Public Health Campaign Using the Latest Psychological Science, Health Data, and Cultural Trends Can Shift Social Norms Around Alcohol and Change Drinking Behaviors

PSY699, Master of Arts in Psychology, Capstone Final Paper, Integrative Literature Review, The University of Arizona Global Campus, June 24, 2023

Introduction

While opioid deaths captured headlines as a devastating health crisis, with a staggering 90,000 deaths in 2022 alone, another silent epidemic has been steadily claiming even more lives. Surpassing 140,000 fatalities annually, alcohol-related deaths have been on the rise, with a particularly alarming spike during the pandemic (NIDA, 2022; NIH, 2022). Astonishingly, despite the magnitude of this public health issue, alcohol has failed to receive comparable attention or be recognized as an epidemic of similar urgency. The answer as to why is multifaceted and complicated, revolving around deeply engrained cultural and social beliefs and behaviors about alcohol consumption. These prevailing beliefs have created dangerous social norms, which upholds alcohol as essential for a vibrant social life, making alcohol the only drug that is widely available, accepted, and even encouraged in society (Arora et al., 2022; Eisenberg et al., 2014). Furthermore, the prevailing cultural perspective on alcoholics, which presents as binary and stigmatized, overlooks the majority of individuals who are at risk, disregarding the heterogeneity and complexity of dangerous drinking behaviors (Arora et al., 2022; Boness et al., 2021; CDC, 2022; Simha et al., 2022). While not everyone succumbs to addiction, every individual who consumes alcohol experiences adverse effects on their physical and mental health, including elevated risks of cancer, anxiety, and depression (CDC, 2022; Holahan et al., 2022; Holcombe, 2022; Martins et al., 2022; NIH, 2022). Emerging scientific research has provided insight into the complex, intricate nature of alcohol consumption and health impacts, revealing the importance of heterogeneity and the interplay between biological, cognitive-behavioral, social, and humanistic psychological factors. These newfound understandings highlight the significant impact of gene-environment interactions, neuroscience, and biopsychosocial aspects, while challenging the prevailing chronic brain disease model of alcohol addiction (Boness al., 2021; Celorrio et al., 2016; Wiens & Walker, 2015; Williams, 2020; Zhang et al., 2020). With these factors at play, almost any human being is susceptible to addiction regardless of their genetic makeup, a critical point for education prevention.

This paper does not intend to present an anti-alcohol narrative, but rather, aims to advocate for the promotion of the latest scientific research and truths around alcohol. With one in three adults categorized as excessive drinkers, our society finds itself in the throes of a global health crisis (CDC, 2022; NIH, 2022). Individuals should have the latest insights from psychological science, health data, and cultural realities to make well-informed decisions about their relationship with alcohol. This requires a biopsychosocial approach rooted in an understanding of the complex and interconnected biological, cognitive-behavioral, social, and humanistic psychological factors influencing alcohol consumption and health across the lifespan (Grace, 2018; Holahan et al., 2022; Waller et al., 2019; Weitzman & Lee, 2020; Winner, 2021; Zhang et al., 2022). A public health campaign focused on the latest psychological science, health research, and cultural trends — and not solely on addiction — can shift social norms and influence an alternative narrative around alcohol, which can change misinformed mindsets, decrease drinking behaviors, and thereby increase overall mental and physical health.

Discussion

State of Alcohol in Modern Society

Excessive alcohol consumption is a worldwide health crisis, with more than one in three adult drinkers engaging in excessive drinking, which increases risks of addiction, cancer, mental health disorders, and death (CDC, 2022). Alarmingly, what is often considered moderate drinking based on societal norms aligns with the medical community’s definition of excessive drinking, revealing the underestimated prevalence of Alcohol Use Disorder (AUD) (CDC, 2022; Eisenberg et al., 2014; Holahan et al., 2022; Waller et al., 2019). A spectrum disorder with severity ranging along a scale, AUD is a problematic and progressive pattern of alcohol use that can lead to significant physical, social, and psychological distress or harm to oneself or others (CDC, 2022; Eisenberg et al., 2014; Holahan et al., 2022; Waller et al., 2019). The current chronic disease model predominantly represents the small percentage, around 10%, of physically dependent chronic alcoholic drinkers, which undermines the vast scope of the disorder (CDC, 2022). An estimated 75% of drinkers who would classify as mild or moderate on the AUD scale will never seek treatment (Wiens & Walker, 2015). Given these facts, one can begin to surmise the vastness of the problem.

