Exploring the mechanisms behind the impact of alcoholic beverages on social behavior and health

1. Introduction to Alcohol Consumption

The consumption of alcoholic beverages represents one of the oldest cultural practices in humankind. Today's global alcohol market is among the largest consumer goods markets and continuously growing. In 2017, the alcoholic beverage world market amounted to 1.5 trillion USD (Statista, 2023). While positive aspects of moderate use are acknowledged, including conviviality enhancement (Wills et al., 2006), improvements in social skills, lower inhibitions, and, hence, greater openness, talkativeness, and assertiveness (Käkelä, 1999; Stoner et al., 2020), far more people are involved in negative consequences. Among them are intoxication-related accidents, including car accidents and drowning (Sullivan et al., 2001). Other socially unwanted effects are aggression and violence, including sexual and verbal abuse and destruction of property (Graham et al., 2006). Consequently, crimes believed to be alcohol-related constitute the largest part of the Dutch police crime statistics (CBS, 2022). Moreover, heavy and chronic drinking is correlated with alcohol use disorders (AUD), which negatively compromise individual health and social roles and are among the world's leading causes of morbidity & mortality (Ezzati et al., 2002).

The effect of alcohol on social behavior has traditionally been in focus, resulting in the notion that drinking has socializing or social lubricating effects. In many cultures, moderate drinking before or during social interaction is suspected to enhance enjoyment and smoothness of the interaction (Dimech et al., 2020). Ethanol is indeed crucial in easing socializing in cultures with a long tradition of drinking. In young naive socialize (drinking) contexts, it is also associated with later and overall higher consumption (Anderson et al., 2009). Learning processes (observational learning, social modeling) and environmental factors (socialization norms, peer socialization) contribute to these long-term effects (Foroud & Li, 2000).

1.1. Historical and Cultural Perspectives

Alcoholic beverages have been an integral part of human culture for thousands of years. The history of alcohol consumption is rich and diverse, with people from different cultures and regions developing unique alcoholic drinks. Ancient civilizations produced fermented drinks from grains, fruits, and honey. For instance, beer was brewed in ancient Mesopotamia around 4000 BCE, and wine was produced in ancient Egypt around 3000 BCE. These drinks played important roles in religious and social rituals, as well as in daily life. The ancient Greeks, for example, held symposiums where wine was consumed in moderation to foster intellectual discussions. Similarly, the ancient Chinese brewed rice wine approximately 7000 BCE, which was used in ceremonial offerings to ancestors. Such historical accounts suggest that alcohol consumption has long been intertwined with culture and society. (Rawat et al.2021)

The cultural significance of alcoholic beverages continued to evolve through the ages. In the Middle Ages, monasteries in Europe became centers of brewing and winemaking, and abbey beers and monastic wines gained renown. The consumption of alcoholic beverages was associated with Christianity and religious devotion. However, in the wake of the Protestant Reformation, cultural attitudes toward alcohol shifted dramatically, leading to the rise of temperance movements in the 19th century that condemned alcohol as sinful and destructive. The interplay between culture and alcohol was not only limited to the West. In Asia, colonial encounters reshaped traditional drinking cultures, often leading to social problems and abuses. (Schrad, 2021)

As familiar as drinking is to many, it is also a misunderstood and contentious subject, particularly in the West. Drinking can induce pleasurable effects such as relaxation, group bonding, conviviality, and sociability. Yet, it can also incite aggressive and violent behavior, abusive and demeaning conduct, and disturbing and dangerous actions. There is a common belief in many cultures that alcohol use helps unfold the ‘true self’ of the drinker. The intoxicated individual may become uninhibited, frank, cheerful, friendly, boisterous, quarrelsome, abusive, or aggressive, fully displayed in actions. However, this belief is culturally contingent. This discrepancy points to the complexity of alcohol’s social effects, revealing what is crucial in understanding the social world. This understanding has implications for public policy regarding alcohol consumption and violence. Furthermore, investigating the mechanisms underlying the cultural shaping of alcohol’s social effects can contribute to the larger theoretical endeavor of understanding the relationship between culture and behavior. As such, it is a worthwhile undertaking. (Thurnell-Read, 2021)

2. Physiological Effects of Alcohol

Alcohol has a range of physiological effects on the body. The concentration of alcohol in the bloodstream and its speed of delivery to the brain will determine the intoxication and its resulting effects. The 'buzz' commonly associated with alcohol consumption is a euphoric feeling experienced within minutes of drinking. This occurs before significant impairment of motor or cognitive function, and it is associated with alcohol’s ability to boost dopamine levels in the mesolimbic system. (Domi et al.2021)

