1 Center for Substance Abuse Prevention/International Center for Alcohol Policies Joint Working Group on Terminology Working Papers Table of Contents Preface Foreword Introduction What Do Others Hear When We Speak About Alcohol? Is Alcohol A Drug? And Why Does It Matter? Afterword Annex 1. List of Participants Annex 2. The Dublin Principles for Ethical Cooperation Appendix Preface Alcohol abuse is a major substance abuse problem in America. It will take a concerted effort by all Americans to prevent or reduce the human, economic, and social costs associated with alcohol consumption at the wrong times, in the wrong places, and in the wrong ways. A decade of research and data from real people in real communities has shown us at the Center for Substance Abuse Prevention (CSAP) just how valuable and synergistic partnerships can be. When people with common goals come together to solve problems, encouraging things happen. It is not difficult for like-minded people to come together and agree on strategies to address the substance abuse problems they see in their communities. CSAP has funded hundreds of partnerships to do just that. An area of special challenge and importance is forming non-traditional partnerships. The papers contained in this publication reflect the work of what might be considered a non-traditional partnership. This partnership included members of different parts of the alcohol industry and members of national, state and local substance abuse prevention organizations. The CSAP/ICAP Working Group is to be applauded not so much for the products it has created but for the process by which it came together. Over two years, the participants slowly, patiently, and respectfully shared their perspectives until they found enough common ground to commit their ideas to paper. Do not see the discussions and term descriptions here as authoritative definitions or official policy statements. See them instead as the product of a useful process that may bring new people and ideas and resources into the "prevention circle."
2 You can find non-traditional partners in your community whose styles or language may be different from your own, but who want to do something about an array of preventable problems faced by nearly every community. Invite them in. Listen to them. Explore the language or other barriers that may contribute to misunderstandings. There is room for everyone to help reduce substance abuse in America. Karol Kumpfer, Ph.D. Director, Center for Substance Abuse Prevention Foreword Beverage alcohol has been an integral part of human society throughout recorded history. Today, the majority of adults in the world have consumed alcohol in one form or another some regularly, some quite infrequently. Generally, people choose to drink because they believe that the experience will be pleasurable. And for most people, most of the time, that is exactly what happens. Unfortunately, however, that is not the whole story. People who drink too much, or who drink recklessly, run the risk of experiencing a wide range of serious health and social consequences. All three sectors of the beverage alcohol industry beer, wine, and distilled spirits have consistently and publicly been involved in efforts to combat alcohol misuse and have sought to encourage moderation in drinking patterns. In their efforts to promote responsible drinking, members of the industry have increasingly worked with governments, scientists, and public health advocates. The International Center on Alcohol Policies (ICAP) was set up by a small group of major international companies to find ways of forging active partnerships between the beverage alcohol industry and the public health community. That is why the CSAP/ICAP Working Group is such an important initiative. Not only did a productive working partnership emerge as these papers certainly demonstrate but the experience was sufficiently positive to encourage others to explore whether similar opportunities exist in other countries and other communities. A process such as this requires a willingness to discard our prejudices and to re-examine the basis for some of our most deeply-held views. What emerged from the CSAP/ICAP experience was not some insubstantial and hollow accord, but a recognition that all those with an interest in alcohol policy governments, educators, scientists, physicians, public health specialists, communities, and the beverage industry all have a legitimate place at the table, and all deserve to be treated with respect. Of course, there will still be differences of opinion. But they will be recognized on their merits, rather than as the products of ignorance, antagonism, or wilful misunderstanding. In such a spirit of cooperation, the alcohol policies of the 21 st century should be more likely to succeed, because they can be cast in a common language. Adrian Botha Chairman, ICAP Board of Directors
3 Introduction Origins, Goals and Methods of the Working Group The Center for Substance Abuse Prevention (CSAP) is an agency of the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services. The International Center for Alcohol Policies (ICAP) is a non-profit organization supported by ten major international beverage alcohol companies. Both organizations are committed to promoting more effective prevention and education policies and programs to reduce alcohol abuse, as well as to increasing understanding of the role of alcohol in society. In January 1995, Marcus Grant (President of ICAP) met with Elaine Johnson (then Director of CSAP) to exchange views on the need for improved dialogue between the beverage alcohol industry and the public health community. It became clear that a broader exchange of views on some key terms could lead to increased understanding of the ways in which these terms are used by different groups, both in the United States and internationally. It was therefore agreed to explore the feasibility of setting up the Joint Working Group on Terminology. Discussions between CSAP and ICAP continued during Finally, terms of reference for the working group were proposed, namely: to review current terminology used by public health advocates and others in relation to alcohol abuse; to identify key concepts so as to achieve a better understanding of different definitions; to explore opportunities for promoting greater consensus on terminology, taking into account international and cross-cultural dimensions. It was agreed that the group would consist of an equal number of persons nominated by CSAP and by ICAP. The group members would serve in their individual capacities and meetings would be chaired alternately by a CSAP and an ICAP nominee. In view of the possible international implications of the work of the group, the World Health Organization (WHO) requested observer status through the office of the Director of the Division on Mental Health and Prevention of Substance Abuse (MSA) at its Geneva headquarters. A list of the members of the group is attached as Annex 1. Robert W. Denniston (CSAP) and Marcus Grant (ICAP) acted as co-secretaries to the group (assisted by relevant technical staff from their respective organizations) and took it in turns to convene meetings. Minutes of meetings were produced jointly. In establishing the Joint Working Group, great care was taken from the start to ensure that there was reciprocity between the organizations, so that neither could disproportionately influence, or be perceived to have influenced, the activities or products of the group. These precautions may have helped to foster the atmosphere of collegiality which emerged in the work of the group and which has characterized discussions throughout the process. Overview of Activities and Products of the Group The Joint Working Group met three times in 1996 and four times in An early focus of the group's efforts was the development of a list of vocabulary relevant to alcohol issues, and which could serve as a basis for future discussions within the group and more broadly. The development of this check-list helped to highlight that there were at least two rather distinct tasks on which the group might be able to work effectively.