Heterogeneity and the interplay between gene-environment interactions, neuroscience, and biopsychosocial aspects play a crucial role in understanding and treating AUD, challenging the conventional chronic brain disease model, and offering more heterogenous and personalized theoretical and treatment approaches (Boness et al., 2021; Celorrio et al., 2016; Wiens & Walker, 2015; Williams, 2020; Zhang et al., 2020). Additionally, new scientific insights and emerging trends contradict many ingrained cultural norms surrounding alcohol, such as the belief that drinking is an integral part of a vibrant social lifestyle, the notion that moderate drinking has health benefits, the misconception that alcohol is not a drug, and the perception that alcoholism is an incurable chronic disease (Chartier et al., 2017; Eisenberg et al., 2014; Sudhinaraset et al., 2016). Consequently, millions are choosing to live alcohol-free and experiencing more fulfilled, healthier, and meaningful social lives, including prominent health professionals and celebrities (Arora et al., 2022; Grace, 2018). Promising new treatment approaches, such as This Naked Mind, employ psychological and cultural science-based approaches that empower individuals to overcome addiction through education, cognitive-behavioral therapy, and self-efficacy practices that encourage personalization and empowerment, contrasting the conventional narrative of alcoholism as an incurable chronic disease where individuals are portrayed as powerless over alcohol (Grace, 2018; Wiens & Walker, 2015). Ireland’s groundbreaking new legislation mandates warning labels on alcohol products about health risks, including cancer, signaling a growing trend for worldwide government action (Hernandez, 2023). Sadly, this new science and cultural information about alcohol are not widely known or understood in modern culture, which perpetuates harmful beliefs and an environment of unhealthy alcohol consumption (Grace, 2018; Holahan et al., 2022; Sudhinaraset et al., 2016).

Alcohol abuse and alcoholism have traditionally been attributed mainly to genetic factors and viewed through a chronic brain disease model. This belief is reflected in organizations like Alcoholics Anonymous (AA), which emphasize powerlessness over alcohol. However, modern science challenges this perspective by highlighting the significant role of environmental and biopsychosocial factors, particularly in the realm of epigenetics, neuroplasticity, and new empowerment treatment practices (Boness et al., 2021; Carreno & Pérez-Escobar, 2019; Charzynska et al., 2018; Grace, 2018; Ray et al., 2021). While genes certainly play a role, there is no single alcoholic gene but rather it is a complex interplay between genetic, biology, and environmental factors that determine an individual’s susceptibility to AUD (Akeman et al., 2022; Celorrio et al., 2016). Shifting the conversation from a focus solely on genetic addiction to a more holistic wellness model would have a significant impact on public health, reaching a larger portion of individuals with hazardous drinking habits and reducing associated stigma (Akeman et al., 2022; Boness et al., 2021; Charzynska et al., 2018; Grace, 2018; Ray et al., 2021; Sudhinaraset et al., 2016). The timing is favorable as this approach aligns with a culture facing a mental health crisis and seeking improved health and mental wellness.

The Heterogeneity and Spectrum Nature of AUD

AUD is a multifaceted, complex disorder influenced by intertwining factors of biology, psychology, and culture which necessitates a personalized, holistic approach (Watts et al., 2021). Its severity is determined by the number of symptoms experienced within a 12-month period, with mild, moderate, and severe levels across a spectrum (American Psychiatric Association, 2022). While AUD is a much more accurate term for alcohol use and abuse, especially over the negative label of alcoholic, it still requires more research and refinement. Despite adaptations over the years, legacy diagnostic manuals like DSM-5 and ICD-10 have been criticized for their homogeneous and unidimensional approach, despite research indicating significant heterogeneity in consumption patterns, cultural influences, family history, and traumatic life experiences (Boness et al., 2021; Ray et al., 2021). Recent research advocates for a personalized, neuroscience-based framework that considers heterogeneity and etiological factors in AUD assessment and treatment (Boness et al., 2021; Ghitza, 2017; Kuhlemeier et al., 2021; Ray et al., 2021; Watts et al., 2021). Alternative frameworks and new empowerment treatment approaches have emerged focusing on cognitive-behavioral therapies, self-empowerment, acceptance, and mindfulness (Grace, 2018; Votaw et al., 2021; Zhang, 2022). However, it is important to note that while many of these approaches are non-evidence-based, their successful track records warrant more attention from the medical community and further research support.

Therefore, a more inclusive, holistic model is necessary to better capture the diverse heterogeneity and range of individuals affected by dangerous drinking. As we will see throughout this paper, we must view AUD from a holistic, heterogenous approach considering how the biological, cognitive-behavioral, social, and humanistic psychological factors interplay across individuals throughout the life span (Grace, 2018; Holahan et al., 2022; Waller et al., 2019; Weitzman & Lee, 2020; Winner, 2021; Zhang et al., 2022).

Biological Psychology and AUD

The biological psychology approach recognizes that psychological disorders can have underlying biological causes, such as imbalances in neurotransmitters or genetic factors. A thorough comprehension of how alcohol impacts our biological and physiological systems is crucial for gaining a comprehensive understanding of and effectively treating AUD. This includes considering factors such as genetic predispositions, epigenetics, neuroplasticity, and inheritable traits (Dahl et al., 2020; de Assis Pinheiro et al., 2021). Recent research led by USC’s Mary Helen Immordino-Yang, while not specific to alcohol, reveals fascinating insights on the interconnections between the brain, social interactions, emotions, and cultural context, showing how neurobiological cognitive processes are deeply intertwined with environment and emotions (Immordino-Yang & Gotlieb, 2017). Her work confirms the importance of a holistic approach and the critical interplay between biology, environment, and psychology.

