Alcohol is currently the third leading cause of premature or preventable deaths in the US, behind smoking and obesity. This is a problem that is ever-growing, with the number of alcohol-related deaths doubling between 1999 and 2017. By 2014 it was reported that 60.1 million Americans were binge alcohol drinkers. Cannabis advocates claim that legalizing cannabis will reduce alcohol consumption, while opponents say that cannabis is a gateway drug that will lead to further issues of addiction and death. In this article, we will investigate some of these claims in the context of some new papers that have been published following the legalization of cannabis in Colorado, Washington, and other states around the country.
Alcohol Addiction and Deaths
Alcohol is responsible for more than 100,000 deaths per year in the US and is one of the only addictive substances we know of for which withdrawal can cause death. Approximately 10% of alcohol consumers will develop a dependence or addiction, leading to both acute and chronic issues. While deaths due to chronic alcohol consumption (liver and neurological diseases, pancreatitis, and cancer) primarily affects older individuals, the acute issues (cardiac arrest and respiratory failure) are more prevalent among younger individuals. These younger individuals are also at greater risk of death due to accidents, violence, and suicide when consuming alcohol.
In a study published last February, it was estimated that alcohol use directly caused approximately 10% of deaths for adults ages 20-65 in the US. A more recent study from November 2019 noted that the vast majority (70.1%) of Americans aged 18 and older consume alcohol, with an average consumption rate equivalent to 3.6 gallons of pure alcohol per year. That rate has been increasing and rose by roughly 4.4% over the last two decades. The more alarming news,, however,, was that the rate of binge drinking (having more than 5 drinks in a night) increased by 7.7% over the same period.
As would be expected, the rates of alcohol-related harms have also increased. According a 2014 report by The National Institute of Alcohol Abuse and Alcoholism, between 2006 and 2014, the rates of emergency room visits involving alcohol increased by 43.7%, to a per capita rate of 1,803 per every 100,000 people, and the rates of deaths due to alcohol-related liver cirrhosis increased by 34.9%, with 21,028 cases reported. According to data collected by the Center for Disease Control, between 2006 and 2010, there were 88,129 deaths directly attributed to alcohol consumption (49,544 acute causes and 38,584 chronic causes.) Furthermore, alcohol is responsible for increased deaths due to other drugs. According to a 2016 CDC report, alcohol greatly increases the risk of respiratory failure when taken alongside opioids and played a dominant role in overdoses between 2010-2014, accounting for 21% of all heroin deaths, 17% of hydrocodone, and 22% of those involving diazepam. More about the dangers of opioid use in the US can be found in our article from last week.
With alcohol being such a problem across all demographics for those between 16 and 75 years of age, the government must be working hard to find solutions, right? Well, actually there is little evidence to show that, with many of the restrictions for alcohol being relaxed. In many states where alcohol used to only be sold in liquor stores, boxes of beer and novel products aimed at younger individuals (such as hard seltzers and candy-flavored liquors) are now stacked throughout grocery stores aisles, including the produce sections. Alcohol never experienced the advertising restrictions that were put on cigarettes, and still enjoys much fewer restrictions on sales then substances such as cannabis. So how are younger generations being affected by all this?
Cannabis use and Binge Drinking
In 2014, it was reported that 59% of full-time college students drank habitually, with more than 29% self-reporting binge drinking within the previous month and 13% binge drinks more than 5 days per month. In 1999, more than half of all twelfth-grade students reported consuming alcohol each month (55.3% of males and 46.8% of females), however by 2017, that had decreased to 34.1% of males and 32.3% of females. Which raises the question, what is responsible for these decreases in youth alcohol use when adult alcohol use doubled over the same period. Some people point to cannabis legalization, but do the reports back that assumption?
In order to investigate this question, we have to look at substance use. Many of the opponents to cannabis claim that it is a gateway drug, and leads to increased rates of harm due to the combination of cannabis with other substances. A report from 2016 investigated this relationship and found that indeed the substances were more likely to be used at the same time by many young individuals than by those using either one separately. Furthermore, those using the two substances simultaneously experienced increased frequency and quantity of alcohol consumed, with approximately twice the chances of drunk driving and harms to self. They found that students in particular who used both substances simultaneously had more depressive symptoms and more problems at school. They accurately concluded that the general public must be made more aware of the risks involved in combining cannabis with alcohol. However, there was a major flaw with this report, a paramount rule in science: “correlation does not imply causation”.
Yes, there is an obvious correlation between combined alcohol and cannabis use that would lead to higher rates of harm and addiction, but what is the causative factor? Is it that cannabis causes people to drink more? Or that drinking alcohol leads to increased cannabis use? Or, could it be that both are related to a third factor such as personal/family history, neurological disorders, or even genetics? In other words, is it just possible that the same people who would be prone to binge drinking are also prone to use cannabis use and not as focused on school?
One of the first studies to investigate this relationship more deeply was published in 2018, following the legalization of recreational cannabis in the state of Colorado. The study found that rates of marijuana use among college students in Colorado were higher than the national average, especially in regards to the percentage of daily users. However, they also found that the relationship between alcohol and cannabis use, in general, was decreasing since the passing of cannabis legalization in all students except the binge drinkers. They found that only a third of those students classified as frequent cannabis users were also frequent binge drinkers. Interestingly though, they also found that the GPAs of the non-cannabis users and the daily cannabis users were about the same, but those of the binge drinkers/occasional cannabis users where lower, and the drop out rates higher. This study shed a little bit more light on the issue of cannabis and binge drinking but is plagued by both the correlation-causation problem of previous studies and also sampling bias. The study was limited to only 1,413 participants, 77% of which were female, and 76% of which were Caucasian – even though the issue is more prevalent in males.
On the other end of the debate, a 2014 study found that cannabis use was not associated with binge drinking among young adults, but instead,, it was stimulants such as extasy that led to the increase. Two more recent studies found also found a negative correlation between cannabis consumption and binge drinking when looking at the rate of binge drinking relative to cannabis legalization. The first is from December of 2019 from the Society for the Study of Addiction and found that undergraduate students in seven legal cannabis states did use more cannabis than those in states where it was illegal, but used less alcohol. In the preprint edition of a follow-up study by the same authors that will be published in March 2020, it was found that cannabis legalization was directly related to a decrease in binge drinking behavior.
Alcohol use in America is increasing, and with it so are the personal harms and damages to society as a whole. Consumption rates have doubled over the last two decades, and rates of hospital admissions and deaths have risen dramatically across most age groups. The great experiment of cannabis legalization has only recently gotten underway in most states but is posed to become ubiquitous across our nation. As such, our policy makers need to be prepared for the externalities of those changes and be proactive in addressing the issues as they arise. The science is still inconclusive as to whether or not cannabis legalization can decrease binge drinking rates, but it is a topic that demands further investigations by less biased researchers with more scientifically rigorous standards. In the meantime, our country’s life expectancy is decreasing over the last decade after more than 50 years of continuous increases. For now, possibly the most effective method to address the issue is parental interventions, which have been found to have a strong positive correlation with decreased rates of alcohol consumption and addiction.
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