MODULE 8:
“AT-RISK” POPULATIONS
Summary:
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“At-risk” populations include those individuals who are particularly susceptible to the harmful
effects of alcohol due to intrinsic or external factors.
Risk for harm may be the result of an individual’s own drinking, that of others, or lifestyle factors.
Genetic difference, general health status, mental health, age, and gender may all contribute to
heightened risk.
For some people social and economic circumstances increase the risk for harm.
“At-risk” populations require policy approaches that allow for prevention and intervention that are
realistic and correspond to prevailing drinking patterns, circumstances, and cultural needs.
Where “at-risk” groups are hard to reach, special interventions relying on non-traditional
approaches may be necessary.
Interventions tailored to the needs of “at-risk” groups should be taken into account and integrated
into the provision of general healthcare services to the extent possible—including education,
screening, and treatment.
For EXAMPLES OF TARGETED INTERVENTIONS, see the Blue Book index page of www.icap.org.
“At-risk” or “special” populations include a broad and diverse range of individuals who are
deemed to be particularly susceptible to either the physical or psychological effects of alcohol and
are, thus, more likely than others to experience adverse outcomes of drinking. For some, harm may
be the result of their own drinking. For others, heightened risk may be related to the drinking of
those around them. Together, these groups represent a particular cause for public health concern
and serve as specific targets for interventions and prevention measures (see also MODULE 9:
Women and Alcohol; MODULE 11: Young People and Alcohol; MODULE 17: Alcohol
Dependence and Treatment; MODULE 23: Alcohol and the Elderly).
Intrinsic risk factors
Risk factors related to drinking may be grouped into two basic categories: intrinsic and
environmental. Factors that are biological and endogenous in nature fall under the former category.
Genetics
Genetic differences in the ability to metabolize alcohol and in physiological responses to it may
increase the risk of negative outcomes of drinking for some people (Begleiter & Porjesz, 1995,
1999; International Center for Alcohol Policies, 2001). 1 They may also underlie variations in how
the brain and neurotransmitter systems respond when exposed to alcohol (Begleiter & Porjesz,
1995; Loh & Ball, 2000). These differences may manifest themselves as low tolerance to alcohol
and the inability for the body to break it down effectively (Goedde et al., 1992; Wall & Ehlers,
1995; Wall, Horn, Johnson, Smith, & Carr, 2000). For example, among some ethnic groups—
notably Asians of Chinese, Korean, and Japanese descent—genetic variation in the enzyme
responsible for breaking down alcohol and eliminating it from the body, aldehyde dehydrogenase
(ALDH), is fairly common (e.g., Maezawa, Yamauchi, Toda, Suzuki, & Sakurai, 1995 ; Smith,
1986; Wall et al., 2000). Similar variations are also found among some Ashkenazi Jews, Native
1
See ANNEX 2: The Basics about Alcohol for an overview of the mechanism by which alcohol is
broken down in the body.
Americans, and certain indigenous populations in South America (Gill, Elk, Liu, & Deitrich, 1999;
Neumark et al., 2004). Physiological symptoms that may follow alcohol consumption for these
individuals include nausea, dizziness, heart palpitations, and a “flushing” reaction.
Increased risk for alcohol abuse or dependence in some individuals is also attributable to genetic
factors (MODULE 17: Alcohol Dependence and Treatment; e.g., Heilig & Sommer, 2004;
Sommer, Arlinde, & Heilig, 2005). This heightened susceptibility is often transmitted across
generations within families (Ehlers, Slutske, Gilder, Lau, & Wilhelmsen, 2006; Goodwin, 1985;
Haber, Jacob, & Heath, 2005; Schuckit et al., 2000). However, the same genetic differences that
underlie differential risk for harm may also provide an opportunity for screening and prevention.
Certain traits may serve as markers for “at-risk” individuals. Characteristic brain activity, certain
personality traits, and a high tolerance for alcohol may be useful in identifying those individuals
likely to develop dependence later in life (Porjesz & Begleiter, 1998; Schuckit & Smith, 2001;
Soloff, Lynch, & Moss, 2000).
