Abstract
Objective:
Alcohol use is linked to a wide and complex range of individual and societal harms. Decisions on whether and how to address alcohol-related harms are shaped by the way in which such problems are understood, particularly through the use of language and concepts in professional and lay discourse. However, all terms and concepts have a complex set of implications which vary by context. For example, some language, particularly that associated with a historically dominant ‘alcoholism’ model, may be clearly harmful in some contexts (eg, via public stigma) and potentially valuable in others (eg, via facilitating recovery processes), or hold ‘mixed blessings’. Careful empirical attention is required to assess the implications of key terms and concepts used in efforts to understand and address alcohol use and problems amongst the public, researchers, policy makers and practitioners.
Methods:
We take an author-led and empirically informed approach to critically evaluate common terms and concepts to describe alcohol use and related constructs.
Results:
We identify how alcohol-related framing and discourse is highly relevant to alcohol-related outcomes via key issues including stigma, public health goals, political and commercial interests.
Conclusions:
Recommendations are made for key partners to consider in the use and evolution of key terms and concepts relating to the broad spectrum of alcohol use and problems.
Introduction
Ethanol (ethyl alcohol) is widely available as a legal drug, despite accounting for over 3 million annual deaths. 1 The cultural normalization of alcohol use, particularly in Western cultures such as the United States and United Kingdom, is therefore a major obstacle to evidence-based policies to reduce associated harm.2,3 Although alcohol consumption is clearly linked to its price and availability, it is also indirectly influenced via less tangible processes such as the terms and concepts used to describe consumption in public and professional alcohol-related discourse. 4 As the adage goes, language matters because the terms and concepts used in any domain have multiple implications for how people and society understand and respond to an issue.5 -8 For example, whether via social process mechanisms such as stigma, or commercial practices of industry marketing and issue framing, these discourses shape public attitudes towards alcohol, and in turn, the level of regulation or other actions to reduce its harms.3,9 -12
The ways in which terms and concepts shape substance use and harms, medical treatment and prevention efforts can be seen across multiple domains. For instance, drug policy decisions (including those related to alcohol) are embedded within moralistic ideas and discourse, reflecting normative and stigma-embedded ideas about what constitutes ‘problematic’ drug use or drug ‘users’.13 -15 The legal status and related policy responses to different drugs therefore typically reflects complex socio-historical, commercial and political factors, rather than the level of harm they cause to individuals and society.14,16 As such, the terms and concepts used to describe alcohol use problems have a range of complex and far-reaching implications, spanning individual level behaviours through to key population level policy controls of price, availability or marketing restrictions.2,12,17
Increasing attention has been given to the role of language and issue framing, particularly in the context of ‘substance use disorder’ (SUD) and ‘alcohol use disorder’ (AUD) policy, research and practice. This attention partially reflects growing evidence around the implications of certain terms and concepts, particularly in terms of their role in stigma processes as a major barrier to addressing alcohol problems.18,19 Notably, stigma is a social process which is enacted via labelling of the stigmatized group or characteristic (eg, ‘alcoholic’). Labelling serves to separate and mark as different those subjected to prejudice and discrimination, which occurs through complex social and structural means.20 -22 Many stigma processes are thus enacted via the use and exclusion of certain terms and their embedded meanings.23 -26 In turn, various terms and concepts relating to substance use, SUD and related issues have been subject to experimental research, debate and advocacy about language choice.
Resources aimed at guiding terminology have been produced by many major bodies. For example, the National Institute on Drug Abuse published ‘Words Matter: Preferred Language for Talking About Addiction’ in 2021. 27 Further, a number of organizations, research centres and academic journals have made name changes to reduce stigmatizing language, such as replacing ‘alcoholism’ or ‘abuse’ within journal titles, 28 published calls for authors to avoid stigmatizing terminology,29,30 or published positions on how they manage disputes over terminology. 31 In 2023, legislation in the US state of New Jersey replaced ‘. . . statutory terms regarding alcohol and substance use, alcoholism, addiction, drug addict, and similar terms with the terms “substance use disorder” and “person with substance use disorder”.’ 32
Although emerging evidence highlights how certain terms are more straightforwardly problematic, at least in most contexts outside of self-labelling (eg, ‘alcoholic’), many terms and concepts are subject to ongoing discussion, reflecting the various motives or contexts in which they may be used (see Tables 1 and 2). In this manuscript we seek to identify and critically evaluate key terms and concepts relating to alcohol use and problems within professional (Table 1) and public (Table 2) discourse. Our approach is based on author consensus in determining what qualifies as ‘key terms’ as well as common professional classification systems and associated terminology (eg, International Classification of Diseases). Although we have separated tables by public and professional contexts, we acknowledge considerable overlap since some terms are prevalent in both contexts (eg, ‘recovery’). We seek to take an author-led, empirically-informed approach, paying particular attention to evaluations of word choice and framing studies, as well as evidence pertaining to conceptualizations of alcohol use and related issues.
