Addiction (1996) 91(4), 473-475
EDITORIAL
Preventing fetal alcohol syndrome: where are
we now?
In 1968 French researchers described special
characteristics of infants bom to alcoholic moth-
ers,' but it was not until the publication of the
Lancet article by Jones, Smith & Ulleland in
1973^ that medical and scientific attention was
focused OB the issue of fetal alcohol syndrome
(FAS). In the United States, the newly indepen-
dent Nationa! Institute of Alcohol Abuse and
Alcoholism quickly developed a substantial pro-
gram of research in the area. The Research So-
ciety on Alcoholism formed an FAS study group.
The National Coimcil on Alcoholism organized
itself to provide public information. Those of us
who specialized in treating alcoholism and other
drug dependencies reviewed our prior experi-
ences, evaluated our female patients' children
and set about to try to wam anyone who would
listen. One of nny first acts upon taking the job of
Director of New York State's Division of Alco-
holism and Alcohol Abuse in 1979 was to chair
a state task force on how best to prevent alcohol-
related birth defects.'
Despite the enthusiasm of those in the field, or
even in some strange way partly because of it,
others in society were slower to accept the reality
of the fetal alcohol syndrome and the need to do
something about drinking dunng pregnancy. I
recall submitting the manuscript of a talk on
FAS I had given at a seminar to the journal that
was preparing to publish its proceedings. It was
returned by the editor (a friend) with the
scrawled notation "you've got to be kidding!".
Older physicians found it hard to believe that
alcohol could cause so much mischief without
their having noticed it before. The beverage in-
dustry sougjit to cast doubt on the validity of the
findings, or at least to challenge the value of
alarming pregnant women with such measures as
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warning posters where drinks are sold or warning
labels on cans and bottles.'' We in the field
wanted research, we wanted education and we
wanted prevention. We wanted every woman to
know about alcohol's teratogetiicity before she
became pregnant; and we wanted readily access-
ible, user-fiiendly (another term that had not yet
been invented) treatment available for any
woman who needed help with an alcohol prob-
lem. Tbe task seemed strai^tforward.
It is now 22 years later. A great deal of valu-
able research has been done and is continuing.'
Magnetic resonance imaging has elucidated
FAS-rekted structural brain defects. Human
and animal studies have described the patho-
physiology and possible mechanisms of alcohol-
related fetal damage. How are we doing in
prevention?
That is a difficult question to answer. We do
not have sufficiently accurate estimates of inci-
dence over time to judge the success of preven-
tion efforts as a whole. Legislation requiring
alcoholic beverage warning labels in the United
States took effect in November, 1989. Unfortu-
nately, the required labels are not uniform in size
or print and, unlike the warning labels on
cigarette packages, are hard to see. Researchers
found an increased awareness of FAS and a
decrease in alcohol consumption durir^ preg-
nancy, temporally related to the introduction of
warning labels.' Unfortunately, the reductions in
drinking were found only among low-risk
drinkers. (As we knew, in high-risk drinkers in-
tervention and treatment are needed.) Infor-
mation about alcohol-related birth defects has
found its way into textbooks and standard curric-
ula in professional schools. However, prevention
programs involving coordinated education.
474 Editorial
screenii^, intervention and treatment for preg-
nant women with drinking problems still tend to
be special "demonstrations", rather than stan-
dard practice. User-fiiendly treatment for preg-
nant women with addictive disorders is still a
rarity. Thousands of infants continue to be bom
with preventable birth defects due to alcohol and
other drug exposure in Mem.
The National Institute on Drug Abuse re-
cently released estimates based on a 1992-93
survey, indicating that about 19% or 757 000
American women drank during pregnancy dur-
ing a 12-month period. Their alcohol use was
closely associated with smoking and illicit drug
use. About 20% smoked durir^ pregnancy. Only
6% of women who did not use illicit drugs re-
ported drinking and smoking wbile pregnant,^
while 32% of those who used one or more illicit
drugs both smoked and drank during pregnancy.
Thus FAS prevention carmot hope to succeed
unless it includes the appropriate services for
women using other drugs of abuse.