Health status
The effects of alcohol are closely linked to the health and nutrition status of the drinker. Thus,
individuals who are malnourished may be particularly susceptible to adverse outcomes, an issue
closely related to socioeconomic considerations (Marmot & Wilkinson, 1999; see section on
“Socioeconomic Issues” below). Indeed, neurological impairment among heavy chronic drinkers
and alcohol-dependent individuals has been linked to nutritional deficiencies (e.g., Manzo,
Locatelli, Candura, & Costa, 1994; Thomson & Cook, 2000).
Certain medical conditions can increase the potential risk associated with alcohol consumption.
Although moderate drinking has been shown to have a beneficial effect on some individuals with
Type II diabetes mellitus, for others even moderate alcohol intake may induce low blood sugar
levels (hypoglycemia) and heavy drinking can result in serious health consequences (Emanuele,
Swade, & Emanuele, 1998). Hypertensive individuals may be adversely affected by drinking, and
those infected with hepatitis C may be at risk for accelerated liver disease if they consume alcohol
(Beilin, 1995; Beilin, 2004; Regev & Jeffers, 1999; Wakim-Fleming & Mullen, 2005).
The interaction of alcohol with a range of medications may also heighten the risk for harm.
Alcohol intake may reduce the effectiveness of some medications and even have dangerous effects
(Ramskogler et al., 2001; Sternbach & State, 1997). In particular, adverse interactions have been
described for analgesics, antihistamines, anticoagulants, psychopharmacologically active drugs,
anti-hypertensive medication, and antibiotics (Weathermon & Crabb, 1999). Such potentially
harmful interactions present a particular concern for older individuals who are more likely than
younger people to take medications and whose health status may generally be weakened (see
MODULE 23: Alcohol and the Elderly).
There is evidence that individuals with certain mental health problems are also at increased risk for
alcohol abuse and adverse outcomes. Comorbidity with alcohol abuse has been reported for a
number of mental health conditions, including panic and anxiety disorders, depression, and bipolar
disorder, especially among those who lack adequate access to support (Alati et al., 2005; Beals et
al., 2005; Pashall, Freistheler, & Lipton, 2005). Attention-deficit / hyperactivity disorder (ADHD)
in children may be a predictor for alcohol abuse and dependence later in life (Schubiner, 2005;
Wilens, 1998). These findings support the notion that alcohol abuse and mental health disorders
share a common genetic linkage. They also suggest that, where comorbidity is evident, special
interventions may be needed (see MODULE 17: Alcohol Dependence and Treatment; e.g.,
Schubiner, 2005; Sher et al., 2005).
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Alcohol abuse and dependence
Individuals with abusive drinking patterns are at increased risk for both health and social harm.
This applies as much to those who are alcohol-dependent as to those who are not (see MODULE
17: Alcohol Dependence and Treatment). Chronic heavy drinkers, for example, are more likely
to develop hepatic disease, including liver cirrhosis, and neurological problems (Harper &
Matsumoto, 2005; McKillop & Schrum, 2005; Sougioultzis, Dalakas, Hayes, & Plevris, 2005;
Willner & Reuben, 2005). A range of social risks related to family life or the workplace are also
more commonly found among these individuals than among other groups (Boyd & Mackey, 2000;
Haw, Hawton, Casey, Bale, & Shepherd, 2005; Hornquist & Akerlind, 1987). The risk of acute
problems—including accidents and injuries—is also increased with alcohol abuse and such
drinking patterns as binge drinking and intoxication (Cherpitel et al., 2006; Moore, 2005; Salome,
French, Matzger, & Weisner, 2005).
Age
Young people are considered to be “at risk” for harm from alcohol for several reasons. Children
and adolescents, for example, may have increased sensitivity to the effects of alcohol due to
specific changes in physiological development (Abate, Spear, & Molina, 2005; Chung, Martin,
Winters, & Langenbucher, 2001; Koob et al., 1998; Spear, 2004). Young people’s inexperience
with alcohol and inability to gauge and enforce their own limits increase the potential risk for
harm, especially where drinking is paired with other activities, for example, driving (see MODULE
15: Drinking and Driving). Adolescence is generally a period for experimentation when young
people take risks and test their own limits. These factors contribute the risk young people may
experience from drinking (see MODULE 11: Young People and Alcohol).
