is too drunk to drive and to intervene so that the drunk individual will not drive? knowing the driver well, perceiving that he or she really needs help, feeling able to intervene, and having had conversations in the past that encouraged intervention all enhance the likelihood that an individual will intervene in a particular situation when a peer is drunk (Newcomb, Rabow, Monto & Hernandez, 1991). But the norms to control others drinking, though growing stronger, still fly in the face of beliefs in individual liberty and personal responsibility. Consequently, many drunk drivers remain on the road.

When drunken drivers are arrested and brought to court, they are typically referred out to drinking programs not unlike those we have just discussed. How successful are these referral programs? A review (F. L. McGuire, 1982) examining these program suggested that ligt drinkers did well in most of them. Unfortunately, heavy drinkers typically did very poorly. As yet, it seems there is no good rehabilitation program for the heavy-drinking driver. Drinking: A Postscript Despite the fact that problem drinking and alcoholism remain major health risks and contribute to overall mortality, modest alcohol intake may actually add to a long life. several studies indicate a relation between moderate alcohol intake (approximately one to two drinks a day) and reduced risk from coronary artery disease. the benefits for woman may occur at even lower levels of alcohol intake (weidner et al., 1991). altough we do not yet know all the reasons why this surprising relationship holds, it appears that alcohol somewhat elevates high-density lipoprotein cholesterol (HDLC), which is involved in removing cholesterol from the tissues and transporting it to the liver for metabolic disposition. in so doing, risk for coronary heart disease (CHD) and cardiovascular mortality may be reduced. while many health care practitioners fall short of recommending that people have a drink or two each day, the evidence is mounting that not only may this level of modest drinking not harm health, but it may actually reduce ones risk for some major causes of death. SMOKING Smoking is the greatest single cause of preventable death and may also be the chief cause of death when all causes are considered (M. McGinnis, et al., 1992). in the united states, it accounts for at least 125,000 deaths from cancer annually- about 30% of all cancer deaths (American Cancer Society, 1989)and another 170.000 deaths from cardiovascular disease (Oncology Times, 1984). in addition to the obvious risks of heart disease and lung cancer, smoking increases the risk of chronic bronchitis, emphysema, peptic ulcers, respiratory disorders, damage and injuries due to fires and accidents, lower birth weight in offspring, and retarded fetal development (Centers for Disease Control, 1989). Cigarette smokers also appear to be less health-conscious more generally and are more likely to engage in other unhealthy behaviors than nonsmokers, including alcohol and coffe consumption (Carmody, Brischetto, Matarazzo, ODonnel, & Connor, 1985; Castro, Newcomb, McCreary, & Baezconde-Garbanati, 1989; istvan Mtarazzo, 1984). An additional concern is that smoking appears to serve as an entrylevel drug for subsequent substance use and abuse. Trying cigarettes makes one significantly more likely to use other drugs in the future (R. Fleming, Leventhal, Glynn, & Ershler, 1989; see also Hanson, Henggeler, & Burghen, 1987). the dangers of smoking are not confined to the smoker. Studies of second-hand smoke encountered by those in regular close contact with smokers demonstrate that spouses, family members of smokers, and co-workers are at risk for a variety of health disorders (E. Marshall, 1986). More recently, research has accumulated to suggest that parental cigarette smoking may actually lower cognitive performance among adolescents (e.g., Bauman, Koch, & Fisher, 1989; Bauman, Flewelling, & LaPrelle, 1991). The likely mechanism whereby this occurs is that carboxyhemoglobin is increasing carbon monoxide levels, which adversely influence mental performance (Bauman, Koch, & Fisher, 1989). Synergistic Effects of Smoking Evidence is beginning to suggest that smoking has a synergistic effect on other health related risk factors, that is, it enhances the impact of other risk factors in compromising health (Dembroski &