4 The first task was somewhat controversial. There are words and expressions that are used both by some in public health and by some from the beverage alcohol industry to advocate specific agendas. These words do not necessarily lack conceptual clarity; rather, they are chosen deliberately to frame a particular perspective, often through the use of strongly emotional language. The group recognized that this practice is likely to continue, but felt that it might be helpful to draw attention to these words and expressions by highlighting the controversies that they embody. The words identified by the group and a short summary of the controversy surrounding each of them are reflected in the first paper, entitled What Do Others Hear When We Speak About Alcohol? A Guide to Some of the Words, Phrases, and Slogans Most Likely To Engender Controversy, Offense, and Misunderstanding. The second task which the group set for itself was to respond to the need for greater conceptual clarity with respect to all, or virtually all, of the terms included in the check-list. Since this task was clearly beyond the scope of the group (unless it was to go on meeting far into the next century), it was agreed to choose just several of the terms as examples for which it might be possible to achieve the enhanced conceptual clarity which the group felt to be lacking. Short papers were therefore developed on each of these topics. Working between meetings of the group, smaller sub-groups (each including both CSAP and ICAP nominees) prepared drafts, which were then reviewed by the group as a whole. There can be little doubt that the process of producing these papers was at least as valuable as the papers themselves. Group members not only learned to appreciate differing points of view, but also to recognize how the area of overlap between contrasting perspectives was much greater than any might have expected at the outset and how the way that language is used can often exaggerate relatively minor shades of emphasis. This is not to say that the group sought or achieved a superficial or illusory consensus. Group members agreed on many issues, but also agreed on where to disagree. The working paper entitled Is Alcohol A Drug? And Why Does It Matter? is one example of the papers produced in these sub-groups. The group then sought the assistance of outside reviewers to ensure the balanced perspective that was the objective of the exercise. Summaries of the reviews received are included with each of the two papers. A summary of comments on the process can be found at the end of this introduction. Neither working paper is intended to be the last word on the topics it covers. Nor do the papers represent the institutional views of CSAP, ICAP, or of every member of the group. What they do represent is the consensus resulting from the group's discussion, which may not reflect the personal views of all the group members. Each paper may contain something with which individual members of the group do not agree. These papers demonstrate a commitment not to let the best be the enemy of the good. They also demonstrate how much common ground in fact exists between those who might, at first sight, be assumed to have almost irreconcilable views. Future of the Group Having completed the work described in this short introduction, the group has come to the end of the first phase of an important task. It is up to CSAP and ICAP to reaffirm their belief in the value of this effort; their reaffirmation will depend in part on the reaction of interested parties to the products that have emerged from the group so far. All involved are encouraged both by the process and by how much has been achieved. The papers may be far from perfect, but warts and all they are unique in this politicized field. It is the hope of all involved that they can encourage others at the community level and around the
5 world to attempt similar experiments, to begin where these papers leave off, and to work towards greater understanding and greater mutual respect. Robert W. Denniston Director, Secretary's Initiative on Youth Substance Abuse Prevention, SAMHSA Marcus Grant President, ICAP Review Summary The papers produced by the CSAP/ICAP Joint Working Group on Terminology were sent to outside reviewers for comment, as agreed by the group. While the number of responses was limited, the reviewers were able to provide valuable insights into both the merit of the process itself and the content of the individual papers from their own perspectives. In addition, the diversity of the opinions expressed served to underscore once again just how contentious the areas addressed truly are and that much work remains to be done before the obstacles of language and ideology can be overcome. While the comments were varied, ranging from enthusiastically positive to highly critical, most of the reviewers agreed that although the individual papers might have their faults, the process in which the group had engaged was a valuable one which breaks new ground in establishing dialogue where it otherwise may not have been possible. Commending the group for its effort, one reviewer summed up the process by writing that "while disagreements will continue to exist, (...) a healthy dialogue between the public health community and the industry will benefit everyone." This view was echoed in the comments of another reviewer. "The Joint Working Group is to be applauded for having the courage and foresight to begin a dialogue. Though there will never be 100% agreement in all areas, a group such as [this] will have forged a bridge which will make communication clearer and less emotionally charged; the outcome can only be positive." Others were not as eager to applaud the group. It appears that in the search for consensus, some of the conclusions of the group were seen as too tentative where the facts support a stronger viewpoint. While the issues identified by the group were perceived as important ones in the alcohol debate, another reviewer felt that there is "little in these specific papers that will either contribute to or improve the field of alcohol research or prevention." Many of the topics addressed, in one opinion, are the exclusive domain of researchers working in the field of alcohol epidemiology and therefore should not be part of the discussions needed with the alcohol industry. In fact, "these are epidemiological discussions to be held among scientists as they seek clear definitions to guide research." Despite the explanatory remarks regarding the composition and goals of the group set forth in the Introduction, this appears to have been the major point of contention for two of the reviewers. As a result, according to these voices, "major sectors of thinking and concern in the alcohol issue arena" were left out of the discussion. In the opinion of one such reviewer, without the presence of epidemiologists, the group was not qualified to offer its viewpoint on some of the issues it chose to address. The very involvement of the industry in this effort was perceived by one reviewer as an attempt at setting the agenda, and not as part of a process which aimed to bring about middle ground between often conflicting viewpoints. By the same token, the effort was seen as addressing the "concerns of the industry, not the concerns of the scientific or prevention community." This sentiment was voiced by another reviewer whose position was that the views of the public health community had not been addressed.