The field of biological psychology examines the brain and body’s reactions to alcohol, resulting in immediate effects like intoxication, as well as enduring alterations in the brain’s reward system through neuroplasticity (Celorrio et al., 2016; Martins et al., 2020). Additionally, regular drinking is empirically shown to reduce overall brain volume with reductions in gray and white cortical matter (Martins et al., 2022). As we will see throughout this paper, the biological results of alcohol are intrinsically intertwined and interplay with the cognitive-behavioral, social, and humanistic psychological experiences. The influence is bidirectional and cannot be viewed in silos but holistically.

The Magic and Mystery of Neuroplasticity

Chronic alcohol consumption, even moderate drinking, leads to dysfunction and dysregulation in the brain’s circuitry, especially in dopamine-based reward and behavioral loops, which can result in abnormal urges and cravings for alcohol (Celorrio et al., 2016; Dahl et al., 2020; Martins et al., 2022). Reward dysregulation is a psychological phenomenon characterized by atypical reactions to pleasurable stimuli, stemming from an impairment in the brain’s reward system. This impairment is believed to have a substantial impact on the development and persistence of addiction in individuals with AUD. Those affected may exhibit heightened sensitivity to drugs or alcohol, while simultaneously experiencing reduced sensitivity to natural rewards (Martins et al., 2022; Verdejo-Garcia et al., 2019). Moreover, the cumulative impact of adversity, stressful life events, and traumatic experiences on specific brain pathways and regions like the amygdala and prefrontal cortex contributes to the emergence of binge drinking, hazardous alcohol consumption, and intensified cravings (Sudhinaraset et al., 2016; Votaw et al., 2021). These modifications in stress and emotion regulation systems contribute to emotional and behavioral dysregulation and increase the susceptibility to AUD (Sinha, 2022).

All this brain circuitry dysregulation happens because of the brain’s remarkable neuroplasticity, a process through which the brain can restructure itself by creating new neural connections and modifying existing ones in response to experiences, learning, and environmental changes over the course of a lifetime (Celorrio et al., 2016; Martins et al., 2020; Pasqualitto et al., 2023). Neuroplasticity serves as a defining characteristic of addictive behaviors and AUD. Neuroplasticity, however, can work in a positive reverse order, undoing dysfunctional neural circuitry and reestablishing balance through modifying cognitive processes. For example, neuroimaging studies suggest that emotionally charged memories play a role in craving experiences, triggering the prefrontal cortex, amygdala, and hippocampus, and that specific psychotherapies can help reframe and retrain emotional components of addiction memories to recalibrate the emotionality of these memories (Dahl et al., 2020; Martins et al., 2020; Pasqualitto et al., 2023; Sinha, 2022). Additionally, empirical research shows self-empowerment therapies and education can help change cognitions and beliefs around alcohol, helping to rewire dysfunctional thought patterns and neural circuitry (Grace, 2018; Ray et al., 2021; Zhang et al., 2022). For example, growing empirical evidence shows interventions targeting implicit alcohol associations and drinking identities have the potential to modify cognitive processes and beliefs to reduce desires and cravings associated with alcohol and help to restructure dysfunctional circuitry (Lindgren et al., 2016; Martins et al., 2020). Additionally, meditation practices and aerobic exercise can also help strengthen key brain circuitry in the prefrontal cortex and hippocampus, which has been shown to help rebalance healthy brain circuitry and help with AUD (Basso et al., 2022; Dahl et al., 2020). A comprehensive treatment plan would incorporate all these interventions and habits to illicit positive neural change and help the brain heal itself.

It was previously believed that the brain’s ability to change and reorganize its structure was limited to early development and that the adult brain was relatively fixed and immutable (Müller et al, 2023; Pasqualitto et al., 2023). However, scientific research in recent years has shown that neuroplasticity continues to occur throughout adulthood (Pasqualitto et al., 2023; Wiens & Walker, 2015). This is a key development that points to alcohol not being an incurable brain disease but the brain being able to heal itself through proper cognitive therapies and environments. Understanding the neuroplasticity associated with addiction is crucial for developing effective new biopsychosocial and lifestyle treatments, as well as enlightening patients’ minds and providing self-empowerment vs powerlessness (Carreno & Pérez-Escobar, 2019; Immordino-Yang & Gotlieb, 2017). By targeting and modifying these changes, interventions can aim to restore normal brain function and reduce the risk of relapse (Müller et al., 2023; Pasqualitto et al., 2023; Wiens & Walker, 2015; Williams, 2020). It is important to note, however, that AUD heterogeneity and severity levels play a role treatment approach and effectiveness.

Elevated Anxiety and Decreased Mood Due to Alcohol Consumption

Another way alcohol consumption influences biological and psychological changes is in chemical and neural systems with increased release of cortisol. Even in moderate drinkers, regular alcohol consumption dysregulates chemical and neural pathways which cause more cortisol to be released into the body even at baseline. This brain-to-body circuitry dysregulation means that drinkers have elevated levels of cortisol in their bodies, which makes people less resilient to stress and lowers overall mood levels, even when they are not drinking (Sinha, 2022). This is crucial in a society battling mental health and anxiety disorders. The prevailing notion of alcohol as a relaxing force is contradicted by the latest scientific research and needs to be understand by individuals so they can be better informed for their mental health (Grace, 2018; Ray et al., 2021; Verdejo-Garcia et al., 2019; Votaw et al., 2021). With our society’s current mental health crisis, the time is optimal for individuals to be aware of this critical information.