MacDougal, 1986; Pomerleau & pomerleau, 1988). For example, perkins (1985) found that smoking and serum cholesterol interact to produce higher rates of morbidity and mortality than would be axpected from simply adding together the risk of smoking and high cholesterol. Since nicotine stimulates the release of free fatty acids, it may increase the synthesis of triglycerides, which, in turn, decreases high-density lipoprotein (HDL) production (the so-called good cholesterol). Carbon monoxide from cigarettes also inhibits low-density lipoproteins (LDL), possibly by altering HDL levels. The blood of smokers also coagulates more easily than that of nonsmokers (Pomerleau & Pomerleau, 1989). These points imply that efforts to reduce smoking and modify diet should be focused especially on the more than 25 million young and have elevated serum cholesterol. Stress and smoking can also interact to produce a cardiac crisis in people already compromised by adverse changes in the heart tissue. Dembroski and his colleagues (Dembroski, MacDougall, Cardozo, & Krug Fite, 1985) found that men who smoked a cigarette and then engaged in a mildly stressful event had increases in heart rate and blood pressure that were about equal to the sum of the effect produced by either smoking or stress alone (see also MacDougall, Musante, Castillo, & Acevedo, 1988; Perkins, Epstein, Jennings, & stiller, 1986; Pomerleau & Pomerleau, 1988). However, in women, the combination of stress and cigarette smoking produced blood pressure and heart rate responses that were larger than the effect of smoking and stress added together (Dembroski, MacDougall, Cardozo et al., 1985; but see MacDougall et al., 1988). Nicotine produces a variety of stimulating effect on the cardiovascular system. Although these changes may be tolerated in people who do not have cardiovascular damage, they may provoke a cardiac crisis in those who do. Sudden death in smokers, for example, may result from deficient blood flow due to constrited or obstructed blood vessels (ischemia) combined with arrhythmias in the hearts action produced by increased circulating catecholamines (Benowitz, 1988). Nicotine can also induce spasms in the coronary arteries (vasospasm) of people with atherosclerotic disease (see Pomerleau & Pomerleau, 1989, for a review). Possibly,smoking and other risk factors for CHD are related to each other. one study (MacDougall, Musante, Howard, Hanes & Dembroski, 1986) found large stable individual differences in cardiovascular reactivity to both stress and smoking that were modestly correlated with each other. These results suggest the possibility that one or more common variables may explain blood pressure reactivity to both stress and cigarette smoking. Manuck & Krantz (1986) suggested that physiological hyperresponsivity to behavioral stimuli may contribute to the etiology of CHD. Responsivity to stressful events may, in turn, increas the propensity to smoke. Whether clinically significant and sustained irregularities in cardiovascular function and lipid activity occur a result of stress and smoking, and whether or not such reactions may be exaggerated in at-risk individuals, remains to be seen. However, the evidence to date is consisten with such hypotheses. Another set potential synergistic factors concerns the relation of Type A behavior and smoking. We cover Type A behavior more fully in Chapter 14. To describe it briefly, Type A behavior refers to a personal style of coping with stress that is a risk factor for cardiovascular disease. It is characterized by easily aroused hostility, a sense of time urgency , and competitive achievement striving. Type B individuals are less driven individuals who do not show these behavior patterns. Although Type A and Type B smokers do not appear to differ in the number of puffs taken or puffs taken or puff volume, Type A smokers inhalation duration is longer than Type Bs. As a result, their alveolar carbon monoxide level is higher. Thus, this difference in consummatory behavior of Type As may help explain the relation between Type A behavior and CHD for smokers. Type A smokers may actually be at greater risk for cancer and lung disease than Type B smokers by virtue of their smoking patterns (Lombardo & carreno, 1987). Interestingly, in one study, in which somokers either smoked or did not smoke before being measured on Type A behaviors, those who smoked showed significantly higher

levels of behaviors traditionally associated with Thype A behavior, such as speaking loudly and in an explosive and rapid fashion, than did sham smokers (those who smoked nicotine-free cigarettes) or people who did not smoke. the results imply the possibility that in chronic smokers, Type A behavior is exacerbated (Dembroski & MacDougall, 1986). weight and smoking may also interact to increase mortality. Specifically, Sidney, Friedman, and siegalaub (1987) found that thin cigarette smokers were at increased risk of mortality compared with averageweight smokers. Thinness was not associated with increased mortality in those who had never smoked or among ex-smokers. The reasons for this relationship are at present unclear. Smoking also appears to interact with exercise. In particula, smokers engage in less physical activity as long as they continue smoking , but when they quit, they activity level appears to increase (Parkins, Rohay, Meilahn, Wing, Matthews, & Kuller, 1993). Whether smoking is simply another factor that contributer additively to the risk for cariovascular disease or whether it operates synergistically with other factors enhancing risk over what would be expected from either risk factor alone remains unclear. Evidence suggest both types of effects at present. What remains evident is that smoking is a substantial risk factor, which may, in turn, increase the risks associated with other risk factors (e.g., Dembroski & MacDougall, 1986). Can these problems be reversed? A number of interventions have now demonstrated that when middle-aged men are induced to quid smoking, their risk for CHD is substantially lowered (e.g., Hjermann et al., 1981; Kornitzer et al., 1983; Puska et al.,1979; G.Rose et al., 1983; Salonen, Puska, & Mustaniemi, 1979; World Health Organization European Collective Group, 1982). In addition, the risk of lung cancer is also reduced by stopping smoking. Despite these statistics, 55 million Americans continue to smoke (American Cancer Society, 1989). A Brief History Of The Smoking Problem For years, smoking was considered to be a sophisticated and manly habit. Characterizatios of eighteenth- and nineteenth-century gentry, for example, often depictedmen retiring to the drawing room after dinner of cigars and brandy. Cigarette advertisements of the early twentieth century built on this image and, by 1955, 53% of the adult male population in the United States was smoking. Women did not begin to smoke in large numbers until the 1940s. However, once smoking became an acceptable habit for woman, advertisers began to bill cigarette smoking as a symbol of feminine sophistication as well (Blitzer, Rimm, & Geifer, 1977). In 1964, the first Surgeon Generals report on smoking came out (U.S. Departement of Health, Education, and Welfare and U.S Public Health Service, 1964), accompanied by an extensive publicity campaign to highlight the dangers of smoking. Although male smoking subsequently declined (to 39% by 1975), womans smoking actually increased during the same period, from 25% in 1955 to 29% by 1979. More frightening still, the percentage of teenage female smokers increased to 20,5% as of 1986, a figure that exceeds 16,0% for teenage boys (Cancer Information Service of California, 1989). Despite dawning awareness of the threat of smoking, then, smoking continued to be a formidable problem. Moreover, counterarguments to the smoking threat, many fueled by the tobacco industry, were plentiful. Rumors persisted that the data linking smoking to cancer were based on studies of rats who smoked excessively in laboratories, and people familiar with the smoking data pointed out that the correlations between smoking and lung cancer were small and statistically