Blood alcohol concentration (BAC) is the ratio of alcohol in the blood measured by mass/volume, percentage weight/volume (wt/w), or common (mass/volume) percentage (g/mL). The amount of alcohol consumed, consumed in a short period of time, and the person’s body composition will impact their BAC. Intoxication is defined in table “Classification of Intoxication by Blood Alcohol Concentration”. Women consistently reach a BAC higher than men after consuming the same amount of alcohol due to the difference in the mean body water composition. People with lower body fat percentages will reach a lower BAC.] (Greaves et al.2022)

Alcohol is absorbed into the bloodstream quickly through the aerial surface of the gastrointestinal tract. Ethanol is highly soluble in water, resulting in rapid absorption through the mucous membranes lining the stomach and upper intestinal tract. The onset of intoxication occurs faster when alcohol is drank on an empty stomach (high alcohol concentrations in beverages) due to a delay in gastric emptying. Women have delayed gastric emptying compared to men, resulting in women’s BAC being elevated further than men’s. CO2-rich drinks, such as champagne, will reach the systemic circulation more quickly as they promote gastric emptying and may cause exaggerated time courses of effects. Paxil, a common antidepressant that causes doses to be absorbed into the bloodstream slowly, may negate the fast absorption of alcohol. (Cox & Klinger2022)

2.1. Metabolism and Absorption

Alcoholic beverages contain various psychoactive substances, the most offensive of which is ethanol (C2H5OH), commonly known as alcohol (Babor et al., 2010). Ethanol is a colorless, volatile, and flammable liquid that can be manufactured either synthetically or by the fermentation of carbohydrates (U.S. Department of Health and Human Services, 2006). Ethanol is widely used as a recreational beverage and as a humectant, solubilizing agent, and medicinal agent. Ethanol intoxication induces mood swings, disinhibition, and socialization, which may facilitate drinking behaviors. Although moderate drinking is said to have health benefits, it has been undeniably linked to various hepatotoxic diseases and other health conditions, such as neurodegeneration and breast cancer, particularly among young women (Liu et al., 2014; Tchouaket et al., 2022; Yamada et al., 2023). (Koob et al., 2021)(Baltariu et al.2023)

Alcohol use disorder (AUD) is a chronic, relapsing brain disease characterized by compulsive alcohol intake, loss of control over drinking, and negative emotional states when alcohol is not available. Recently, safe and effective pharmacotherapies for managing AUD have been drawn increased attention (Volpicelli et al., 1992). AUD is characterized by brain maladaptation to chronic alcohol drinking, including adaptive changes in neurotransmitter signaling systems. In particular, the neurotransmitter systems that mediate the actions of ethanol include the gamma-amino butyric acid type A (GABAA) receptor, opioid, serotonin, dopaminergic, and glutamate systems (Volpicelli et al., 1992). Normalization of forebrain neuroadaptations to chronic ethanol through region-specific electrophysiological approaches provides a promising new pharmacotherapy that holds broader implications for other neurological disorders associated with behavioral inhibition and compulsive behaviors (Babor et al., 2010). (Ferreira et al.2021)

The bioavailability of ethanol is almost 100%, with peak blood concentrations reached 30 to 90 min after ingestion of alcohol in a fasting state and about 120 to 240 min in a fed state. The rate of gastric emptying affects peak blood alcohol concentration. During acute exercise, subcutaneous alcohol injection increased blood ethanol levels faster and created a higher peak blood ethanol concentration than intragastrically administered alcohol. Gender differences exist in ethanol absorption, with higher blood alcohol concentrations noticed in females. Ethanol absorption is also dependent on age, body weight, concomitant carb intake, psychological condition, drinking history, type of beverage (carbonated beverage has a more prominent effect), and other factors. Ethanol is distributed in body water and body tissues in a relatively uniform manner. Ethanol is a small polar molecule that is lipophilic, and its small molecular weight (46.07 g/mol) plays a role in its rapid absorption in the gastrointestinal tract. After rapid absorption, ethanol flows into the blood circulation. According to the theory of alcohol spectrum, ethanol can passively diffuse across biological membranes via the lipid bilayers, resulting in concentration gradients of alcohols across membranes (Yamada et al., 2023). Ethanol is absorbed with a very low first-pass metabolism in the gastrointestinal tract and liver (Babor et al., 2010). The body weight-adjusted volume of distribution for ethanol is 0.6 to 0.7 L/kg in males and 0.5 to 0.6 L/kg in females. Ethanol concentration in tissues and organs can be predicted based on the body water and body fat contents. (Wilson & Matschinsky, 2020)(Tarantino et al.2022)