Epigenetics and Rise in Breast Cancer

The epigenetic effects induced by alcohol consumption are not widely understood despite empirical evidence showing the significance of epigenetic mechanisms in alcohol consumption influencing psychological processes and development (de Assis Pinheiro et al., 2021). Epigenetics involve chemical modifications to the genome due to gene-environment interactions that shape gene expression, influencing responses to environmental, social, and life experience factors (Chartier et al., 2021; de Assis Pinheiro et al., 2021; Grace, 2018). Transgenerational epigenetic effects have been observed, with greater heritability of adolescent drinking in families with drinking parents (Williams, 2020). This means a child’s environment regarding alcohol can influence gene expression and either increase or decrease a propensity for AUD later in life. Additionally, children who experience their parents becoming intoxicated, even if just tipsy, have been shown to have increased levels of anxiety which can lead to neurotic internalizing and negative externalizing behaviors (Chartier et al., 2021; Grace, 2018; Müller et al., 2023; Sinha, 2022). So, essentially, parental drinking, even in moderation, could negatively impact a child’s healthy psychological development and make them more susceptible to AUD.

Alarmingly, alcohol consumption leads to epigenetic changes associated with cancer development, including an approximate 30–50% increased risk in breast cancer (Breastcancer.org, 2023; CDC, 2022). The process of alcohol metabolism causes abnormal gene expression and methylation, global hypomethylation, and reduced antioxidant defense, which increases the risk of breast cancer. In fact, women who consume three alcoholic drinks per week have a 15% higher risk of breast cancer compared to those who abstain from drinking. The risk increases by an additional 10% for each additional drink regularly consumed each day (Breastcancer.org, 2023; CDC, 2022). According to latest research, the vast majority of Americans are unaware that alcohol increases their risk of cancer, especially breast cancer (CDC, 2022; NIH, 2022). This is information that should be widely known for our public health.

Pharmacological Treatment of AUD

As noted, AUD is a prevalent yet under-treated condition, with limited approved pharmacological treatments. Due to the heterogeneity of AUD, a single medication is unlikely to be effective for all individuals. However, despite these limitations, there are several evidence-based pharmacological treatments for AUD that when combined with other psychotherapies have proven successful in individuals. Some of those medications include disulfiram, acamprosate, naltrexone, and several others (Simha et al., 2022; Zhang et al., 2022). For example, for highly motivated individuals, who consent to the drug’s potential side effects, combining disulfiram (Antabuse) with cognitive behavioral and empowerment therapies has been one of the more promising treatments, especially for advancing precision medicine and personalized treatment. However, barriers such as limited access, stigma, and treatment-seeking behavior still need to be addressed to improve AUD management (Burnette et al., 2022).

Cognitive-Behavioral Psychology and AUD

Cognitive-behavioral psychology is a broad theoretical framework which operates on the premise that our thoughts have a significant impact on how we feel and behave, and by modifying our thought patterns, we can cultivate positive transformations in our emotional state and behaviors. Often our thoughts can be flawed or maladaptive, leading to emotional turmoil and harmful behaviors. By challenging the accuracy of these thoughts and developing alternative, more rational perspectives, we can develop healthier thinking patterns which produce healthier behaviors (Cloninger, 2019).

A critical component of AUD arises from unhelpful and false beliefs, thoughts, and acquired behaviors about alcohol that contribute to the disruption of dopaminergic brain circuitry and behavioral loops, as mentioned earlier (Boness et al., 2021; Ray et al., 2021; Zhang et al., 2022). This is a key area where all psychological disciplines interplay and influence one another in a complex and bi-directional manner. For example, societal norms and environments play a role in reinforcing these cognitive-behavioral patterns that promote the development and intensification of alcohol cravings and behaviors (Sudhinaraset et al., 2016; Wang, 2017). Cognitive factors, such as attitudes, expectations, and self-efficacy towards alcohol use, influence how individuals perceive and interpret alcohol’s effects, as well as their beliefs regarding its role in managing stress, social interactions, or other situations (Cole, 2022; Grace, 2018; Winner, 2021). Within the cognitive-behavioral approach, the emphasis lies in identifying and modifying these maladaptive or false thoughts and behaviors associated with alcohol use. By challenging and replacing negative, distorted, or untrue beliefs about alcohol and adopting healthier coping strategies and alternative behaviors, individuals can transform their relationship with alcohol (Cole, 2022; Winner, 2021). This approach recognizes the interconnectedness of cognitive factors (thoughts, beliefs) and behavioral factors (actions, reinforcements) in an individual’s association with alcohol. It is important to emphasize that cognitive-behavioral factors are closely intertwined with biological, social, and humanistic psychological experiences and principles and cannot be viewed in a silo (Boness et al., 2021; Cole, 2022; Müller et al., 2023; Ray et al., 2021; Zhang et al., 2022). Cognitive-behavioral psychology is a critical field with several prominent psychological theories that can be leveraged to understand an individual’s relationship with alcohol and AUD.