There is also evidence suggesting that young people who begin drinking at an early age may be at
greater risk for alcohol problems later in life (Maggs & Schulenberg, 2005; Pitkanen, Lyyra, &
Pulkkinen, 2005; Warner & White, 2003). However, the nature of this relationship has not been
clearly identified. Drinking culture, family, and social context are all likely to play a role in
whether risk is elevated (Baumeister & Tossmann, 2005; Kuperman et al., 2005; Pitkanen et al.,
2005).
The elderly are also considered an “at-risk” group when it comes to alcohol (see MODULE 23:
Alcohol and the Elderly). Although drinking in moderation has been linked to health benefits for
the elderly, some older people are at increased risk for harm. The ageing process is associated with
physiological changes, such as a reduction in body water content, decreased hepatic blood flow,
and a reduced efficiency in the metabolism of alcohol (Scott, 1989). The pharmacological
interaction of alcohol with various medications also increases risk in the elderly. The stresses of
ageing, loneliness, and various lifestyle changes in this group further increase their risk for alcohol
abuse and harm.
Gender
Women, particularly pregnant women, are generally identified as an “at-risk” population in terms
of alcohol consumption. The physiological differences between women and men influence their
respective abilities to metabolize alcohol and mean that the harm threshold for women may be
lower than that for men (see ANNEX 2: The Basics about Alcohol). The need to provide access to
gender-sensitive prevention and treatment has been recognised. Some of these approaches, as they
relate to both women and pregnancy, are discussed in MODULE 9: Women and Alcohol and
MODULE 10: Drinking and Pregnancy.
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Environmental factors
External factors also play an important role in determining the degree of risk an individual is likely
to experience from his or her own drinking, as well as from the drinking of others.
Parental drinking
There is evidence that parental alcohol consumption plays a significant role in the drinking
behaviour of offspring, both in establishing positive patterns and in increasing risk for harm (e.g.,
Houghton & Roche, 2001). Drinking problems among parents are predictive of elevated risk for
similar problems in children. In general, those whose parents are alcohol-dependent are more likely
to themselves be dependent or abusive drinkers (Chalder, Elgar, & Bennett, 2006; Kuperman et al.,
2005; Pulkkinen & Pitkanen, 1994). It should be noted that many parental influences beyond
drinking have a profound effect on the development of drinking behaviors and potential problems
in young people (MODULE 11: Alcohol and Young People; e.g., El-Sheikh & Buckhalt, 2003).
Another aspect of parental drinking relates to alcohol consumption during pregnancy and the
increased risk for harm this may represent, as discussed in MODULE 10: Drinking and
Pregnancy.
Stress
Stress of various types—including that associated with traumatic events or situations, work stress,
abuse, and issues related to maturation and ageing—may contribute to the development of drinking
problems (e.g., Anisman & Merali, 1999; Pulkkinen & Pitkanen, 1994; Ragland, Greiner, Yen, &
Fisher, 2000; Sawchuk et al., 2005). The body’s response to pressure at the physiological and
psychological levels exacerbates risk for harm from alcohol consumption. There is evidence that
some individuals who are under stress, especially for prolonged periods of time, may be at
increased risk for problems relating to their drinking, as many of them may consume alcohol in
order to cope (Sayette, 1999).
Socioeconomic issues
Risk exposure is directly related to access to nutrition, health care, education, and a social network.
Where any of these is inadequate, risk for harm in general is heightened, including harm related to
drinking. The poor tend to be more susceptible to harm and have fewer means of coping
adequately with risk. Alcohol problems and abuse may be often observed as side-effects of social
deprivation (e.g., Lee & Jeon, 2005; Subramanian, Nandy, Irving, Gordon, & Smith, 2005). Access
to intervention—whether specific to alcohol problems or to health care in genera—is largely
limited or even entirely non-existent for these populations.