6 While the critical opinions expressed by a minority of reviewers were quite strong, they were not representative of the broader majority view that the process represents a promising first step which has paved the way for real common ground and with implications for prevention and harm minimization. In the words of one commentator, the real question now facing CSAP and ICAP, is "Where next?" "How do they take a promising start forward into action?" What Do Others Hear When We Speak About Alcohol? A Guide to Some of the Words, Phrases, and Slogans Most Likely to Engender Controversy, Offense, and Misunderstanding People working in the beverage alcohol industry and the public health/public policy communities need to find a common language for talking about topics of mutual concern. Because the cultures of public health and the alcohol industry have developed largely in isolation from one another, each group has its own accepted jargon for issues related to drinking. Particular words, concepts, and phrases that seem innocuous to one party may be the cause of offense or alienation to another. The often polarized debate about alcohol has been known to turn otherwise polite people into fierce apologists for their own point of view, without respect for those who think otherwise. The CSAP/ICAP Joint Working Group on Terminology was formed to raise the level of linguistic awareness among professionals in these fields. Part of the group's job was to create a compendium of words, concepts, and phrases that are laden either with judgment or emotional baggage. The idea is not to stop people from using these phrases, but to ensure that they are used with a high degree of awareness about the prejudices, implications, and ambiguities that may accompany them. To this end, the Joint Working Group has compiled the following annotated list of sensitive, controversial, imprecise, or otherwise problematic words, phrases, and slogans that are often used in discussions concerning alcohol. This compendium is not intended to be exhaustive, nor is it written in stone. We would encourage readers to help us work toward creating a more comprehensive guide to the problematic verbiage used and overheard in discussions about the laws, customs, regulation, promotion, prevention, and practice of drinking. Our goal here is not to define these terms, many of which defy a cut-and-dried explanation, but rather to highlight the controversies inherent in them. Annotated List of Terminology Abuse There is a high degree of consensus among clinicians about the meaning of "alcohol abuse." The term is given a detailed definition in the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association, for instance. Outside the treatment community, "abuse" is often used loosely in discussions about alcohol, without reference to the word's technical meaning. In the absence of a medical or diagnostic context, the term is tainted by an array of unsavory cultural associations (e.g., drug abuse, child abuse). See also Misuse and Use, and Blaming the Victim. Advertising targeted to youth There is disagreement on whether advertising results in more underage drinking. The U.S. beverage alcohol producers state that their ads are not designed to appeal to underage drinkers, nor is their placement targeted at those under the legal drinking age. In many countries, including the United States, targeting youth is prohibited by industry codes; codes also prohibit materials that have a particular underage appeal. Some public health advocates argue that some ads have
7 strong underage appeal and recognition. The disagreement lies in whether such advertising influences young people to have favorable attitudes towards drinking in general, or towards particular brands of alcohol, and encourages underage drinking. There is research pointed to by both sides of the argument. Alcohol (tobacco) and other drugs (AOD, ATOD) Pharmacologically, all of these substances contain a psychoactive component. However, lumping them together blurs a number of important distinctions between them, not the least of which is their legal status and the regulatory controls governing them. In some countries, such as the U.S., linguistically linking anything with drugs is a way of demonizing it or denigrating its value. Many of those charged with protecting the public health have argued that the linkage is a valid one, in that alcohol like other psychoactive substances can be addictive and is potentially lethal, and public ambivalence can be addressed through this use of terminology. Alcohol control is crime control This slogan implies a causal relationship between alcohol and crime which is still under debate. There is an experiential correlation between excessive or inappropriate alcohol consumption in some individuals and aggressive and/or criminal behavior. However, conclusions from populationbased studies are less clear. Alcohol-related This adjectival phrase is linked to a broad range of social problems commonly associated with destructive and/or irresponsible drinking practices. Because the phrase is used so frequently and so unquestioningly, a cause-and-effect association between alcohol and many of these problems has become implicit in the media and the public mind, for instance, in the context of "alcoholrelated" traffic accidents, violence, and crime. Implied or presumed causality can obscure the complexity of the issue, deflecting attention from the many other factors that may be involved. Nonetheless, even in the absence of any cause-and-effect relationship, excessive or inappropriate alcohol consumption is often present. Alcoholic When used as a noun, this word serves as a lay term to describe a person manifesting the alcohol dependence syndrome or patterns of behavior related to this syndrome. In some countries, most notably the United States, the beverage alcohol industry has registered its objections to the adjective being applied loosely or with imprecision in a nonmedical context, such as in "alcoholic beverage." See also Abuse. Alkie This is one of many derogatory words used to describe individuals who suffer from alcohol dependence syndrome or who simply drink a lot. Like all such words, it is not one that polite people would use in the presence of an individual who fits the description. "Alkie" and other slang words describing people who drink to excess have an almost cinematic association with Skid Row. This type of stigmatization can create barriers to effective treatment. See also Beer bum, Beer gut, Boozer, and Wino. All drinking is risky drinking Although accurate for some individuals, this slogan does not reflect the current scientific consensus that moderate and appropriate alcohol consumption is compatible with a healthy lifestyle for most people, and, in fact, offers cardiovascular health benefits to certain individuals. See also Health benefits of drinking, No safe use, No responsible use, and Your first drink is your first step towards alcoholism / addiction.
8 Attitude adjustment hour The problem behind such phrases as "attitude adjustment hour" is not linguistic so much as it is conceptual. There are people who object to the very notion of alcohol being marketed as a tool to "adjust" one's attitude, and find the entire business of promoting drinking to be unethical or at least undesirable for society as a whole. The controversy is more often centered, however, around the practice among drinking establishments of offering economic inducements for their customers, such as discounted prices for drinks. If we agree that bars, pubs, and lounges have a rightful place in our communities, their proprietors also have the right to engage in lawful and responsible business practices designed to increase their sales. The challenge lies in finding ways to exercise this right without promoting excessive or inappropriate alcohol consumption. See also Happy hour and Twofers. Beer bum There are many definitions of "bum" in the dictionary, none of which one would enjoy hearing applied to oneself or any other esteemed person. In this instance, "bum" indicates that the individual in question is excessively devoted to drinking beer. This type of stigmatization can create barriers to effective treatment. See Alkie. Beer gut This is on one level a merely physiological description of the abdominal distension characteristic of some individuals who consume excessive quantities of beer. The phrase is sometimes used as a derogatory way of referring to the whole person. See Alkie. Beverage alcohol industry This term is often interpreted to mean a unitary industry. In fact, it includes a diverse group of manufacturers, wholesalers, and retailers of beer, wine, and distilled spirits. Many members of this industry are parts of larger enterprises involved with other products and services (e.g. hotels, grocers, stores, beverage bottlers, etc.). See also Prevention community. Binge drinking This term is commonly used within the prevention / public health community in the U.S. to define an occasion during which an individual consumes five drinks or more. A problem arises in how one defines "occasion." While five drinks consumed in rapid succession would be considered by many people to constitute a drinking binge, the Blood Alcohol Concentration (BAC) of an individual consuming the same number of drinks over the course of an all-day event might well remain low. "Binge drinking", when used in this way, can be misleading in that it stresses quantity out of context. Another problem with this term is the lack of international consensus about what constitutes a binge. In popular usage, binge drinking often refers to incidents of notable excess, involving long periods of time spent under the influence (weeks, in some cases) and prodigious quantities of alcohol and loss of control. Blaming the victim When alcohol abuse is described only in terms of "personal and individual responsibility", some people believe that this is unduly blaming drinkers without taking account of promotion and sales. In their view, the roles of alcohol, the drinker, and the social context must all be considered. Blood border This emotionally charged expression refers to the phenomenon of people traveling from one jurisdiction to another in pursuit of the legal purchase of alcohol (as opposed to people simply wishing to avail themselves of the lower prices for alcohol in a neighboring nation or state). Often the people traveling from the "dry" location are young. Sometimes, under the influence of alcohol, a small percentage of them may be injured or even die in car crashes following their purchase and consumption of alcohol.