Social Cognitive Theory and Self-Efficacy

Albert Bandura’s Social Cognitive Theory suggests that people’s behavior is influenced not only by external factors but also by their cognitive processes, including their thoughts, beliefs, expectations, and self-perceptions. This social learning theory includes reciprocal determinism, which highlights the dynamic interplay between individuals and their environment; observational learning and modeling, where individuals acquire new behaviors and skills by observing and imitating others; and the role of self-efficacy, an individual’s belief in their own ability to successfully perform a specific task or behavior (Aronson, 2018; Bandura, 2015). All three concepts play key roles in an individual’s relationship with alcohol. For example, self-efficacy, an individual’s belief in their capabilities to achieve goals, plays a crucial role in motivation, behavior, and overcoming AUD. Higher self-efficacy is associated with greater motivation, persistence, and resilience in the face of challenges (Akeman et al., 2022; Charzyńska et al., 2018; Cole, 2022; Dahl et al., 2020). However, framing addiction as a chronic, incurable disease can diminish perceptions of agency, increase stigma and shame, and weaken drinking self-efficacy. Social learning and observation play a key role in how our parents, peers, and society teaches us about alcohol beliefs and behaviors, which underscores the interplay between social-cognitive-behavioral connections (Eisenberg et al., 2014; Holahan et al., 2022; Immordino-Yang & Gotlieb, 2017). Research supports the idea that internalizing a biopsychosocial model of addiction strengthens empowerment and reduces the perception of addiction as an inherent characteristic (Wiens & Walker, 2015). Bandura’s landmark theory is crucial in understanding the development and treatment of AUD.

Cognitive-Behavioral Therapy and AUD

Sharing some common principles with Bandura’s work, cognitive behavioral therapy (CBT) is a specific form of psychotherapy that falls under the umbrella of cognitive behavioral psychology. CBT has been proven to be effective in reducing alcohol consumption, preventing relapse, and enhancing overall quality of life in individuals with AUD (Winner, 2021). Pioneered by Aaron T. Beck, CBT highlights the interplay between thoughts, emotions, and behaviors and the profound influence they have on our development. CBT endeavors to enhance mental health and overall well-being by identifying and challenging irritational thoughts to change behaviors. Combined with other treatments, including pharmacology, group therapy, and family therapy, CBT has been shown to reduce AUD symptoms (Boness et al., 2021; Kuhlemeier et al., 2021; Ray et al., 2021; Zhang et al., 2022). Research findings have suggested that interventions associated with CBT, such as mindfulness techniques, have therapeutic benefits for improving decision-making and treatment outcomes in individuals with AUD (Avcu Meriç & Sönmez, 2022). The incorporation of new knowledge and education in combination with CBT and empowerment-related therapies have revealed significant success in non-evidence-based programs by enhancing patient motivation and empowerment (Cole, 2022; Grace, 2018; Winner, 2021; Zhang et al., 2022).

Social Psychology and AUD

Social psychology examines the intricate interplay between individuals and their environment, encompassing cultural, social, and family contexts. It explores the influence of these factors on thoughts, emotions, and behaviors, providing insights into how social context shapes human psychology and conduct. Social psychology seeks to comprehend individuals through the lens of their unique kaleidoscope of emotions, perceptions, biases, beliefs, and experiences (Aronson, 2018; Bandura, 2015). Social and environment plays a massive role in drinking behaviors and is intricately interwoven with biology, cognitive-behavioral and humanistic psychological factors. More recently, Mary Helen Immordino-Yang’s research at USC underscores the interconnectedness between brain, social interactions, emotions, and cultural context, affirming the interplay between biology, environment, and psychology (Immordino-Yang & Gotlieb, 2017). However, social norms still uphold alcohol as an essential and even healthy part of an individual’s social life, which exacerbates the AUD problem.

As a recently published report stated: “The portrayal of alcohol as necessary for a vibrant social life has diverted attention from the harms of alcohol use, as have the frequent and widely publicized claims that moderate drinking, such as a glass of red wine a day, can offer protection against cardiovascular disease” (Arora et al., 2022, p. 2).

AUD involves a complex interplay of genetic, epigenetic, and environmental factors. While genetics contribute to the propensity for compulsive alcohol use, environmental factors and social and cultural influences also play a crucial role. Epigenetic modifications, as mentioned in the biological section, influenced by environmental factors like stress, trauma, diet, and alcohol exposure, can impact gene expression related to alcohol consumption, potentially persisting across generations. Additionally, the social and cultural environment, including norms and attitudes towards alcohol within a particular culture or peer group, can shape an individual’s beliefs and patterns of alcohol consumption, interacting with genetic and epigenetic factors. These insights highlight the multifaceted nature of alcohol use and the importance of considering social, cultural, and environmental influences in understanding alcohol-related behaviors (Jarczak et al., 2023). For example, if a person’s social circle frequently engages in heavy drinking and deems it acceptable, it can influence one’s own drinking patterns. Social factors and cultural norms also encompass the availability, acceptability, and even endorsement of alcohol as a part of a vibrant and fulfilling lifestyle, particularly in Western societies (Arora et al., 2022; Eisenberg et al., 2014). As we saw in the earlier sections, a child’s social environment regarding alcohol can impact gene expression and influence the likelihood of developing AUD later in life. Furthermore, witnessing parents becoming intoxicated, even mildly, has been linked to increased anxiety levels in children, leading to negative internalizing and externalizing behaviors. Social psychological experiences are closely linked to cognitive-behavioral and humanistic, and all influence biological and physiological changes (Ray et al., 2021).