3. Social Behavior and Alcohol Use

The association between alcohol use and social behavior has been a topic of interest for social psychologists, sociologists, physicians, and epidemiologists for years. There is substantial empirical evidence that social context plays a role in influencing differential levels of alcohol consumption. This is particularly relevant for young adults, who tend to consume alcohol more frequently and in greater quantities when with friends. However, there is still much to explore regarding the nature of this association. A social networking perspective is proposed to better understand the role of social context in influencing drinking behavior. (Corbin et al.2021)

The expression of social behaviors is not solely based on internal factors such as individual motivation, personality, or drug use. Context matters. Social networks, which are the web of social ties linking individuals, have been shown to influence behavior. Network attributes, including individual positioning in the network, the network's structural and homophilic features, and peer effects, have all been linked to social behavior. Networks are crucial for the transmission of social behavior and social norms through relational ties.

Normative mechanisms are important for understanding how social context shapes behavior. Social norms define acceptable conduct in a given context and regulate social behavior by sanctioning norm violations. Social norms regarding alcohol use can either encourage or discourage behavior within a network, regardless of individual characteristics. East African communities are used as an example where drinking norms have shifted, promoting consumption among women and economically disadvantaged individuals. This highlights that social norms may promote both individual and collective risky behaviors.

Descriptive norms refer to perceptions of typical behaviors within a social context, while injunctive norms refer to perceptions of approval/disapproval. A pipeline model is proposed to understand how these normative mechanisms and social contexts interrelate to shape individual behavior, taking into account relative timing in alcohol use behavior. Contextual aspects such as physical environment and network homophily are relevant for drinking behavior. Normative mechanisms are explained, and convergence between descriptive and injunctive norms is considered.

3.1. Social Norms and Alcohol Consumption

Alcohol use is commonly embedded in the social life of different cultures, and the availability of alcoholic beverages facilitates such consumption. Understanding how social contexts shape drinking behaviors has been a focal point of research, leading to a large body of work on normative influences. Numerous cross-sectional and longitudinal studies have shown associations between alcohol use and the attitudes and behaviors of peers and friends, but it remains to be understood how such influences come into play. Social norm approaches have been employed in several interventions, both in public campaigns and as "brief interventions" in treatment programs for problem drinkers. The latter are commonly called "feedback" interventions, where survey feedback is used in one-to-one settings to confront drinkers with a higher personal use compared to their peers. Feedback interventions have often produced an immediate decrease in alcohol consumption. (Marziali et al., 2022)

Several mechanisms have been suggested that may explain the impact of social norms on drinking behaviors. Social norms processing is facilitated by the tendency of individuals to fall back on common sense when they lack information. In the absence of direct experience on how much alcohol is consumed by peers or friends, default assumptions are that consumption is close to limits permitted by the law, or even above the average limits suggested by population statistics. Norm comparisons are also facilitated by the prevalence of thus shared estimates rooted in culturally transmitted knowledge. Such estimates easily come to mind when individuals seek advice on whether their personal consumption is inappropriate, inviting students and other young adults to be concerned about their drinking as potentially high. Alternatively, exposure to drinking may boost activated estimates and filtering norms, rendering high individual consumption acceptable.

Both normative processing styles and consumption levels go through systematic changes during the transition into independent drinking, creating an intertwining of the two processes that cross-fuel the impact of social norms on drinking. In early phases of drinking, high normative estimates provide a protective window of opportunity against binge drinking in normatively constrained group settings. Once individuals increase drinking, normative estimates adjust to match drinking levels within social groups, which may set the stage for drinking escalation within resulting drinking cultures. Alcohol consumption is a variable that has attracted much attention in both the social sciences and the biomedical sciences. In recent years, attempts have been made to find common ground among these fields, and interest groups have attempted to utilize knowledge gained in the social sciences on the social risk factors of drinking behavior for the development of intervention policies to diminish alcohol-related problems. (Graupensperger et al.2021)