9 Booze Even though "booze" has a time-honored place in the common lexicon of slang, the word carries an inescapable array of negative associations. Such terms as "booze merchants" or "booze barons" are sometimes used to describe people in the beverage alcohol industry. The phrases are not considered to be laudatory. Boozer See Alkie. Car accidents Although the use of this term is pervasive, some feel that it is imprecise. The term car accidents describes events that are not usually seen as preventable. "Car crashes", however, describes events that are seen as preventable, especially when alcohol is a factor. Therefore, "car crashes" is preferred by some as it does imply causation. Others prefer the word "accidents" because it is less likely to suggest alcohol or anything else as a causal factor. See also Alcohol-related. Demonizing a legal product This is the emotional outcry of those who wish to denigrate the public health goals of preventionists. Some argue that the phrase gives too much emphasis to the legal status of alcohol. Preventionists are in general concerned with dangers posed to public health by excessive alcohol consumption, notwithstanding the product's legal status. Drug pusher and Legal drug pusher These are inflammatory and, most people would agree, inappropriately insulting terms when used to describe individuals who produce, sell, serve, or offer alcohol for legal consumption. Failure to distinguish between use and abuse Research tells us that most drinkers suffer few, if any, harmful consequences as a result of their alcohol consumption. Most governments, as well as most individuals, are clear on the distinction between the use and abuse of alcohol (even though the term "abuse" is often used loosely in the alcohol debate). Some researchers object to the juxtaposition of these two terms when they are used to draw comparisons between illegal drug use and alcohol abuse. This controversy is exemplified by slogans such as "Alcohol it's an equal opportunity troublemaker", which imply that all alcohol consumption, in any context, is conducive to danger and harm. Personifying alcohol as a "troublemaker" suggests either malice lurking in the substance itself, or linkage with an outside force of evil. See also Abuse and Blaming the victim. Gateway drug The message promoted by this expression, when used in reference to beverage alcohol, is that drinking leads to the use of illegal drugs. Although for many individual drug users it may be true that alcohol came first, research does not seem to support a simple cause-and-effect explanation for populations as a whole. Others contend that there is a strong correlation between underage drinking and other high-risk behaviors, including substance abuse. Happy hour See Attitude adjustment hour. Hard liquor Although this expression is sometimes used to distinguish spirits from beer and wine, the distinction is resented by distilled spirits producers. The spirits industry is sensitive to the common misperception that their product is inherently more "alcoholic" (we use the term advisedly) than either beer or wine. Serving size and percentage alcohol determine the amount of pure alcohol consumed, not the choice of product. See also Standard drink.
10 Health benefits of drinking This phrase has limited usefulness when deprived of context, as does the phrase "health risks of drinking." Drinking, like most human activities, offers benefits as well as risks. In the case of drinking alcohol, benefits will depend on each individual's biological and psychological profile and on the pattern of consumption. See also All drinking is risky drinking. Impairment (Impaired driving) begins with the first drink This statement suggests that alcohol consumption, even in small amounts, causes physical and / or mental impairments that make drinking fundamentally incompatible with driving a motor vehicle or any other activity requiring motor coordination. The slogan suffers from imprecision, as the effects of a given amount of alcohol vary considerably from individual to individual. There is no scientific evidence of a universally valid threshold for impairment. See Standard drink and Zero tolerance. Industry contributions to prevention Because of the traditional mistrust and lack of cooperation between the beverage alcohol industry and the prevention / public health community, efforts on the part of producers to promote safe drinking practices have sometimes been viewed with suspicion, or, at best, as "mixed messages." For example, programs funded by the industry to reduce underage drinking and drunk driving have nonetheless earned respect within the public health community. See also Mixed messages. Intoxicated There is no international consensus about the objective parameters of intoxication. This concept describes a state that most people can readily identify. The American Psychiatric Association's Diagnostic and Statistical Manual IV (DSM-IV) and the World Health Organization's International Classification of Diseases (F10.0) each provide guidelines for determining levels of intoxication. See also Legally drunk. Legally drunk There are varying levels of Blood Alcohol Concentration (BAC) used to define legally drunk within states in the U.S. and by countries around the world. The general controversy surrounding the term "legally drunk" focuses on the question At what level should the BAC be set to make this determination? The prevention community generally supports lower BAC levels than does the beverage alcohol industry. Some critics of the concept argue that BAC is a measurement invented for legal purposes only and is not necessarily the most effective way to determine an individual's degree of impairment. See also Zero tolerance and Intoxication. Lifestyles free from alcohol and other drug use See Substance-free lifestyles and Alcohol (tobacco) and other drugs (AOD, ATOD). Liquor industry The beverage alcohol industry includes a vast array of producers, distributors, retailers, and advertisers selling beer, wine, and distilled spirits. "Liquor industry" is often misunderstood in that many people interpret the phrase as referring to all beverage alcohol products beer, wine, distilled spirits whereas, technically it refers exclusively to the spirits segment of the industries. See also Hard Liquor. Mind-altering drug The words may be accurate when applied to alcohol, but the phrase has unmistakable associations with the culture of illegal drug use. Misuse Proponents of beverage alcohol point out that we don't speak of "using" coffee or even cigarettes although "misuse" is often preferred to the term "abuse" by the same people lodging this
11 objection. "Reckless drinking" is an expression that has won approval from some people in the alcohol field as an alternative to either of these terms. Proponents suggest a logical parallel between reckless drinking and reckless driving, both of which emphasize individual responsibility for exercising controls. See also Abuse and Use. Mixed messages Critics contend that "mixed messages" offered by industry to encourage moderation are only advertising in disguise. Such slogans may lend to the product recognition of a particular brand of alcohol without offering meaningful guidelines for sensible consumption. "Think when you drink", for instance, is seen as objectionable because thinking can be impaired under the influence of alcohol. Other controversial slogans offered by industry in the U.S. include "Know when to say when." See also Industry contributions to prevention. Moderation or Moderate drinking Although these terms seem innocent enough, and are commonly used, there is a wide range of opinion about what they mean, as well as great disparity around the world among official definitions of "moderate" alcohol consumption. See also Responsible drinking and Sensible drinking. Neoprohibitionist Although it is clear that prohibitionists advocate the elimination of beverage alcohol from society, the term neo-prohibitionist has been indiscriminately applied to those who advocate a range of regulatory controls. In general, it may be appropriately applied to those who advocate very restrictive controls, which severely limit the availability of alcohol. By contrast, the term is particularly derogatory and dismissive when applied to people in the prevention field who are focused on reducing the harm associated with irresponsible drinking. Some preventionists believe that the best means of reducing this harm is by reducing overall consumption. They see themselves as focused on reducing harm; alcohol industry representatives see them as focused on reducing total consumption. The use of the term can therefore create misunderstanding and resentment. No safe use Research tells us that most drinkers suffer few if any harmful consequences as a result of their alcohol consumption. U.S. Department of Agriculture and U.S. Department of Health and Human Services guidelines, however, warn that for certain individuals including children and adolescents, people predisposed to alcohol dependence, individuals taking certain medications, and pregnant women or women trying to conceive there is no safe use. In all cases but that of medical contraindications linked to prescription drugs, there is a lack of international consensus on these issues. See All drinking is risky drinking and Use. No responsible use See All drinking is risky drinking and No safe use. Prevention community This term implies a unitary field. In fact, it is a diverse group of professionals, advocates and volunteers who purposefully promote healthy lifestyles at the individual, family, and larger community levels, using an array of evolving research-based strategies that prevent diseases, injuries, and other social harms before they occur. In the substance abuse prevention field these strategies include information dissemination, education, alternative activities, intervention, and treatment, social and environmental policy change, and community organizing. See also Beverage alcohol industry.