Social exclusion and marginalization are also identified risk factors for alcohol abuse. Indigenous
populations and certain ethnic and social groups in some countries are often outside the
mainstream of society, generally enjoy lower socioeconomic status, and inadequate access to
health care and other services (e.g., Alaniz, 2005; Brady, 2000; Ehlers et al., 2006; Hughes, 2005;
MODULE 24: HIV/AIDS, High-risk Behaviors, and Risky Drinking Patterns).
Professions and workplace
Individuals in a number of professions may be at increased risk for alcohol-related harm. Among
them are those involved in the production and service of beverage alcohol. There is evidence that
individuals involved in the retail sector of the beverage alcohol industry, notably those working in
pubs and bars, may have higher risk for alcohol abuse than the general population (reviewed in
International Center for Alcohol Policies, 2003).
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Professions with high levels of stress may also place those working in them at risk for alcohol
abuse and other problems. These include law enforcement, as well as professions exposed to high
rates of occupational hazards, such as chemical or biological substances, physical hazards, injury
risk, and mental stress (e.g., Conrad, Furner, & Qian, 1999; Davey, Obst, & Sheehan, 2000).
Journalists have been reported as having a higher incidence of alcohol problems compared to those
in other professions, as have military personnel and doctors (e.g., Cosper & Hughes, 1982; Engel
et al., 1999; Kumar & Basu, 2000).
Policy considerations
Because of their heightened susceptibility for harm, “at-risk” populations represent specific targets
for interventions and policy. Approaches that are sufficient to address the needs of the general
population may not adequately address theirs. Carefully tailored approaches should be considered
to ensure that the risk for harm to each of the groups outlined above can be minimized.
Data collection
Any policies aimed at particular “at-risk” groups require a sound understanding of the actual
drinking patterns and problems among these populations. This argues for the collection of detailed
information so that appropriate measures can be developed.
Some “at-risk” populations are socially marginalized and thus difficult to access, which is one of
the reasons risk for them in increased. For instance, those who belong to particular ethnic or
indigenous groups may not be fluent in the “official” language of the country or have a stable
residence. Creative approaches are therefore needed to reach these populations in a way that is
sensitive to their particular cultures and utilizes relevant social networks and venues. Thus,
pharmacists, social workers, or individuals working in shelters may be well placed to collect
information and could be trained to do so. Where data are already collected on risk groups’ health
and social issues, attention to drinking patterns and outcomes would be a useful addition.
Prevention
An important element in prevention is educating those at risk about drinking and its potential
outcomes. Alcohol education includes informing key audiences about risks, benefits, and related
issues, raising their awareness and ultimately attempting to change behavior. It is provided through
a range of channels (see MODULE 1: Alcohol Education), but, in the case of “at-risk” populations,
careful tailoring should be considered both in terms of the channels that are used and the messages
conveyed through them.
Prevention efforts, including education, should strive to be delivered in a way that is meaningful to
target groups, will resonate with them, and make sense. There is also evidence that prevention
measures that empower individuals receiving them and allow active participation may be of
particular value. For example, peer education and the involvement of family in intervention and/or
treatment could be effective approaches when dealing with young people.
Prevention also requires the use of appropriate channels most likely to reach intended audiences.
Schools offer a convenient setting for information dissemination and awareness building among
young people, although the effectiveness of these efforts has been debated. Prevention can also be
targeted through venues that are likely to be frequented by “at-risk” groups—for instance, social or
athletic clubs and organizations, youth groups, shelters for the homeless or abused, emergency
rooms, foster care, soup kitchens, and others.
The workplace also offers a powerful approach to preventing harm for “at-risk” drinkers through
training, awareness building, education and the provision of counseling and treatment services.
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Codes of practice and regulations on alcohol and the workplace, when properly enforced, are
useful measures for preventing harm.
Where “at-risk” groups are particularly hard to reach, unconventional approaches may be most
effective. For example, reliance on radio and television broadcasts may be advisable where
illiteracy rates are high. Theatre groups have also been helpful in conveying certain key messages.
This approach has been used in developing countries when focusing on several areas of health
(e.g., MODULE 24: HIV/AIDS, High-risk Behaviors, and Risky Drinking Patterns).