Key alcohol use and problem terms and concepts in professional contexts.
Abbreviations: AUD, alcohol use disorder; UK, United Kingdom; WHO, World Health Organization.
Key alcohol use and problem terms and concepts in public and recovery contexts.
Abbreviations: AA, Alcoholics Anonymous; AUD, alcohol use disorder; UK, United Kingdom.
Our consideration of terms does not take a systematic approach and therefore reflects author-identified terms based on existing literature. Where available, the primary focus was on empirical data in line with the authors’ position that the primary issues presented are best addressed via empirical methodologies. This is not to suggest other methodologies or lived experience accounts are not valuable (and indeed are included), but rather that to evaluate the key implications of terms and concepts as presented is foremost an empirical question. Our selection of terminology involved iterative discussions to reach consensus, with reference to established frameworks such as ICD where relevant. There was limited disagreement between authors but in some instances the first author decided on final wording. In doing so, we acknowledge that there are limitations to the terms and concepts presented and available evidence identified, including the authors’ own interpretations and positionalities. Further, we wish to acknowledge that language and its meanings, including those described here, are never static, but rather in a stage of change and subject to multiple influences, often directly or indirectly in competition with each other. Our results should therefore be interpreted in light of this.
Terms and Concepts for Alcohol Use and Problems
It is important to note that adopting specific terminologies or constructs such as ‘AUD’ to encompass a myriad of alcohol-related issues raises a number of concerns which are of particular relevance to our objectives. Alcohol use and harms exist as unquestionably complex, heterogenous and dynamic issues, thus we use the term ‘AUD’ only to refer to specific practical and clinical applications within that diagnosis/concept.33,74 As identified in Table 1, multiple AUD-related concepts and diagnostic criteria are currently utilized in research, policy and practice—each of which confer strengths and weaknesses. Varied approaches to classifying ‘AUD’ partially reflects historical and socially constructed ideas about alcohol ‘problems’. 87 Therefore, we use broader, non-diagnostic terms (eg, ‘alcohol problems’) specific to the parameters of alcohol use under consideration to reflect such complexities and avoid reification of ‘AUD’ diagnostic concepts and their limitations. This choice reflects the challenges inherent in setting thresholds which, although required for various research, policy and clinical purposes, raise important issues in terms of how problems are in turn reified by marking who (or which symptoms) does or does not ‘qualify’ as having ‘AUD’.35,36,88 Indeed, there are large populations which may not meet AUD criteria but are at risk of or experience a range of alcohol-related problems, and are therefore especially important in terms of prevention efforts (see Table 1) and natural recovery.4,41 Classifications including lower risk, hazardous, harmful or heavy episodic drinking (see Table 1) are utilized to identify groups that may not meet AUD criteria, but such approaches are also subject to a range of notable issues and limitations33,89 (see Table 1). Our use of the general term ‘alcohol problems’ is therefore used as a limited attempt to mitigate such issues by indicating the broad and heterogeneous range of risks and harms associated with alcohol use. Our broader use of the term ‘alcohol problems’ is therefore intended hold a different meaning from ‘problem drinking’ (see Table 1) which may more typically be associated with a narrower repertoire of problems such as AUD.
