summarizes the evidence synthesized from this review. Two key findings are highlighted. First, in general, for those injured, Native Americans and Asians have rates of alcohol-attributable injury and percent blood alcohol content positivity that would be expected given their level of alcohol consumption documented in national surveys. Native Americans are at higher risk of many alcohol-involved injury deaths than are individuals of other racial/ethnic groups, including motor vehicle crash fatality (driver, child occupant, or pedestrian), suicide, and falls; conversely, Asians have the lowest rates of most alcohol-attributable outcomes of any ethnic group measured.
| Table 6.Summary of Findings Across Published Literature on Racial/Ethnic Differences in Overall Alcohol-attributable Injury and Percent Blood Alcohol Content Positivity Comparing Racial/Ethnic Minorities With Non-Hispanic Whites in the United States |
Second, the rate of alcohol positivity and intoxication for Hispanic injury deaths is disproportionately high relative to the use of alcohol documented in national survey data, particularly for injury involving motor vehicle crash, suicide, and homicide. Black subgroups also evidence higher rates of alcohol positivity than we would have expected given national estimates of alcohol use for some outcomes, including alcohol positivity among drivers of fatally injured black children and homicide. Racial/ethnic differences in rates of blood alcohol content positivity differ considerably from rates of overall alcohol-attributable injury because overall rates are likely driven by factors unrelated to alcohol consumption (e.g., the rate of alcohol-attributable homicide is highest among blacks, consistent with the overall high rate of homicide among blacks due likely to non-alcohol-related factors such as concentrated disadvantage and segregation (
35–
37)).
Thus, we found that rates of blood alcohol content positivity are particularly illuminating in examining alcohol-related health disparities. The results of this literature review are concordant with a 1991 review of race/ethnicity and drunk driving (
38), which reported that blacks and Hispanics were disproportionately more likely to be involved in drunk driving yet less likely to be lifetime drinkers and less likely to binge drink compared with whites. This disparity between rates of alcohol consumption and rates of alcohol-attributable injury indicates that the fatal consequences of excessive alcohol consumption are higher for blacks and Hispanics than for other non-Hispanic whites.
The high rates of several alcohol-attributable injuries experienced by Native Americans compared with other racial/ethnic minorities as well as non-Hispanic whites highlight the well-documented health disparities in this group. Compared with other racial/ethnic groups including other minority groups, Native Americans are more likely to die of sudden infant death syndrome (
39,
40), hypothermia (
41), and complications due to type 2 diabetes (
42), among other outcomes, and evidence indicates that this disparity is growing over time (
43). Native Americans in the United States have a long history of structural discrimination, which is hypothesized to lead ultimately to a cascade of health problems and disparities that remain among the most pressing public health issues of our time (
44).
The high prevalence of alcohol consumption and alcohol use disorders among some Native American groups is well documented. In , we present data from the largest population-based survey of alcohol use and related problems ever known to have been conducted in the United States; as shown, Native Americans/Alaska Natives have a higher prevalence of every alcohol outcome analyzed compared with all other racial/ethnic groups. Evidence suggests that Native Americans are less likely than other racial/ethnic groups to use seat restraints and child car seats (
19,
45,
46) and that use of child restraints and seat belts is inversely related to alcohol consumption (
47). Further, national data indicate that Native Americans have higher rates of major depression than other racial/ethnic groups (
48), which may at least partially explain higher overall alcohol-attributable suicide rates. Overall, these data highlight the continued public health importance of reducing excessive alcohol use among this high-risk population. Taken together, these results indicate that intervention and prevention programs to reduce problematic alcohol consumption among Native American populations may result in a reduced incidence of many health outcomes, including many injuries.