If language proficiency is a problem—for instance, among indigenous populations, immigrant,
and/or various ethnic groups—messages should also be conveyed in the language with which the
target population is most comfortable and in a way that is culturally appropriate. Attention may
need to be given to who conveys the message. Among Native American populations, for example,
involving community elders may increase he likelihood that messages will be received.
Finally, the success of interventions also hinges upon whether those who provide them understand
the issues they are meant to address and can communicate effectively with their targets. This
necessitates appropriate training of health professionals, social workers, educators, and others in
close contact with “at-risk” groups. Again, dealing with such populations requires an
understanding of key issues, sensitivities, and the reality of the drinking behavior and problems
among target groups.
Screening and intervention
The identification of those at particular risk for harm relies on effective screening. Individuals at
risk for alcohol abuse and dependence can be assessed through several useful instruments,
including the Alcohol Use Disorders Identification Test (AUDIT), which has been validated crossculturally (MODULE 17: Alcohol Dependence and Treatment; MODULE 18: Early
Identification and Brief Intervention). In many cases, only brief intervention that modifies
potentially harmful drinking patterns may be necessary. The primary health care setting offers an
appropriate venue for such screening, as do emergency rooms, practices of general practitioners,
general health services, social services, or other facilities that are at the disposal of different groups
whose risk for harm may be elevated.
Appropriate and affordable treatment for individuals identified as “at-risk” for alcohol problems is
an integral part of any comprehensive policy. Treatment providers need to be aware of the
particular needs, cultural requirements, and lifestyle issues of the “at-risk” groups they are likely to
encounter. Where possible, integrating treatment for alcohol problems into the general provision of
health care is preferable.
Primary health providers, educators, social workers, and others can also be instrumental in
screening individuals at risk for harm from others’ drinking or certain lifestyle factors.
Recognizing the signs of abuse, stress, or other hazards can help identify “at-risk” individuals and
offer means for intervention.
Conclusions
Individuals who are at increased risk for harm from drinking require special attention with regard
to prevention and intervention measures as compared to the general population. As they are often
outside of the mainstream with regard to health care and access to resources, reaching them may
present a policy challenge. However, balanced policies around alcohol should also take “at-risk”
groups into account, including special provisions for understanding and meeting their needs.
Particularly in countries where social disparities are common and related to disparities in access to
proper care, greater attention is needed to identifying and protecting those most at risk.
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POLICY OPTIONS: “At-risk” Populations
In developing policies and approaches, consideration of a number of key elements is required.
While some may be necessary at a minimum and under most conditions, others may not be
appropriate in all cases, or may be difficult to implement. The list below offers a menu of areas
that need to be addressed, based on effective approaches that have been implemented elsewhere.
Specific examples are provided in the TARGETED INTERVENTIONS section of the ICAP Blue
Book.
Information
Collection of detailed information on “at-risk” groups, their drinking patterns, and health
outcomes through general surveys and in venues where access to these populations is possible.
Provision of tailored information: education about drinking patterns and outcomes.
• Realistic information within the context of the lives of “at-risk” groups.
• Culturally sensitive information and delivery.
• Inclusive approaches that empower those at risk.
• Realistic and achievable goals and behavior modifications.
Access to prevention and treatment
Provision of adequate health care and screening where “at-risk” groups can be reached (e.g.,
prenatal care, shelters, soup kitchens).
• Train health professionals, social workers, and educators to provide guidance and advice
applicable and relevant to “at-risk” groups.
• Sensitivity to particular social and health issues that may obscure drinking problems.
• Where mainstream access is unavailable, alternative methods should be explored.
• Ensure availability of screening tools appropriate for individual sub-populations at risk
(e.g., the elderly, young people).
Special considerations
• Access to prevention and treatment through the workplace, including screening for
problems and brief interventions.
• Culturally appropriate access and interventions for indigenous populations and ethnic
groups outside the social mainstream.
• Attention to cultural context and views on drinking, language considerations.
• Implementation of non-traditional approaches for hard-to-reach groups that rely on
alternative means of communication (e.g., illiterate individuals).
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