A social-ecological framework provides a comprehensive perspective on the influences of alcohol use, illustrating how individual-level factors are embedded within various contexts. These contexts include home, work, and school environments, which, in turn, are situated within the broader community. At a macro level, factors like exposure to advertising can impact the attitudes and norms within family and peer networks, subsequently shaping the attitudes and behaviors of individuals (Sudhinaraset et al., 2016). This approach focuses on the environmental factors that contribute to AUD, including reinforcement and conditioning by social and environmental cues and emphasizes the importance of identifying and modifying these cues to change drinking behaviors (Cloninger, 2019; Sudhinaraset et al., 2016).

Additionally, social factors influence neuroplasticity, including social interactions, environmental influences, stress levels, social support networks, individual beliefs, and life experiences. Negative social experiences can influence dysfunctional brain plasticity through factors like reward value, stress-induced alterations, and cognitive processes. Positive social support and psychosocial interventions promote recovery and beneficial neuroplastic changes, while executive functions are influenced by psychosocial factors, affecting the development of functional and dysfunctional brain plasticity. For example, adolescent alcohol use is more strongly associated with parental alcohol use showing the influence of environment. The same influence can hold true in households where parents do not drink, leading to children that either do not drink or drink only occasionally (Bignardi et al., 2022).

From the Rat Park experiment to Immordino-Yang’s research

The Rat Park experiment challenged earlier notions of addiction and suggested that social and environmental factors play a significant role in addiction. Conducted by psychologist Bruce K. Alexander, the study implied that addiction is not solely determined by the chemical properties of drugs but is influenced by various contextual factors, such as social connections, environmental conditions, and opportunities for fulfilling experiences. This study underscored the need to consider social and environmental factors in addiction research and the development of effective prevention and treatment strategies (Gage & Sumnall, 2019). This finding does not discount the role genes play but emphasizes the importance of environment, gene-environment interactions, and social psychological factors. Numerous studies have since been done providing empirical, evidence-based research for the strong influence of environment on drinking habits.

In groundbreaking research by Stanford’s Mary Helen Immordino-Yang, fascinating discoveries have been made regarding the intricate connections among the brain, social interactions, emotions, and cultural context (Immordino-Yang & Gotlieb, 2017). Her work proves that our biological development and psychological development are two sides of the same coin and interplay bi-directionally throughout our lifespan. Although not directly focused on alcohol, this research is applicable to alcohol and sheds light on how social experiences and environment are intricately intertwined with our neurobiological development and emotions (Immordino-Yang & Gotlieb, 2017). Immordino-Yang’s work reinforces the significance of adopting a holistic approach that recognizes the dynamic interplay between biology, environment, and psychology. These findings contribute to a deeper understanding of human cognition and emphasize the multifaceted nature of our lived experiences.

Social Influence, Social Norms, and Conformity

All the above plays directly into powerful social psychological principles like influence, norms, identity, and conformity. Alcohol, deeply entrenched in our culture as a strongly held social norm, is widely accepted and often considered vital for a vibrant social lifestyle. Social norms, recognized as influential social psychological principles, have a significant impact on individuals’ thoughts, emotions, and behaviors, including drinking behaviors (Aronson, 2018; Cialdini, 2007). Various sources, including parents, media, and advertising, portray alcohol as enjoyable, exciting, and conducive to relaxation and fun, often contributing to peer pressure associated with drinking (Eisenberg et al., 2014; Stalgaitis et al., 2022; Sudhinaraset et al., 2016; Weitzman & Lee, 2020). In fact, most individuals first experiences with alcohol come from a social or peer influence or pressure, and continue due to group thinking, identity, and conformity.

However, an increasing number of individuals are voluntarily abstaining from alcohol due to wellness considerations, experiencing improved well-being and a sense of fulfillment. This shift challenges the belief that alcohol is indispensable for a socially vibrant and healthy life (Arora et al., 2022; CDC, 2022; Eisenberg et al., 2014). In light of these emerging cultural trends, it is crucial to inform the public so that they can make informed decisions about their alcohol consumption (Holcombe, 2022). Drawing upon insights from social psychology, we can leverage new social influence, group thinking, and knowledge to cultivate a commitment to social change related to alcohol consumption. Moreover, influencers can play an important role in amplifying this impact by serving as role models and mentors who propagate new social influences and foster alternative group thinking (Aronson, 2018; Holcombe, 2022; Sudhinaraset et al., 2016). By applying robust social psychological principles and providing new scientific education, we possess the potential to reshape societal norms surrounding alcohol, challenging misconceptions, reducing harmful drinking behaviors, and promoting enhanced mental and physical wellness (Grace, 2018; Sørensen & Lien, 2022; Sudhinaraset et al., 2016; Weitzman & Lee, 2020).