12 Punitive regulations The sale of alcohol is more tightly regulated than the sale of most other commodities. This is most obviously true in connection with underage drinking, where distinctions between legal and illegal consumption are precisely drawn. The beverage alcohol industry cries foul when regulations seem less in the service of legal standards than moral ones. Others counter that tighter regulation of alcohol is warranted by the public health risks widely associated with its consumption. See also All drinking is risky drinking and Sin taxes. Responsible drinking This term was coined by the first director of the U.S. National Institute on Alcohol Abuse and Alcoholism to denote drinking that results in neither impairment nor any other "alcohol related" problems. It means different things to different people. Further, it is sometimes seen as placing the burden of responsibility on the individual without taking into consideration the promotion, sale, and service of alcohol. See Moderation and Moderate drinking. Self-regulation This term is used in reference to the beverage alcohol industry's internal controls concerning the appropriateness of its advertising and merchandising strategies. Opponents of this honor system would like to see more extensive external regulation with a greater array of legal and regulatory controls. Sensible drinking "Sensible drinking" is the phrase preferred in the U.K. to express what is termed "moderate drinking" in the U.S. British government guidelines suggest slightly higher daily volumes for sensible or moderate alcohol consumption. See Moderation or Moderate drinking. Sin taxes Usually invoked in reference to excise taxes on gaming, alcohol, and cigarettes, this expression reflects the notion that one should contribute extra money to the public coffers to make amends for committing a sin or for experiencing pleasure. The phrase also expresses the dissatisfaction felt by some with the blurry boundary between legal and moral censure in reference to alcohol. See also Punitive regulations. Standard drink Ways of measuring alcohol consumption would be welcomed by all factions and for a wide variety of purposes, from marketing to prevention to medical research. Definitions vary widely among countries. As a convention for easy comparison of amounts of alcohol consumed over time, many U.S. survey researchers assume the following approximations, which yield equivalent amounts of ethanol measured in percent by volume: beer, 12 oz at 4 percent; wine, 5 oz at 11 percent; spirits, 1.5 oz at 40 percent. Obviously, in actual practice, the sizes of drinks differ, as does the alcohol content, rendering the "standard" less than precise. Substance-free activities This expression refers to the practice of consensual prohibition of psychoactive substances at designated community events. Some consider the absence of any alcohol to be one safeguard against rowdy or otherwise undesirable behavior. Proponents of the concept are most concerned with community events involving the participation of young people and families. Critics argue that enforced abstinence denigrates the individual's ability to make responsible drinking decisions. Twofers or 2fers Originating in the U.S. this is a slang expression to describe the practice of serving two drinks for the price of one for a limited time. It is objected to by preventionists as a practice that encourages drinking more than one might be normally inclined to drink in the absence of economic incentives. See Attitude adjustment hour.
13 Unfair burden on merchants This is the term of protest most frequently heard when the responsibility for underage or inappropriate drinking is shifted away from consumers and is placed instead on people who sell beverage alcohol. Both contribute to the problem, and both preferably with society's wise guidance should contribute to its amelioration. Use Although a word of only three letters and one syllable, "use" speaks volumes in terms of its associations with the culture of illegal drugs. Those who see alcohol as properly categorized with "other" drugs their legal status notwithstanding find "use" to be an appropriate term in reference to alcohol consumption. See also Misuse and Abuse. Wino This is a derogatory word used in reference to mostly impecunious and often homeless individuals who drink wine to excess typically cheap wine with a high alcohol content. See Alkie. Your first drink is your first step towards alcoholism / addiction The implied causality of this statement contradicts the experience of the vast majority of drinkers, who never develop alcohol dependence. For a small minority of individuals, the phrase may in fact be true. See also All drinking is risky drinking and No safe use. Zero tolerance In the U.S. and other countries where the driving age is lower than the drinking age, zero tolerance laws result in the suspension of the driver's licenses of underage drinking drivers. The threshold for zero tolerance in some U.S. communities is calibrated at.02 percent (to allow for very small amounts of alcohol in the bloodstream that can be accounted for by mouthwash, salad dressing, cough syrup, and so on). See also Legally drunk. Review Summary The working paper which explored some of the controversial terminology currently in use within the alcohol field was submitted for independent review. The range of comments received was broad. The process was applauded by some, criticized by others. According to one reviewer, such a discussion, "which is beyond the scientific research issues of prevention or treatment could be a useful one for practitioners from industry, prevention, and science to engage in." It was the view of some who reviewed them, that the terms chosen for this purpose reflected more the concerns of the industry than those of public health advocates. In order to address this perceived bias, several of the reviewers suggested including language taken from alcohol advertising and promotion, as well as concerns relevant to the public health and medical communities. Examples of such terms were provided by most of those who reviewed the paper. The view that the list of terms was not sufficiently comprehensive was also espoused by those who did not perceive a bias in the selection. The suggestion from these reviewers was that terminology be included which would broaden the cultural relevance of the list beyond the context of the United States. Several of the reviewers also offered specific suggestions on ways in which the discussion of some of the terminology could be expanded. While controversy persists about the way in which the group attempted to undertake the task before it, the "dialogue should be encouraged but enlarged to include the full range of language about alcohol including popular, scientific, and commercial terms."