We therefore highlight the importance of advancing recognition of a continuum model of alcohol use and problems which emphasizes ‘no clear boundaries’ between groups. 35 The advantages of a broad continuum model are in part reflected by DSM-5’s (now DSM-5-TR) shift to identifying AUD as either mild, moderate or severe, 90 although this only goes some way in advancing such objectives. 35 In some countries including the US, diagnoses from nosologic systems that are categorial in nature are required for alcohol treatment reimbursement. However, it has been proposed that continuum models can be advanced without undermining treatment agendas 36 and should therefore be promoted amongst the public to advance public health goals, including reducing public perceptions of alcohol problems as confined to more severe ‘dependence’ issues. In turn, continuum beliefs can assist with reducing public stigma whilst increasing problem recognition, particularly amongst populations which may be identified as drinking at ‘hazardous’ or ‘harmful’ levels (see Table 1) levels. 4
Not ‘Word Policing’: Evidence for Why Language Matters
Although many organizations have made efforts to attend to potential issues around drug and alcohol-related language and concepts, such actions are not universally supported. For instance, some take the position that language choice is an inconsequential issue, or that calls to attend to language can equate to ‘word policing’ that can provoke resistance and divert attention from more important action 91 or fail to address the deeper causes of addiction.92,93 Another objection made is that of the euphemism treadmill in which neutral terms used to replace pejorative ones eventually become pejorative themselves. 94 However, we argue that the goal of evaluating and shaping alcohol-related terms and concepts must not be considered an end goal in and of itself, but rather an important component of broader, multi-component reform including shifts in public, policy and structural approaches to AUD. 4 That is, language both reflects and shapes how people understand, feel towards and react to issues of alcohol use and problems, thus indirectly influencing alcohol-related outcomes.
Calls for the use of person first language (PFL) have been increasingly endorsed by stigma and substance use researchers.29,95 -97 PFL relates to the use of terms such as ‘person with an AUD’ in place of stereotype-embedded labels such as ‘addict’ or ‘alcoholic’. PFL thus places emphasis on the person—not the ‘disorder’– in turn reducing implicit and explicit stigma-related judgements and their consequences.62,98 -100 Other substance-related terminology is also subject to similar attention, particularly terms associated with moralizing or blame-related notions such as ‘abuse’ or ‘misuse’.54,101 However, the term misuse may be less problematic than abuse since the latter is commonly associated with physical or sexual harm, which can imbue harsher internal feelings of shame and judgement, and external discrimination. Instead, misuse may be a more neutral term that suggests a harmful or inappropriate behaviour, whilst not explicitly denoting a moral failing. That said, misuse may still incur a moral undertone via the implication of individual choice and a failure to exercise control, thus to some extent still potentially a reductionist and stigmatizing framing of substance use.4,102
Importantly, ‘word policing’ based objections generally argue that stigma is not removed when stigma-laden terminology is avoided. 91 We acknowledge such a position as a valid cautionary note. However, PFL and related efforts should not be seen as ‘policing’, but as efforts at guiding empirically beneficial framings, or as leading by example. Although language shift does not eradicate stigma or address the causes of alcohol problems, this does not mean that terms and concepts are inconsequential. Indeed, as Corrigan concludes in their caution against ‘word policing’; ‘of course’ stigmatizing terms are ‘not okay’ 91 (p. 235), thus, word change efforts must form part of multi-component strategies to address stigma, including further evaluation of their impact. 91 We concur; empirical approaches to examine how different terminology and concepts affect key processes or perceptions relating to substance use and problems59,103,104 are important because of their more distal broader implications.105,106
It is therefore important to re-iterate that calls for the adoption of PFL do not necessarily include when people self-label via terms such as ‘alcoholic,’ as may be considered an integral aspect to Alcoholics Anonymous (AA) membership. 60 Over-extending PFL calls to self-labelling contexts would amount to ‘word-policing’, but this is not what is being advocated. Rather, we argue the primary concern regarding alcohol-related language is outside recovery contexts where ‘alcoholism’ terminology and its meanings have skewed public thinking about the nature of alcohol problems. 4 A growing number of studies have attended to implications of how ‘alcoholism’ concepts or terms may differ from other framings in how the public consider, evaluate and respond to alcohol use and problems. In one study amongst a general population sample, use of the term ‘alcoholic’ was associated with higher stigma rating on both implicit (ie, subconscious evaluations) and explicit (ie, conscious or reported actions taken based on bias or stigma) measures versus ‘person with an alcohol use disorder’ in an otherwise identical text. 98 Such findings highlight the clear devaluing consequences of labelling a person as an ‘alcoholic’, which has been argued as inherently stigmatizing due to its deeply embedded negative stereotypes. 62 That is, the public’s idea of being an ‘alcoholic’ casts the person as fundamentally different, diseased and thus belonging to a marked and de-valued out-group.62,107,108
Alternatively, a revaluing approach argues that rather than adopting PFL, alcoholic/alcoholism terminology itself should be ‘destigmatized’. Although there is little detailed empirical or conceptual work attending to revaluing as a stigma-reduction strategy, it has been proposed as ineffective for more heavily stigmatized terms, 109 including in the case of ‘alcoholic’ terminology. 62 That is, where a term is so deeply entrenched in stigma, as is in the case with public stigma towards ‘alcoholism’, 19 revaluing efforts are unlikely to succeed. 109 Indeed, it has been argued that the heavy public stigma towards ‘alcoholism’ is in fact driven by many sections of the public who ‘other’ problems in order to protect their own drinking behaviours from stigma. 4 Thus, whilst we recognize that revaluing has been utilized as a strategy for challenging stigma in some contexts (eg, by some groups to revalue racist or homophobic terms 110 ), we propose the extant evidence suggests PFL offers more promise in achieving substance-related stigma-reduction goals.