While peer-reviewed literature and research about alcohol consumption and social norms is limited, there are a few studies on alcohol, as well as many on smoking and social norms. The similarities between smoking and alcohol as a social and cultural norm serve as an excellent strategic guide (Stalgaitis et al, 2021). Eisenberg et al., (2014) conducted a longitudinal study that demonstrated the predictive role of social and peer influences in school regarding substance abuse behaviors. The findings emphasized the potential of proactive social communications and social influencers to shift norms and reduce drinking behaviors. In a separate study, researchers implemented a social-branding campaign aimed at reframing the conversation around smoking, promoting a smoke-free lifestyle, providing a relevant framework to counter prevailing perceptions (Stalgaitis et al, 2021). By leveraging longitudinal data, the researchers examined how positive smoke-free lifestyle content influenced sociocultural and psychological factors related to individual identity and group associations regarding smoking (Eisenberg et al., 2014; Stalgaitis et al, 2021). Furthermore, a study conducted in 2020 explored the similarities between alcohol and tobacco advertising exposure and its impact on adolescent usage. The study revealed that exposure, association, and influence related to both substances were remarkably similar, highlighting the significance of this research methodology and the need for public education (Weitzman & Lee, 2020).

The influence of societal, community, and cultural norms on higher alcohol use and abuse emphasizes the need for a fresh approach to studying alcohol use and social norms (Sudhinaraset et al., 2016). Research has also shown that engaging in active thought and reflection, accompanied by new knowledge and group deliberation, can enhance awareness of the negative consequences associated with behaviors such as smoking and drinking, potentially leading to subsequent behavior change (Immordino-Yang & Gotlieb, 2017; Müller et al., 2016). Understanding the impact of social and cultural factors on behaviors, like drinking, is a crucial aspect of social psychology (Aronson, 2018; Sudhinaraset et al., 2016).

Henri Tajfel’s social identity theory provides insight into how our close-knit groups contribute to our sense of belonging, membership, and self-esteem, shaping our behaviors and perceptions of others within and outside of our groups. This often results in an “us-vs-them” mentality, creating distinctions between ingroups and outgroups, which holds significant social influence (Aronson, 2018). Research indicates that social identity has a profound effect on cognitive, affective, and evaluative dimensions, driving changes in thinking and behaviors, like drinking (Sudhinarasetet al., 2016; Wang, 2017). Numerous social cognitive studies have demonstrated how mental processes intertwine with social norms, diverse processes, and biases to influence group thinking and behaviors (Aronson, 2018; Sudhinaraset et al., 2016). Psychologist Robert Cialdini emphasizes the power of liking and similarity in his discussion of the principle of social proof. According to Cialdini, social proof comes into play when individuals are unsure about the appropriate behavior or action and seek validation or proof from others or groups, which we see in drinking behaviors especially with adolescents (Cialdini, 2007). He asserts that social proof is most effective when there is a sense of similarity, as people tend to observe and mimic the behaviors of those who resemble them (Cialdini, 2007). Considering all these factors it becomes evident that social norms, social identity, and social proof significantly influence drinking behaviors. Therefore, these elements must be incorporated into any public health education campaign for it to be successful in effectively addressing and promoting positive changes in drinking behaviors.

Cognitive Dissonance and AUD

Cognitive Dissonance Theory, proposed by Leon Festinger in the 1950s, is a prominent theory within social psychology (Aronson, 2018). It seeks to explain the psychological discomfort that arises when individuals experience a conflict between their attitudes, beliefs, or behaviors; essentially, when we hold two conflicting cognitions in our mind at once that leads to mental pain and tension (Aronson, 2018). In the context of alcohol use disorder, cognitive dissonance can occur when an individual’s alcohol consumption conflicts with their beliefs, values, or self-perception, like engaging in heavy drinking when they believe it is not healthy or when self-disciplined people cannot control their drinking. It can also occur when their alcohol consumption conflicts with what they believe are cultural norms and societal standards, whether those are accurate or not (Muller et al., 2023). As we noted above, there are many dubious cultural norms around alcohol that impact one’s cognitive dissonance. Cognitive dissonance creates a desire to reduce the mental pain, often in maladaptive ways that perpetuate shame, blame, and anxiety that can increase drinking. They may engage in cognitive processes such as justification, rationalization, compensatory behaviors, or they might downplay the negative consequences of their drinking or find alternative explanations to align their behavior with their self-perception (Aronson, 2018; Sørensen, T., & Lien, 2022). On a positive side, individuals might try to reduce dissonance by seeking treatment, or adopting cognitive strategies that align their beliefs and behaviors.

Addressing cognitive dissonance in the context of AUD often involves interventions that promote cognitive restructuring, self-reflection, and behavior change to align beliefs, values, and behaviors with desired outcomes and self-perceptions (Aronson, 2018). These interventions aim to align beliefs, values, and behaviors with desired outcomes and self-perceptions, and address truisms, science and cultural norms that can influence individual’s cognitive dissonance (Aronson, 2018; Muller et al., 2023; Sørensen, T., & Lien, 2022). Since cognitive dissonance is deeply interconnected with biological, social, and humanistic psychological factors, a holistic view is required to understand and address within the individual.