14 Is Alcohol A Drug? And Why Does It Matter? Why Words Matter As diverse sectors in communities see the need to come together to address how excessive alcohol consumption affects society, they face formidable challenges. Some of these challenges are obvious and others are subtle. One of the stumbling blocks to effective dialogue and collaboration in recent years has been the presence of emotionally charged language. Such polarized terminology is exemplified by phrases such as "alcohol and other drugs" (AOD), sometimes "alcohol, tobacco, and other drugs" (ATOD), which convey significantly different meanings to different people and evoke strong but diverse responses at the grassroots level, or the community at large. AOD / ATOD was brought to the attention of the American public by Secretary Bowen of the U.S. Department of Health, Education and Welfare (now Health and Human Services) in 1988 in a speech at the Secretary's Second Conference on Alcohol and Alcoholism. In 1989 the then Alcohol Drug and Mental Health Administration developed internal editorial guidelines to encourage use of these terms, as they were believed to be useful in breaking through the denial that alcohol problems are significant, treatable, and preventable. In 1990, it was included in the Healthy People 2000 Health Objectives for the Nation. When examining the meaning of any expression, it is important to consider not only the literal or dictionary meanings of the individual words used, but also that audiences negotiate meaning. People interpret what they see and hear based on a lifetime of experiences, education, and personal history. While seemingly straightforward, "alcohol and other drugs" has clearly evoked very different responses from individuals in the health professions on the one hand, and from individuals who manufacture, distribute, sell, or serve beverage alcohol on the other. The purpose of this paper is to examine the levels of meaning that both sides bring to the term "alcohol and other drugs" at this time, recognizing that language is a dynamic entity and that connotations of words and phrases change over time. It will also signal some of the issues inherent in this terminology and suggest some alternative phrases that may help bridge the divide. Beyond that, we will suggest how, despite strikingly different reactions to this phrase and associated slogans, it has been possible to forge real partnerships that have been beneficial in furthering the fundamental goal that we share reducing problematic use of alcohol in our communities. Is Alcohol A Drug? There is a sense in which alcohol is clearly a drug, and few would try to argue otherwise, if, as some would suggest, we use the term "drug" to refer to "any chemical substance in the area of pharmacology" (U.S. Department of Health and Human Services 1993). This means any substance that, when ingested, effects changes in the body (Goeders, 1996). Under that loose usage, ethanol (the only kind of alcohol that people habitually drink in any culture) fits the definition as do a host of other substances (Goeders 1996). And let's not forget that not all drugs are scorned; some are hailed as "miracle-drugs", contributing to health and social welfare by stemming infections, regulating heart problems, preventing and even curing diseases, and so forth. A somewhat more targeted usage reserves the word "drug" for any substance that, when ingested, has a bodily impact that is specifically psychoactive, that is, altering the chemistry of the brain in ways that change mood and perceptions (Brecher et al. 1972). Here again, beverage alcohol fits the definition and so do caffeine-containing drinks such as coffee, tea, chocolate, and many soft drinks, among a host of others (Heath 1992). It is important to remember that it is not simply the pharmacology or biochemistry of psychoactive drugs that makes them "risky" or "dangerous" but also their social and cultural interpretations (Blum et al. 1974). Different cultures, at different periods in history, have chosen to accept or even approve of some such mind- or mood-altering substances, and to reject others. For example, both coffee and chocolate were banned by various European and Asian rulers when they were first introduced some centuries
15 ago, whereas tea-drinking became an important social (and sometimes religious) ceremony. Many now consider coffee and alcohol inappropriate for young people, although they have no such compunctions against chocolate or caffeinated soft drinks. Few scientists pay much attention to specific psychoactive drugs and their effect unless such drugs are widely perceived as causing problems. In recent lay usage (dating from the 1960s in the U.S. and perhaps a little later elsewhere), the term "drug" has taken on a third meaning, coming to stand for a wide range of substances that are not only psychoactive but also illegal, associated with behavior that may be immoral and dangerous, both to the user and to others (Heath, 1992). Other phrases in the same vein such as "drug culture" and "drug trade" also convey a negative meaning. One part of this powerfully negative connotation has to do with the attribution of addiction (or dependence) as an inevitable consequence of use. But the power of semantics is not limited to those who know little about a subject. What used to be "drug companies" have, in the past few decades, chosen to call their products "pharmaceuticals" rather than "drugs", and "the pharmaceutical industry" is distancing itself in many other ways from association with drugs. Even if big business sometimes shapes a culture, it is also true that it is often shaped by culture. Alternative Perspectives in the United States Those who are involved in the alcohol industries are not comfortable with being labeled with the derogatory association with "drugs" or "other drugs." They are quick to point out that alcohol, unlike drugs such as heroin or crack cocaine, has been a significant part of cuisines, cultural events, and economies for centuries (Hanson 1995). Manufacturers, wholesalers, distributors, and retailers of licensed and legal products are concerned about alcohol abuse and willing to invest in prevention, treatment, research funding, or doing what it takes to stop excessive drinking and the problems that can result. Those who manufacture, sell, or serve alcohol believe they have been unfairly demonized and labeled as the enemy by many public health and other groups that fail to understand the damage that is done by linking alcohol with illicit drugs. There is no question that the word "drug" is often used in our society to refer to substances that are illegal and dangerous. Insisting that alcohol be categorized with "other drugs" therefore places a strong negative value judgment on a legal, popular, and widely accepted substance that has been part of human culture for 6000 years (Heath 1996). Such usage also taints people who make, sell, or drink it. Some professionals in the alcohol industry report that their children are confused or resentful when they hear in school that their parents are "dealing in drugs" or "legal drug pushers." And, parents who are responsible social drinkers express concern about the confusion created by linking alcohol with drugs of abuse when it makes them "drug users" in the eyes of their children. Further confusion is created when a community health goal is to be "drug-free", as suggested in the U.S. Department of Education's "Drug-Free Schools and Communities" grant program. Does that imply that no alcohol is to be consumed in that community? An alternative perspective is often taken by those who call themselves "health advocates" and others in public and private agencies that focus their attention on substance abuse and its outcomes. Many of them assert that alcohol should be recognized as a drug because it has all the important properties of a drug: it is a psychoactive substance, and one that, in increasing doses, can produce tolerance, craving, addiction, and even death. But addiction is not the full extent of the problem, as there is an even greater prevalence of individual and social harm that occurs as a result of drinking by people who are not addicted to alcohol and may not become so. Furthermore, both human and animal studies have linked alcohol with violence (Pernanen 1991) and have suggested a possible correlation with crime, suicide, drunk driving, sexually transmitted diseases, birth defects, school truancy, absenteeism, and increased costs for health care and law enforcement (Collins 1981; Secretary of Health and Human Services 1993). Alcohol is often a problem on college campuses (Wechsler et al. 1995) and, despite impressive progress in