Further evidence of the problematic effects of ‘alcoholic’ labelling can be seen from a study which found inclusion of the term ‘alcoholic’ was associated with lower problem recognition amongst a community sample of people drinking at harmful levels. 38 The authors theorized that the stigma-related threat of an ‘alcoholic identity’ resulted in a process of label avoidance, leading to lower evaluations of their level of alcohol-related problems, similar to how people might avoid a ‘mental illness’ label. 111 Such findings align with broader evidence regarding the effects of the stigma around alcohol problems as a major barrier to treatment engagement112,113 and a key predictor or psychological distress and AUD symptoms. 114 Stigma has also been associated with reduced self-efficacy amongst people who internalize stereotypes via self-stigma. 115 Clinician stigma towards people seeking or obtaining treatment for substance use results in discrimination and poorer treatment across a range of settings.116,117 For example, stigma towards AUD has been identified as a key barrier to the prevention, early detection and intervention of alcohol-associated liver disease. 118
In contrast, PFL—for the present time at least—avoids embedded negative stereotypes, instead placing emphasis on the person rather than reducing them to the ‘disorder’. Since stigma processes are fundamentally dehumanizing, emphasizing the person rather than their addiction is a key stigma reduction strategy, 99 as demonstrated by the effectiveness of contact with stigmatized groups.26,119 Contact functions to reduce perceptions of fundamental difference (ie, ‘us’ vs ‘them’), which underpin processes of separation and discrimination. 21 Indeed, ‘othering’ problem drinkers has been proposed as a key driver of the heavy stigma around public perceptions of those deemed to be problem drinkers, particularly by drawing on extreme stereotypes of the ‘alcoholic other’. 18
The Role of Context in Evaluating Alcohol Terms and Their Applications
As highlighted, it is essential to consider the importance of context when assessing the implications of terminology and concepts for alcohol use and problems. Notably, ‘alcoholic’ self-labelling is a central component of AA, in part reflecting member’s commitment to overcoming ‘denial’, identifying with other group members, 60 and for some, resolving guilt and shame (facets of self-stigma).93,64 However, many people who disengage from AA reportedly do so because they struggle with ‘alcoholic’ self-labelling and/or the corresponding disease-based characterization of their experiences. 120 People are therefore aware of and evaluate the harmful stigma consequences specifically associated with ‘alcoholic’ labelling.38,98,113 However, adopting a stigmatizing identity may be managed via a range of self-stigma ‘coping responses’. 121 These coping strategies have the potential to be helpful or harmful to the individual and their recovery, thus termed the ‘paradox of self-stigma’. 122 For some, actively fighting stigma may become of source of self-worth and part of a recovery identity 123 and marker of group membership. 60 However, for others, AUD self-stigma via alcoholic self-labelling may undermine recovery through reduced self-efficacy, 115 increased feelings of guilt and shame 124 or reduced autonomy and recovery optimism.62,125,126 This may reflect how the accounts of people who self-label as ‘alcoholics’ often convey mixed views about the implications for the self and management of self-stigma.93,64
This is not to argue that people should not self-label as ‘alcoholics’, particularly given its centrality to AA membership as an often effective and free route to abstinence-based recovery. 65 However, it is notable that AA members are cautious and strategic about disclosing an alcoholic identity outside of AA and are aware others will view and treat them differently. 127 Research suggests that some AA members report wishing to distance themselves from an alcoholic identity at later stages in their recovery. 128 It should therefore be noted that whilst alcoholic self-labelling may itself become a positive aspect of a recovery identity, this experience is far from universal and potential negative consequences should not be overlooked. As such, the potential for alcoholic labelling to help or hinder efforts to address a person’s AUD ultimately depends on how the person themselves evaluate the term and its implications for the self. However, we argue the most important consideration here is that most people with AUD will never consider themselves as ‘alcoholics’ or engage with AA.47,74,129,130 This reflects the many ways in which dominant public beliefs about ‘alcoholism’ overlook the broad continuum nature of alcohol use and problems, and why othering one’s self from an ‘alcoholic’ identity appears a common strategy for resisting problem recognition. 38 Consequently, there is a need for alternative and less stigma-embedded terms and concepts for people to evaluate their drinking against. 4