Humanistic Psychology

The humanistic approach in psychology places significant importance on subjective experience, personal growth, self-actualization, and recognizing the inherent worth and dignity of individuals. It highlights the unique qualities of each person, their capacity for personal agency, and their pursuit of self-fulfillment. This perspective has had a profound impact on various psychological domains, including counseling, therapy, and the study of human motivation and well-being (Cloninger, 2019). When examining alcohol consumption and addiction through a humanistic lens, it considers how underlying emotional and psychological needs can influence drinking behaviors. For instance, individuals may turn to alcohol as a form of self-medication to alleviate emotional pain, cope with negative experiences, or seek heightened pleasure. Conversely, individuals may view abstaining from alcohol to achieve their full potential and use that as motivation to refrain from drinking (Akeman et al., 2022; Song et al., 2018; Sørensen & Lien, 2022). Humanistic psychology underscores the significance of personal autonomy, self-awareness, and self-actualization in overcoming addiction. It serves as an integral component alongside biological, cognitive-behavioral, and social psychology to gain a comprehensive understanding of AUD.

Humanistic principles, aimed at building self-efficacy, can foster psychological flexibility and endurance, enabling individuals to pursue their goals despite challenges. This flexibility is considered the pinnacle of emotional health and well-being (Doorley et al., 2020). Humanistic psychology principles do not align with the prevailing chronic brain disease model that promotes AUD as an incurable brain disease and AA’s powerlessness message. On the contrary, incorporating humanistic psychological principles complements other treatment areas and fuels self-empowerment, agency, and self-efficacy, which has been empirically proven to drive healthy and successful behavioral changes (Carreno & Pérez-Escobar, 2019). As such, humanistic psychology is intertwined with cognitive-behavioral, social, and biological psychology, and must be understand in a holistic, heterogenous view to treat AUD.

Maslow’s Theory and Positive Psychology

Abraham Maslow was a prominent psychologist who played a crucial role in shaping and popularizing the humanistic approach to psychology. He developed the theory of self-actualization and the hierarchy of needs, which are central concepts within humanistic psychology. Maslow’s hierarchy of needs proposes that individuals start with basic physiological needs and progress to higher-level needs such as safety, love and belonging, esteem, and self-actualization (Cloninger, 2019). While Maslow’s work primarily focused on humanistic psychology, it has had an influential impact on the development of positive psychology as well. Positive psychologists draw upon concepts and ideas from humanistic psychology, including Maslow’s emphasis on self-actualization and the pursuit of personal growth and fulfillment. These humanistic and positive psychology aspects are critical to a holistic understanding and treatment of AUD (Akeman et al., 2022). Focusing on positive aspects of an individual instead of what is wrong, as we see in the chronic disease model, helps build empowerment and self-efficacy, which has been empirically shown to help aid in abstinence. The root of this psychological issue lies in the inability to effectively deal with the challenging aspects of life and the unhealthy pursuit of positive emotions. Empowerment therapies help find purpose in life and establish a sense of meaning and fulfillment (Carreno & Pérez-Escobar, 2019). Aspects of humanistic and positive psychology, including spirituality, personal growth, accountability, and self-actualization, have been shown to be foundational for successful AUD treatment (Akeman et al., 2022; Bandura, 2015; Charzyńska et al., 2018; Dahl et al., 2020; Song et al., 2018; Sørensen & Lien, 2022).

Additionally, humanistic and positive psychology can be used to motivate people to decrease or abstain from drinking to attain better health and wellness. For example, if an individual is educated and made aware of the dangers of cancer and mental health issues from even moderate drinking, they could be empowered to take accountability and strive for better personal health (Akeman et al., 2022; Arora et al., 2022; Dahl et al., 2020; Song et al., 2018; Sørensen & Lien, 2022).

Conclusion

We find ourselves at a pivotal moment where a change in societal attitudes towards alcohol is not only necessary but also within our reach. By harnessing the power of the latest psychological science, health data, and cultural trends, we can challenge deeply ingrained social norms and transform drinking behaviors for the better. Similar to the shift that occurred with smoking, where cigarettes went from being widely accepted to socially stigmatized, we have the potential to bring about a parallel transformation in our perceptions of alcohol (Arora et al., 2022; Weitzman & Lee, 2020). By leveraging the prevalence of excessive alcohol consumption, emerging scientific insights, and evolving wellness trends, we can challenge cultural norms, foster alternative narratives, and empower individuals to make informed decisions (Grace, 2018; Holahan et al., 2022; Sudhinaraset et al., 2016). Through this approach, we can drive a significant shift in attitudes, improve public health outcomes, and reduce the devastating impact of alcohol use disorder (Boness et al., 2021; Celorrio et al., 2016; Wiens & Walker, 2015; Williams, 2020; Zhang et al., 2020).

In conclusion, while the opioid crisis rightly deserves significant attention, the alarming rates of alcohol-related deaths should not be overlooked. A public health campaign focused on the latest psychological science, health research, and cultural trends — and not solely on addiction — can shift social norms and influence an alternative narrative around alcohol, which can change misinformed mindsets, decrease drinking behaviors, and thereby increase overall mental and physical health.

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