4. Alcohol Use Disorders

In Western societies, alcohol use is ubiquitous, and a large majority of the population consumes alcoholic beverages of various kinds. For most, alcohol consumption is limited, involves only the occasional drink, and does not lead to any adverse consequences. However, for a sizable minority, alcohol use leads to a chronic social and health problem characterized by hazardous and harmful consumption. According to the latest guidelines of the World Health Organization, about 40% of the Western adult population qualifies as having an alcohol use disorder (AUD), defined as at least one of the following 11 criteria within the last 12 months: 1) consuming alcohol in larger amounts or over a longer period than intended; 2) wanting to cut down or stop, but not succeeding; 3) spending a significant amount of time obtaining, using, or recovering from alcohol; 4) craving alcohol; 5) causing conflicts with family or friends; 6) neglecting social, occupational, or recreational activities due to drinking; 7) using alcohol in hazardous situations; 8) continuing to use alcohol despite causing problems; 9) developing tolerance; 10) experiencing withdrawal symptoms; 11) engaging in behavior that poses a risk to health, such as liver disease, accidents, and overdosing. In the United States, someone dies of alcohol consumption every 12 minutes. It has been estimated that alcohol consumption costs the United States over $223.5 billion per year, accounting for 1.9% of its gross domestic product (GDP). In 2004, Canada drank on average 14.9 liters per person, the second highest among the countries more developed organizations. (Neufeld et al.2021)

There is a clear need for effective preventive measures to deal with AUDs. A wide range of risk factors have been identified that make individuals more vulnerable to develop an AUD, which can be divided into factors that are biological, genetic, environmental, social, and psychological in nature. The implementation of preventive measures should focus on combating the impact of these factors. Several institutions provide clear insight into AUDs and guidelines focused on at-risk populations, available for health workers, educational institutions, governments, and online.

4.1. Risk Factors and Prevention

Causal pathways exist through which such risk factors exert their effects, modifying, mediating, or influencing measures of social behavior in youth. In turn, such behaviors affect alcohol use and intoxication and, consequently, the risk for the development of AUDs later in life. In recognizing how time and different levels of organization along such pathways may modify the effects of risk factors on the progression of alcohol use, intoxication, and abuse would allow for development of more effective approaches for prevention and intervention at different stages in development. (Karunamuni et al., 2021)

Although relationships exist between higher level demographic and societal influences, such as advertising, pub and bar availability, and college status, there has been less focus on identifying specific mechanisms through which higher level influences affect individual level risk factors. This has limited understanding of how societal level forces, such as alcohol marketing directed at youth and the availability of alcohol on campuses, shape the risk of early onset drinking across different cultures and societies.

Persons who drink to intoxication are at elevated risk for alcohol dependence. Because alcohol intoxication is the putative mediator of most of the acute pharmacological effects of alcohol consumption on social behavior, it is important to identify risk factors that affect the progression of drinking and intoxication. Various risk factors are likely to exert their effects on drinking and intoxication in different ways over the course of development. Factors that affect the earlier and initial use of alcohol are likely to have different effects on the risk and timing of intoxication. Factors that influence drinking in adolescence and young adulthood are likely to be distinct from those that influence use patterns in older adults.

The concept of drinking trajectories is introduced as a way to explore individual differences in drinking and intoxication patterns over the course of development. Such trajectories can be inferred indirectly through the analysis of longitudinal data or can be modeled directly from cross-sectional data. Trajectories of use can take different forms, such as user/non-user, increasing/decreasing, or stable patterns, or they can involve different types of use (e.g., average quantity or frequency of use), different substances (e.g., alcohol and cigarettes), or levels of a dependent variable (e.g., alcohol abuse, sensation-seeking, neuropsychological functioning). Likewise, trajectories of intoxication can vary, ranging from never intoxicated to a steady increase in intoxication as drinking increased.

5. Conclusion and Future Directions

Throughout this essay, alcohol's wide range of effects—both socially and physically—has been examined. It was revealed that when consumed in moderation, alcoholic drinks can improve confidence and decrease anxiety or discomfort in company settings. However, the motivation behind alcohol consumption often changes as consumption escalates. The negative impact of excessive drinking becomes evident, as this change can include violence or disagreements. Furthermore, while binge drinking occasionally can be viewed as harmless fun, at-risk groups often develop substance abuse, which heavily affects health and social engagement. Such groups often include younger people, who are still learning social norms and have less experience with substance use. Studies show that those aged 18-30 account for the highest number of deaths due to binge drinking, and that those who begin drinking before age 15 are more likely to develop substance abuse.

There are many factors that lead to this escalation of drinking patterns. Properties of the drink itself can play a role; alcohol consumption increases in bars or clubs after drinks are bought, because of their higher alcohol content and cheap price. The environment can also affect drinking patterns; programs intending to reduce drinking in bars often focus on the drinking culture, which consists of music and dancing, and urges the idea of drinking to escape reality. Women’s drinking often shapes the social culture in such venues. However, it does not appear that alcohol programs successfully reduce drinking, often leading to disappointment, an increased need for alcohol, and uptake in drug use. Future directions could include investigating the intoxication of substances other than alcohol, exploring whether binge-drinks increase or decrease drug use, and utilizing rodent models with social behavior experiments greatly differing from existing paradigms, with a focus on sex differences.

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