Complexity in Concepts for Alcohol Use and Problems
Although the implications of specific terms are more easily tested via experimental studies, concepts attempting to capture alcohol use and problems are by their nature more complicated to evaluate. AUD is the main contemporary conceptualization for alcohol problems in professional contexts, yet still reflects a varied set of classification approaches and limitations, which are largely divergent from the public’s beliefs about what alcohol problems exist as.4,87 Notably, representations of ‘alcoholism’ as a chronic relapsing disorder/disease are still evident in many scientific articles, 131 including as a ‘chronically relapsing brain disease’ according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA). 132 However, disease-orientated concepts have been highlighted as problematic for several reasons.62,133 These include important challenges to the validity of AUD/addiction as a primarily biomedical or disease entity,133,134 but also a tension with ‘upstream’ public health efforts which emphasize population level approaches. 4 Indeed, sections of the alcohol industry have been known to favour disease model framings in order to undermine support for population level measures and protect profits.75,135 In this context, a disease framing is used to denote alcohol problems as an issue of a biologically distinct minority population. In turn, industry narratives portray the majority of the drinking population as ‘in control’ via an emphasis on ‘personal responsibility’, thus discrediting the role of public health policies to control price, availability or marketing.10,136
Nonetheless, disease models may reduce some components of stigma, notably blame,137,138 or at least in specific contexts.59,118 This may reflect how addiction-related beliefs may serve as functional attributions.139,140 Attributions are thus mechanisms for how terms or concepts are deployed to achieve objectives such as sense-making or recovery processes, or goals such as stigmatization or policy influence (by either health or industry groups). However, rises in disease model attributions amongst the public have failed to reduce public stigma towards both mental health problems and alcohol problems.141,142 One explanation is that the public still holds moralizing views towards people with addiction, even when not considering them as blameworthy. 143 This may derive from evolutionary motives such as disease avoidance or efforts to signal or punish social norm contraventions, often reflecting emotionally mediated stigma responses such as fear or anger.15,144 Notably, in one recent experimental study of public stigma towards people with alcohol problems, psychological (ie, coping mechanism) and nature (ie, innate drive to alter consciousness) models of AUD were associated with lower stigma, but no difference was found for a disease model. 145
Disease orientated models of alcohol problems may therefore be ‘mixed blessings’146,147—potentially valuable in some recovery or medical contexts, 118 but also indirectly facilitating public stigma 62 whilst obstructing the uptake of more effective alternative models for advancing public health goals.4,145 Several alternative models have been proposed as potentially advantageous to public health goals including stigma reduction. These include promoting the continuum nature of alcohol use and problems which emphasize the absence of categorical differences between groups 35 and increase recognition of drinking reduction goals as a valid route to recovery. 148 Psychological models typically emphasize the development of alcohol problems in response to lived experiences or psychological distress.145,149,150 Dynamic models of responsibility have proposed that with increasing severity of problems, increased recognition of the role of society, rather than only the individual, is more conducive to recovery outcomes and stigma reduction. 118 This approach is consistent with efforts to emphasize distinctions between responsibility (whereby individuals are still accountable for their actions) and stigmatizing blame, 151 and arguments against the use of social ‘disapproval’ to address addiction problems across society. 144 Other objectives proposed as important to reducing alcohol-related problems include better recognizing the role of quality-of-life measures and drinking reduction goals.74,76,152