16 reducing impaired-driving fatalities in recent years, many people still die or are injured in alcoholinvolved car crashes. In view of these negative and sometimes tragic outcomes, use of the phrase "alcohol and other drugs" makes perfect sense to those who believe that the public needs to be informed that the real effects of drinking do not always coincide with the images of glamour and success that are so often placed in the media. The language "alcohol and other drugs" sensitizes the public to important facts about a substance which is widely abused. The argument is made that it is past time to see drunkenness as funny, view alcohol as a harmless social lubricant, or turn a blind eye to the problems that are correlated with its consumption. The portion of these problems that results from alcohol misuse would be preventable if the community were to support prevention more actively, both philosophically and in practice. Preventionists in the public health arena argue that for communities to be truly informed about the social costs of alcohol consumption, there should be as many counter-advertisements on alcohol in the mass media as there are advertisements. Furthermore, health advocates believe that there are sound reasons to be concerned about the human and economic costs associated with excessive drinking. They resent being sometimes labeled "neoprohibitionists", "health Nazis", or "anti-alcohol zealots" for what seems to them to be an objective, fact-based orientation. From the perspective of many in public health, there is a long way to go to create constant and consistent awareness of the dangers of alcohol. For all of these reasons, backing away from the term "alcohol and other drugs" is not defensible in the judgment of many who deal daily with the suffering and costs that they associate with drinking. These advocates also believe it helps in a small way to counterbalance the power of the alcohol industry to promote its products and influence public policy. It is evident that the question of whether alcohol should be called a drug depends on what is meant by the term "drug" and also on the relative emphasis that one puts on various aspects of the role of alcohol, even in a single culture or society, namely the contemporary United States. The issue is even more complex when we look at other cultures, where drugs, the historical roles of alcohol, and present-day attitudes, beliefs, and practices are vastly different. Cross-Cultural Perspectives There is significant variation in the ways that cultures and countries view beverage alcohol (Heath 1995), and also drugs (Knipe 1995), and these words are also affected by context. In some cultures, alcohol is considered a food, an integral part of meals, and a normal part of daily life. In Italy or France, where meals take on an integrating social function and most people eat with others, alcohol served with food is a socially accepted norm. By extreme contrast, there are Islamic countries and Protestant congregations that specifically forbid beverage alcohol under any circumstances. In Italy, eight drinks a day might be considered normal (Farchi et al. 1992), while that would be considered excessive in the United States. A single drink at any time would be unacceptable in Iran or Saudi Arabia, whereas alcohol symbolizes hospitality in many other areas and it is considered rude not to offer guests a drink. Cultural norms also shape attitudes toward whether alcohol should be characterized as a drug. Some languages have no term for "drugs", while others use the word in the broadly inclusive sense that used to dominate in English i.e., including both medications and psychoactive substances (but rarely including ethanol). In France, wine is classed as a food, and in the French language neither "drugs" nor "beverage alcohol" constitute a meaningful category. In many cultures, the distinction between alcohol and drugs, both legal and illegal, is clearly made. While the psychoactive effects of beverage alcohol cannot be disputed, it is far more common that alcohol is viewed as a dietary component, a religious sacrament, an adjunct to hospitality, a symbol of celebration, or something else, rather than as a pharmacological agent.
17 Implications for Action Perhaps the first step in coming together as a community of people who share concern about the hazards and harms that are associated with alcohol and society is to admit that there are significant differences in perceptions and definitions, and to try to understand the variety of sensitivities that are triggered with the use of certain words and phrases. We must also understand that there will still be people on both sides who are not eager to shift perspectives, or move toward common ground. Even those who serve as spokespersons for the alcohol industries are quick to admit that their product is a drug in the sense that it affects the body, especially the brain, but they tend to focus on the majority of drinkers who enjoy moderate drinking as an adjunct to daily life or as a symbol of celebration, without apparent harm, and, for certain individuals, with recognized health benefits. Perhaps the only simple answer to the question whether alcohol is a drug, is an incomplete one: "Yes, but..." Much more to the point is the subsidiary "Why does it matter?" In this paper, we have tried to sketch briefly the rationales that are given by two important constituencies, and a brief sample of other views from around the world. In practical terms, it will probably be far more fruitful for us now to collaborate in seeking ways to lessen the risks of excessive drinking and the harms that result from it. Both public health and industry groups seek sufficient information, education, and discussion to foster safe and healthy personal, public, and corporate policies. There may be other words that convey similar meanings adequately, without the problematic use of the term "alcohol and other drugs." For example, some prevention groups in the U.S. state of South Carolina have found the phrase "drug free and alcohol safe" appropriate for signaling what they want to promote. It implies zero tolerance for illegal drugs and for underage drinking, while allowing for safe and legal consumption of alcohol by adults. Inserting the word "illicit" or "illegal" before "drugs" (as in "alcohol and illicit / illegal drugs") conveys a similar message. Likewise, some believe that discussing the term "misuse of alcohol" is an area of increasing importance. Alcohol poses little or no risk for most people, but its misuse has been implicated in the incidence of injury, violence, and various illnesses. Prevention and early intervention are crucial to cutting health care costs and societal costs of misuse. The phrase "no use of illicit drugs and no misuse of alcohol" may be helpful, especially if cited within the context of what constitutes misuse in official government-issued guidelines, in the definition of blood alcohol levels that constitute impaired driving, or in definitions of drinking to the point of intoxication as taught in server intervention courses. We must understand that people talk about drinking as nutritional, medical, recreational, relaxing, religious, addictive, or sinful largely on the basis of the teachings of their cultures and families. While an airing of differences such as this may be helpful in identifying certain contrasts in orientation and interpretation, we are pleased that, rather than dealing in blame, it provides a basis for working jointly to lessen the negative outcomes that too many people associate with alcohol. Every group and individual must, in the end, decide what terminology is most helpful toward achieving whatever goal is desired. We hope that the shared goal of lessening risk and damage from alcohol misuse may help create better informed, more thoughtful and constructive individual and collective choices. In light of the strikingly different daily occupations of its members, it is a positive sign that a working group such as ours has been able to collaborate so effectively in identifying and addressing joint aims and concerns. Our talk about collaboration is not just "pie-in-the-sky" rhetoric, but rather it is reflected in some activities that are already underway. For example: In communities in California, local alcohol retailers and community coalition members are working together to support and implement Responsible Beverage Service Training for both on- and off-premise establishments. Also in California, some chains of convenience