Blacks and Hispanics evidenced more fatal consequences of alcohol consumption for some injury outcomes than non-Hispanic whites did despite a lower population prevalence of alcohol use. Blacks and Hispanics had higher rates of alcohol positivity among those fatally injured in motor vehicle crashes as drivers, child occupants, or pedestrians and from suicide, homicide, and other unintentional injuries, especially alcohol poisoning (although we importantly note that not all studies were consistent regarding these findings (
24,
26), suggesting more research is needed before a firm consensus can be formed). These results coincide with the broader injury literature showing that racial/ethnic minorities are more likely to die in a motor vehicle crash than non-Hispanic whites are (
49). Further, these results are consistent with other health outcomes; for example, rates of alcohol-attributable cancers such as those of the esophagus and larynx are higher among non-Hispanic black men compared with non-Hispanic white men (
11,
12). As shown in , population-based estimates indicate that blacks, and especially Hispanics, are less likely than non-Hispanic whites to consume alcohol, binge drink, and evidence alcohol use disorders, yet these groups are not only more likely to die from some alcohol-attributable injury outcomes, but, regarding injury deaths, individuals in these groups are also often more likely to be alcohol positive.
Differential underreporting of alcohol consumption by black and Hispanic subgroups
One possible explanation for these results is that national surveys, which collect information on self-reported alcohol consumption, underestimate the true prevalence of consumption among black and Hispanic subgroups. This possibility would explain the results by suggesting that actual patterns of alcohol consumption for blacks and Hispanics are higher than those for whites, leading to a higher prevalence of alcohol-attributable injury. Limited data are available at the national level to validate self-reports of alcohol consumption or to evaluate the extent to which some racial/ethnic groups differentially underreport consumption. However, several factors strongly associated with lower alcohol consumption are more prevalent among black and Hispanic groups, most notably religiosity (
50–
52). This finding suggests that the lower prevalence of alcohol consumption among black and Hispanic groups compared with non-Hispanic whites, as reported by national surveys, is valid.
Lower prevalence of health-promoting behaviors
Some researchers have posited that the disparity in outcome for motor vehicle crash derives from a lower use of child car seats and seat belts (
19,
45,
46,
53). For child-occupant deaths, blacks and Hispanics are more likely to have children in the car than non-Hispanic whites are, creating a higher exposure opportunity (
49). However, for fatally injured children, the odds of having an alcohol-positive driver versus an alcohol-negative driver at the time of the death is equal across racial/ethnic groups (including black, Hispanic, Native American, Asian, and white), suggesting that, conditional on death, racial/ethnic minorities are not more likely to drive with a child while under the influence of alcohol (
19). Further, the consistency of this finding across injury outcome suggests that exposure opportunity and restraint use do not entirely explain these results.
Differential drinking patterns
Others have suggested that perhaps blacks and Hispanics have a lower drinking frequency than whites do but that they drink more heavily per drinking occasion or consume beverages higher in alcohol content. If this pathway were operative, it would explain a higher risk of injury; evidence suggests that individuals who engage in heavy-volume occasional drinking are at a higher risk of injury outcomes (e.g., falls (
54,
55), motor vehicle crash (
56), and suicide (
57)) compared with individuals who engage in more frequent low-volume drinking.
Some specific problems associated with alcohol have been shown to be more common among racial/ethnic minorities who drink compared with non-Hispanic whites who drink, such as interpersonal and occupational problems and trouble with law enforcement (
14,
58), although these factors could be linked to racial/ethnic discrimination. Evidence from the National Alcohol Survey indicated that blacks and Hispanics experience significantly higher rates of alcohol problems than non-Hispanic whites do, but only among those consuming very low levels of alcohol, suggesting that social context is an important aspect of the development of problem alcohol use (
59). National data (e.g., ) indicate that blacks and Hispanics are less likely to engage in any binge drinking as well as frequent binge drinking compared with non-Hispanic whites, although available data indicate substantial heterogeneity within racial/ethnic subgroups (
60–
62) that should be investigated more systematically as an explanation for these findings. Further, there is evidence that blacks and Hispanics experience a later age at onset of dependence but a longer persistence compared with non-Hispanic whites (
13); in fact, some cross-sectional evidence exists of an age crossover in the epidemiology of alcohol use (
15), whereby blacks and Hispanics in older age groups have higher rates of drinking than do non-Hispanic whites in the same age group.