Without delving further into the complex arguments about the precise nature of alcohol problems and associated concepts, we aim to highlight that its framing is embedded within social, commercial and political contexts which are often overlooked.87,153,154 As such, alcohol-related terminology and concepts are inescapably embedded within—and shape—agendas including research funding, 155 policy making/lobbying and regulation,10,12 and ‘recovery’ movements. 156
The Need for Clarity and Precision in Research, Policy and Practice
Precision in terminology is crucial throughout the research journey, starting from conceptualization and study design through to communication and implementation. 157 This includes how alcohol problems or risks are communicated, with ongoing challenges identified related to how ‘lower risk’ drinking guidelines are communicated,50,158 including efforts to enable people to identify or monitor their consumption via ‘units’ or ‘standard drinks’ (see Table 1). Similarly, terms such as ‘binge drinking’ (see Table 2) have been identified as problematic due to significant variation in their meaning and application.67,159 Notably, alcohol-related terminology within academic research journals is frequently inconsistent, imprecise or stigmatizing. For example, as described, ‘alcoholism’ is generally a highly problematic term, yet is often used to describe AUD or alcohol dependence criteria, sometimes without any clarification. 160 Shi et al 97 identified prevalent use of the term ‘alcoholic’ in alcohol research over the last decade. Specifically, in 2020, over 40% of articles searched for included ‘alcoholic’, whilst other studies have identified the persistence of other stigmatizing terminology within publications of AUD clinical trials. 161 Stigmatizing terminology (ie, ‘alcoholic’, ‘alcoholism’, ‘alcohol abuse’) is also widespread within clinical contexts including on websites of addiction and liver disease providers. 162 Imprecision or inaccuracy is also commonly evident in describing differing levels of alcohol use. 41 For instance, levels of ‘hazardous’ use (eg, as per ICD-11) may be incorrectly described as ‘harmful’, 160 thus, conflating different categories and undermining the advantages of emphasizing the heterogeneous nature of alcohol use and problems. 35 A wide range of other terms are also used as imprecise primary descriptors of AUD criteria or related components in contemporary scientific publications including ‘excessive’ 163 or ‘unhealthy’ use, 164 ‘abuse’, 165 ‘misuse’, ‘addiction’ 166 and ‘relapse’. 167
One important opportunity to improve scientific and professional conceptualizations and discourse is via addiction ontologies. Ontologies are designed to provide accessible and consistent definitions and concepts to provide clarity to complex constructs and thus reduce ambiguity. 157 The Addiction Ontology (AddictO) provides a transparent guide for using key terms to ensure that the writer’s definition is clear, whilst facilitating conceptual understanding of important but complex related concepts, 168 though it does not explicitly advocate for PFL. Additionally, researchers and clinicians must endeavour to use clinically accurate and medically precise language when discussing AUD symptomology (ie, physiological dependence, craving), or frequency and patterns of consumption.
Precision in terminology reflects the importance of delivering treatment (see Table 1) in a consistent and appropriate way to ensure and assess the best possible outcomes for individuals and providers. For example, a common, lay conception of the term ‘relapse’ implies moral failure if a person resumes alcohol consumption after a period of omittance, and should be strictly avoided in the context of treatment provision. 169 Conversely, a systematic review found that the term has been used with multiple different connotations within published AUD research, 84 though often without clear definitions or empirical criteria. In the same context, researchers should avoid using euphemistic phrases such as ‘suffers from’ or ‘has problems with’ which infer a subjective helplessness to the person or group under study. Instead, authors should objectively state the symptoms the participant(s) or group is reported to be experiencing. In addition to the Addiction Ontology, other examples include an online ‘addictionary’ (https://www.recoveryanswers.org/addiction-ary/), and the College on Problems of Drug Dependence has published a list of resources to provide guidance in destigmatizing language in research (https://cpdd.org/destigmatizing-sud-language/).