Where are we with services for women? The
early 1990s saw a growing number of women
arrested and prosecuted for manslaughter, "pre-
natal child abuse" and delivering controlled sub-
stances to a minor (via the umbilical chord) as a
result of drinking and/or drug use during preg-
nancy. One hospital routinely reported positive
drug tests in neonates to the local district at-
torney's office for maternal prosecution. Advo-
cates for women have had their hands full
fighting these cases in court and trying to
influence makers of public policy. MeanwhUe,
the political pendulum has swung to the right in
the United States and public addiction programs
face a serious decrease in suppon. Criminal jus-
tice approaches will once again be preferred to
prevention and treatment. In the midst of such
trends, what is needed to do the job that seemed
so clear 22 years ago? If we can believe our
colleagues, each prevented FAS case will save
society hundreds of thousands of dollars in life-
time costs.* More important, each will preserve
the potential of a human being.
A rational agenda to prevent alcohol (and
other drug) related birth defects would include:
(1) Producing real change in drinking norms
and customs for young women through
curtailing beverage advertising and pro-
motion and through relevant education
(including "counter advertising").
(2) Screening and referral for alcohol prob-
lems in all health settings as a requirement
(by licensing, accrediting and/or inspect-
ing agencies), this requirement especially
implemented in obstetric practice.
(3) Adequate teaching in medical and other
professional schools to allow health pro-
fessionals to feel comfortable in the
identification of drinking problems and
knowledgable about intervention. This
would mean the acceptance of addiction
medicine as part of mainstream medical
care.
The needs, in sbon, are much as they were 22
years ago, and the stakes are as high.
In 1962 the world leamed that thalidomide, a
sedative-hypnotic drug prescribed in many
countries, produced birth defects if used in early
pregnancy. Within months the world community
acted, and thalidomide-related birth defects be-
came a tragic but limited episode in medical
history. Is it so much to ask that we organize
ourselves to do the same for FAS?
SHEILA B . BLUME
Medical Director Alcoholism, Chemical Dependency
and Compulsive Gambling Programs,
South Oaks Hospital, 400 Sunnse Highway,
Amityville, New York 11701,
and Clinical Professor of Psychiatry,
State University of New York at Stony Brook,
Stony Brook, New York, USA
References
1. LEMOINE, P., HAROUSSEAU, H . , BORTEYRU, J. P. &
MENUET, J. C . (1968) Les enfants de parents al-
cooliques: anomalies observees a propos 127 cas,
Quest Medical, 21, 476-482.
2. JONES, K. L., SMITH, D . W . , UIXELAND, C . N . &
STREISSGUTH, A. P . (1973) Panem of malforma-
tion in offspring of chronic alcoholic mothers,
Lancet, 1, 1267-1271.
3. RUSSELL, M . , KANG, G . E . & UHTEG, M . S. (1983)
Evaluation of an educational program on the fetal
alcohol syndrome for health professionals, Journal
of Alcohol and Drug Education, 29, 4 8 - 6 1 .
4. BLUME, S . B . (1986) Women and alcohol: public
policy issues, in: Women and Alcohol- health-relaud
issues. Research monograph no. 16, Publication no.
(ADM)S6-n39, pp. 294-311 (Washington, DC,
Department of Health and Human Services).
5. ALCOHOL HEALTH & RESEARCH WORLD (1994)
Special Focus: akohol-rektted birth defects, 18, N I H

Publication No. 94-3466 (Washington, DC, US
Government Printing Office).
HANKIN, J. R. (1994) FAS prevention strategies:
passive and active measures. Alcohol Health &
Research World, 18, 6 2 - 66.
NATIONAL iNSTmrre ON DRUG ABUSE NATIONAL
Editorial 475
OF HEALTH (September 12, 1994)
Statement of Alan I. Leshner, Ph.D., Director.
Release of Finding from NIDA's National Preg-
nancy and Health Survey (Rockville, MD).
BLOSS, G . (1994) The economic cost of FAS,
Alcohol Health & Research World, 18, 53-54.