18 stores and prevention coalitions are involved in joint safety and support services for employees who live in the community. Until recently, it was a popular custom throughout parts of the midwestern United States for bars and taverns to help commemorate a 21st birthday, the advent of the legal drinking age, by buying a drink for the person celebrating. The pressure on a newly legal drinker to accept free drinks as friends accompanied the celebrant from place to place posed a potentially serious risk, especially if the individual had little previous experience with drinking, and wanted to prove that he or she could "handle it." It was on the initiative of a beverage alcohol distributor that a public service campaign was launched, and subsequently supported by the public health community, which has resulted in increased awareness of this unhealthful practice and no further participation by the more community-minded bars and taverns. Collaboration was essential in the preparation and wide dissemination of a simple and practical set of guidelines for "responsible hospitality" by a partnership that includes representatives from all three tiers of the alcohol beverage industry (producers, wholesalers, and retailers), as well as from public health, highway safety, regulatory, law enforcement, and community organizations (both Canadian and U.S.). On the sensitive issue of drunk driving, the major national council in the U.S. includes not only public health and transportation officials but also members who represent the beverage alcohol, insurance, hospitality, and automobile manufacturing industries, as well as representatives from some legislative and popular interest groups a broad coalition which has been effective over the years. Combined alcohol industry / prevention group efforts have been effective in the passage of tougher drunk driving laws at the state level, especially Administrative License Revocation and "Zero Tolerance" for youth. To better monitor and prevent underage sales of alcohol, local U.S. law enforcement departments have worked with an organization set up by a group of alcohol producers to create "Cops in Shops" programs in retail outlets. Social aspects organizations that work with local communities have also been set up by alcohol producers in the United Kingdom, The Netherlands, Germany, and other countries in Europe, Africa and Asia. There are many areas of common ground for those of us who have the same goal of lessening human suffering to come together. Let us purposefully work in tandem to maximize our resources and ensure that commonalities loom larger than differences between these constituencies. If semantics are driving and keeping us apart, let us think through new phrases that will help frame new ways of doing "win-win" business together. The many alcohol industries will benefit from the safe and legal use of their product, and so will communities. Alcohol, health, and culture should appropriately be viewed as parts of a whole rather than as opposing "sides" in an issue that affects us all. References Blum, R.H. et al Drugs I: Society and Drugs, Social and Cultural Observations. San Francisco, CA: Jossey-Bass. Brecher, E.M Licit and Illicit Drugs: The Consumers' Union Report on Narcotics, Stimulants, Depressants, Inhalants, Hallucinogens, and Marijuana - Including Caffeine, Nicotine, and Alcohol. Boston, MA: Little-Brown. Clark, W.B. & Hilton, M.E (eds.) (1991). Alcohol In America: Drinking Practices and Problems. Albany, NY: State University of New York Press.
19 Collins, J.L. (ed.) Drinking and Crime: Perspectives on the Relationship Between Alcohol Consumption and Criminal Behavior. New York, NY: Guilford Press. Farchi, G., Fidanza, F., Mariotti, S. and Menotti, A Alcohol Mortality in the Italian Rural Cohorts of the Seven Countries Study. International Journal of Epidemiology 21: Goeders, N.E. (1996). Drug. In Encyclopedia of Drugs and Alcohol (vol. 1), ed. J.M. Jaffe. New York, NY: Macmillan. Heath, D.B U.S. Drug Control Policy: A Cultural Perspective. Daedalus: Journal of the American Academy of Arts and Sciences 12: Heath, D.B International Handbook on Alcohol and Culture. Westport, CT: Greenwood. Heath, D.B Alcohol: History of Drinking. In Encyclopedia of Alcohol and Drugs, Vol I, ed. J.M. Jaffe. New York, NY: Macmillan. Knipe, E Culture, Society, and Drugs: The Social Science Approach to Drug Use. Prospect Heights, IL: Waveland Press. Pernanen, K Alcohol in Human Violence. New York, NY: Guilford Press. USDHHS Eighth Special Report to the U.S. Congress on Alcohol and Health. Washington, DC: GPO. USDHHS The Alcohol and Other Drug Thesaurus: A Guide To Concepts and Terminology In Substance Abuse and Addiction. 1 st ed. Washington, DC: GPO. Wechsler, H., Dowdall, G.W., Davenport, A. and Castillo, S Correlates of College Student Binge Drinking. American Journal of Public Health 85: Review Summary The paper exploring the issue of whether or not alcohol can be classified as a drug was reviewed independently by experts in the alcohol field. The paper was generally perceived as balanced in its representation of perspectives. Most of the reviewers agreed that the group's concern with the issue was a legitimate one and recognized that the views on this issue are disparate. One of the criticisms of the paper was that it confuses political and economic concerns about alcohol with its scientific properties. While the concerns of the industry about the term "alcohol and other drugs" are understandable, they do not "change the risk of alcohol to individual drinkers and to others who may be harmed because of impaired judgement in a complex task." According to the reviewer, this risk is not inherent only in heavy drinking or alcohol abuse, but may be present even at lower consumption levels. Another reviewer found the paper's suggestion to use the phrase "alcohol and illicit drugs" a less emotionally tinged but equally concise substitute for "alcohol and other drugs" and a workable solution for policy purposes. This would require, however, an elaboration of how illicit drugs are defined. Not all of the reviewers agreed that overcoming differences of definition would provide a basis for working jointly to reduce the negative outcomes that people associate with alcohol. Other issues
20 would need to be addressed, such as whether the elimination of alcohol as a "drug" in U.S. federal legislation would also mean the elimination of resources to deal with its consequences. Labels and definitions of whether alcohol is a drug are largely determined by culture. It was therefore suggested that the issues of how cultural norms shape attitudes about alcohol and about the distinction between legal and illegal drugs should be expanded. As one reviewer pointed out, the view of alcohol as a drug prevalent in the United States may not be representative of views held in other countries. Despite their criticisms of specific aspects of this paper, all reviewers found the broader goals of increased dialogue and collaboration worthwhile and to be encouraged. Afterword The output of the CSAP / ICAP Joint Working Group on Terminology in the form of these working papers is not intended to be the final word on the topics addressed. Rather, the papers should be viewed as the results of a process of consensus building among sometimes unlikely partners who brought with them their diverse backgrounds and unique perspectives. This diverse group came together to address what all those involved in it agreed was a significant obstacle to dialogue, namely the issue of polarized and emotionally charged language currently in use in the alcohol field. Finding common ground and a common language was a priority to all those who participated in this effort and who were united in the belief that more can be achieved by collaboration than by conflict. One of the main goals of this group was to explore the extent to which such collaboration would be possible and to lay the foundations for future efforts. Perhaps this coalition can serve as a model for other partnerships which might be forged in a common effort to reduce the abuse of alcohol. At the international level, such efforts could involve governments, nongovernmental organizations, and industry representatives. At the community level, this model could bring together educators, local regulators and government representatives, distributors, and community groups. The process that was initiated by the Working Group is an ongoing one. Although the partners may change, we hope that the spirit in which they were brought together will persist. The Working Group would welcome comments about the process described here or about any other similar partnerships that may have been forged elsewhere. Please direct all correspondence to: CSAP / ICAP Joint Working Group on Terminology 1519 New Hampshire Avenue, NW Washington, DC