Key Terms and Concepts for Advancing the Reduction of Alcohol Problems
We have discussed a number of terms and concepts as of key relevance to advancing efforts to reduce alcohol problems, although many other important terms identified in Tables 1 and 2 have not been discussed in detail. Since we did not take a systematic approach to included literature, we recognize this as an important limitation and suggest that future research systematically develop and evaluate alcohol-related terms and constructs and their likely impact on efforts to reduce alcohol harms. Despite these limitations, we argue the key priority for evaluating terms and concepts for alcohol use and problems reflects the many issues associated with alcoholism models and associated stereotypes. For example, denial (see Table 2) is another common term that has been cautioned against due to a lack of scientific validity and stigmatizing implications. Notably, ‘denial’ leads to over-simplification of the many complex reasons behind people not explicitly self-identifying as having a ‘problem’. 170 As Pickard 71 examines, there are various context-related factors that undermine the legitimacy of ‘denial’ stereotypes, such as the absence of clear harms, the subjectivity of what ‘problems’ are, or significant variation in norms about what constitutes ‘addiction’ and ‘denial’. Morris et al 170 propose alcohol problem recognition involves a range of social (eg, stigma-related threats) and cognitive (eg, implicit bias) processes which are overlooked when ‘denial’ terminology is used.
Relatedly, the roles of natural recovery (ie, self-change) and non-abstinent recovery (historically termed ‘controlled drinking’) also remain overlooked or discredited despite clear evidence for their existence as important routes to recovery, perhaps because of the dominant societal emphasis on ‘alcoholism’ models of AUD.47,74,76,152,171,172 Although abstinence is an important and valid goal for many people with AUD, a 2020 systematic review and meta-analysis found no inferiority in outcomes for those with non-abstinent goals. 171 Despite this, cynicism towards non-abstinent recovery persists, reflecting a history of events that have undermined and even actively smeared controlled drinking research. 173 One proposed response is an increased availability of lived experience narratives that highlight drinking reductions as legitimate and effective responses to alcohol problems for many. 47 A focus on outcomes other than alcohol use, notably quality of life measures, has also been advocated for improving the uptake and effectiveness of alcohol treatment.74,83,174,175
‘Natural recovery’ broadly denotes the resolution of alcohol problems without formal help or treatment, but is also overlooked as an important facet of alcohol use and problems. 176 Indeed, longitudinal studies show most people who develop alcohol problems resolve these without formal treatment, 177 in turn underpinning calls for broader recognition of the multiple and complex pathways to resolving alcohol problems. 74 Cynicism towards natural recovery also reflects the pathologization of alcohol problems as a ‘disease’ in need of treatment (see Table 1), thus undermining problem recognition and self-change intentions amongst people with lower severity problems such as those with ‘hazardous’ levels of consumption or ‘mild’ or sub-threshold AUD.41,62 Lay terms such as grey area drinking (see Table 2) reflect public attempts to capture such experiences of alcohol problems without using ‘alcoholism’ orientated terms and concepts129,156 and therefore warrant further investigation for their utility in advancing the reduction of alcohol problems. 4
Conclusion
Language and concepts relating to alcohol use and problems are complex, dynamic and subject to multiple contextual issues. This in turn reflects a range of challenges in how concepts such as AUD and associated facets are understood and addressed across professional and lay settings. Nonetheless, some important objectives are apparent. Most notably, outside of recovery contexts, PFL should be adopted wherever possible, and professional stakeholders should cease use of ‘alcoholic’ and ‘alcoholism’ terminology due to the clear problems associated with their use, including their over-application in wider discourse relating to alcohol use and problems. In doing so, it is important to emphasize that the use of PFL reflects empirical evidence pertaining to how alcohol use and problems are understood and treated in order to mitigate ‘word-policing’ and related concerns. Crucially, seeking to progress alcohol-related language and concepts must not be seen as an end in itself, rather as a means to facilitate important but more distal alcohol-related outcomes including public attitudes and policy decisions. Specific objectives include developing more nuanced public understandings about the nature of alcohol use and problems as a broad continuum, and recognition of the multiple routes to its resolution, including via drinking reduction goals and self-change. Indeed, the voices and direct contributions of people with lived experience are crucial to many such objectives, but their inclusion must reflect consideration of the broad heterogeneous nature of alcohol problems and the under-representation of its existence in less severe forms, and experiences of non-abstinent ‘recovery’. A further important shift should be to move away from individually focused ideas about alcohol problems as primarily biomedical problems or failures of ‘personal responsibility’, instead towards increased recognition of the broader structural and environmental factors at play.
Footnotes
Author Contributions
JM conceptualized the study and led the project administration. All authors contributed to manuscript writing, data analysis and interpretation, reviewing and editing the manuscript. All authors approved the final draft.
Funding:
The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: NIAAA K08 AA030301 (partially supporting investigator effort).
Declaration of conflicting interests:
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