Neighborhood factors
The disproportionate risk of alcohol-attributable homicide for non-Hispanic blacks and Hispanics, relative to non-Hispanic whites, may be partly related to a racial/ethnic difference in overall risk of homicide as well as to neighborhood factors. Independent of alcohol use, blacks and Hispanics are at higher risk of being victims and perpetrators of homicide (
35), which may in itself partly explain the higher rate of alcohol-attributable homicide among these groups. Beyond this overall difference, however, blacks and Hispanics are more likely to reside in neighborhoods with higher concentrations of alcohol outlets and alcohol advertising (
63,
64). Such outlets and ads are particularly directed at the sale of high-alcohol-content beverages, which may lead to faster inebriation and contribute to the escalation of fights into fatal outcomes. In fact, area concentration of outlets and advertising has been repeatedly linked with a higher rate of homicide and nonfatal assault (
65–
67). Hence, the patterns of street and bar consumption of alcohol associated with concentration of such outlets may make low-income blacks and Hispanics particularly vulnerable to alcohol-attributable homicides.
Neighborhood factors may also explain disparities in alcohol poisoning. The unintentional drug overdose literature has shown that income inequality of the neighborhood is associated with rate of drug overdose (including overdose in which alcohol was detected on autopsy) (
68) and that neighborhood disorganization and disorder at least partially mediate this relation (
69). Given that alcohol poisoning is associated with unintentional drug overdose and that blacks as well as Hispanics, compared with non-Hispanic whites, have higher rates of alcohol poisoning, neighborhood and other contextual factors may at least partially explain this association. More generally, disadvantaged neighborhoods may have less access to and worse-quality health care resources in the event of an unintentional or intentional injury. Taken together, further examination of the context in which racial/ethnic minorities live and work as potential risk factors for alcohol-attributable injury is warranted.
Unreliable racial/ethnic data
Methodological issues may explain part of this discrepancy, but they are unlikely to explain all of it. Substantial evidence indicates differential misclassification and incomplete record keeping of racial/ethnic status for injury data. For example, data on the race/ethnicity of injured persons for the FARS record are typically drawn from the National Center for Health Statistics Multiple Cause of Death file. FARS and National Center for Health Statistics records are then matched to provide estimates of racial/ethnic differences in motor vehicle crash in which alcohol was involved; however, linkage rates between FARS and the Multiple Cause of Death file are lower for Hispanics compared with non-Hispanic whites (
70), and 17 states report Hispanic ethnicity in less than 79% of crash fatalities (
70). Further, states vary in the extent to which Hispanic ethnicities are included on death certificates (
70), and Hispanic ethnicity is often unrecorded or incorrectly recorded on death certificates (
71–
73). The reliability of race/ethnicity recorded on death certificates in the United States ranges from a kappa of 98% for whites and blacks to only 57% for Native Americans and less than 50% for some Hispanic ethnicities (
74). In addition, blood alcohol content is recorded in the FARS data for a majority of drivers involved in fatality-resulting motor vehicle crash, but differences are documented by race/ethnicity (by racial/ethnic group, the percentage tested ranges from 69% among blacks to 79% among Asians (
18)).
Subgroup variation
Categorization of individuals according to subjective and dynamic concepts such as “race” and “ethnicity” is, while powerfully predictive of health, problematic (
75). Definition of these terms depends on the context, changes over time, and has little meaning beyond predicting social circumstances (
76). Even when studies included in the present review attempted to disaggregate rates beyond white versus nonwhite, substantial misclassification is likely present. Further, most studies combine all those who report Hispanic ethnicity into a single category, which may obscure important subgroup variation (
20); previous studies have documented substantial variation in patterns of alcohol use within ethnic subgroups (
13,
60–
62,
77). Discrete categories also create false dichotomies between categories such as black and Hispanic (i.e., in reality, these groups overlap substantially).
In general, however, we acknowledge the inherent limitations in using administrative classes based on ambiguous concepts such as race and ethnicity, but we point to the importance of continuing to study outcomes across racial/ethnic groups, despite these problems, to identify and ultimately rectify inequities. These misclassification errors would explain the higher alcohol-attributable death rate only if those Hispanics who were incorrectly classified were less likely than correctly classified Hispanics to experience an alcohol-attributable death. While some differential misclassification of this nature is plausible, it is unlikely to account for all of the differences we found. More data on the association between alcohol consumption and misclassification would be useful to tease apart these associations. The alcohol injury literature would be served by greater attention to ethnic subgroups rather than race classifications, as has been the direction in alcohol epidemiologic literature more broadly.
Discrimination and prejudice
Additionally, there may be racial bias in the assessment of alcohol positivity among injury victims, in police involvement, or in bystander aid (leading to more fatal consequences of alcohol-involved injury). Crosby et al. (
30) documented that blacks and Hispanics classified as suicides are more likely than non-Hispanic whites to be tested for drugs and alcohol. In fact, blacks are most likely to be tested but are least likely to be found positive. Consistent with this, Voas et al. (
20) found that drivers of black and Hispanic children fatally injured in a motor vehicle crash are more likely to be tested for drugs and alcohol compared with drivers of non-Hispanic white children. Further, blacks and Hispanics may face greater scrutiny for alcohol use when police or law enforcement become involved in a situation in which injury has occurred. Finally, research in experimental psychology has demonstrated that bystanders are less willing to intervene to aid racial/ethnic minorities (
78), which may lead to more fatal consequences of an injury if medical assistance is delayed. Additional research into this issue is necessary to gauge how much this bias accounts for the discrepancy between alcohol consumption and injury outcomes, an important future step in this research area.
Foci for future research
Given that the FARS database has included information on race/ethnicity for over a decade, more research using this database to explore racial/ethnic correlates of driver-related, road-related, and vehicle-related injury is accessible, publicly available, and needed to fully understand the patterns presented here. Future research should focus on effect-measure modifiers of the relation between race/ethnicity and injury outcomes to elucidate the pathways through which these effects arise. For example, Abdel-Aty and Abdelwahab (
28) found that nonwhites had higher rates of alcohol-attributable injury compared with whites only after age 55 years, suggesting important age-related variation in the relation between race/ethnicity and injury.
These results are consistent with those from major epidemiologic studies of alcohol comparing blacks and whites, which suggest that whites have higher rates of alcohol and tobacco use at younger ages, but, at older ages, no differences between blacks and whites are observed or blacks have slightly higher rates than whites do (
79). Among Hispanics, more attention to background, immigration status, and bicultural identity is necessary to fully understand the troubling increases in alcohol-attributable injury risk. As shown in this review, and consistent with the alcohol epidemiologic literature (
60,
80,
81), rates of alcohol consumption and alcohol-attributable injury are lower among more recent immigrants to the United States compared with native-born persons or immigrants living for a longer time in the United States. Further, the likelihood of alcohol involvement varies by injury severity (
82), and we did not identify any studies that examined racial/ethnic differences in injury severity (other than nonfatal vs. fatal, whereby results were largely consistent). Future research incorporating race/ethnicity and injury severity would provide much needed nuance to this literature.
Additionally, the extent to which these results are driven by socioeconomic differences between racial/ethnic groups is not firmly established. Voas et al. (
18) and Braver et al. (
21) documented that racial/ethnic differences are substantially attenuated if not completely explained when indicators of socioeconomic position are controlled, yet reliable socioeconomic data are not routinely incorporated into studies of racial/ethnic differences in injury. Finally, the validity of the results presented here is largely dependent on the validity of ARDI estimates, which calculate the contribution of alcohol to major causes of death (
83). The ARDI is based on empirical studies, few of which incorporated distinctions between ethnic groups and all of which may have internal biases that affect the results of the ARDI and thus this review.
In conclusion, this review indicates that some patterns of racial/ethnic differences in alcohol-attributable injury, particularly for blacks and Hispanics, cannot be easily explained by racial/ethnic differences in patterns of alcohol consumption. This is a conspicuous gap in the literature for which more research is needed. The present review also indicates that Native Americans remain at high risk of many alcohol-attributable injury outcomes, especially motor vehicle crash involving pedestrian, occupant, and driver fatalities. While blacks and Hispanics currently evidence lower rates of binge drinking compared with non-Hispanic whites, time-trend analysis indicates increases in binge drinking since 1979 among black and Hispanic groups, especially women, suggesting that increased attention to the consequences of drinking by racial/ethnic minorities is urgently needed. Further, data from the Centers for Disease Control and Prevention suggest that suicide rates among black youth have been increasing since 1980 (
84), suggesting the need for an increase in public health resources. Finally, more detailed data on racial/ethnic differences in injury outcomes is needed to develop and empirically test theories regarding the etiology of injury differences across racial/ethnic groups. Such theories may promote the development of public health prevention and intervention efforts and also more broadly inform study of the social epidemiology of health.
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