We admit we are powerless over alcohol and we need help to break the habit.
We will participate in meetings and speak frankly about ourselves.
We will reflect on our mistakes and accept the damage that alcohol has caused.
We will strive to change and create a new life for ourselves.
We will repent for the trouble we have caused our families and others.
We will help others struggling with alcohol abuse by sharing the joy of abstinence.
— “Danshu no Chikai,” or “The Vow of Abstinence”

Japan is renowned for taking a tough stance on illicit substances, but when it comes to legal drugs such as alcohol and tobacco, it tends to turn a blind eye. People associate drug abuse with the criminal underworld, while alcohol is glorified for being an integral part of Japanese culture.

Indeed, the country’s liberal attitude toward drinking means that alcohol can be found almost anywhere at any time of day. It is not uncommon to see salarymen passed out on benches, women swaying from side to side on their walk home or piles of vomit (jokingly called “platform pizza”) at train stations.

Should more be done to rein in the country’s drinking problem? Before we even get to that, we first have to admit there’s a problem.

A large group of people gather in a room in Tokyo on a weekday evening. Most of them are more than 60 years old, although some younger folk are also scattered among the crowd. The atmosphere is lively, with warm greetings exchanged between regulars. Some attendees munch away at the candy they have been given at the door, while others pop outside for a quick cigarette. At exactly 6:30 p.m., the meeting starts.

The meeting has been organized by the Tokyo branch of the All Nippon Abstinence Association (Zen Nihon Danshu Renmei), a support group for recovering alcoholics. “I tried to quit alcohol on my own but I couldn’t. It wasn’t until my doctor introduced me to this support group that I was able to,” a retired man from Tokyo’s Koto Ward tells participants. “I’ve made friends and, together, we’ve been able to stay sober.”

Alcohol is widely accepted as a part of life in Japan. It’s included in Shinto ceremonies such as weddings and a newborn baby’s first shrine visit, where participants drink sake to express gratitude to the deities. The winner of a sumo tournament is often shown on the evening news drinking sake from a massive sakazuki cup after each tournament.

In everyday life, too, alcohol seems to play a major role in people’s social networks. Employees are encouraged to go out for drinks after work with their colleagues for “nomunication,” a Japanese portmanteau coined from nomu (to drink) and communication. Young adults, meanwhile, can regularly be seen signing up for two-hour all-you-can-drink sessions, while convenience stores offer a wide variety of alcoholic beverages 24 hours a day.

When it comes to alcoholism, however, Japan tends to look the other way.

“Not many people are aware that alcoholism is a disease,” says Gen Otsuki, secretary-general of the All Nippon Abstinence Association. “Anyone can become an alcoholic. However, many people in Japan believe that it is a matter of character, and that alcoholics are generally slovenly and weak.”

Statistics show that Japan has a drinking problem, and the number of people who are struggling with alcohol is only getting larger every year.

An estimated 1.09 million people are thought to have been battling alcohol abuse in 2013, according to a survey conducted by a health ministry research team every five years, a figure that is almost 300,000 higher than what it was a decade ago. Almost 10 million people in Japan potentially have a dependency problem, the study adds. Alarmingly, only 40,000 to 50,000 addicts are currently undergoing treatment.

“Japan is a society that loves to push people to drink a lot,” says Susumu Higuchi, director of the National Hospital Organization Kurihama Medical and Addiction Center in Kanagawa Prefecture. “However, once someone becomes an addict, he or she is looked down on and it is not easy for that person to regain his or her status back in society after recovery.”

Higuchi, who headed the health ministry’s research team, is Japan’s leading expert on alcoholism, and the medical center where he works is the largest treatment facility in the country. He believes more than 1 million people in Japan are not getting the treatment they need, adding that patients typically only come when they are very seriously ill.

Alcoholism is not exclusively defined by whether or not someone has a compulsion to drink, Higuchi says, pointing to other symptoms such as delirium tremens (“the shakes”), depression and chronic disease (diabetes, high-blood pressure, cirrhosis of the liver, etc.).

In Japan, most medical experts use the World Health Organization’s International Classification of Disease 10 as a standard diagnostic tool for identifying alcoholism. It comprises six categories — including such factors as “a strong desire or sense of compulsion to take the substance” and “a physiological withdrawal state” over the past year — and if you identify with more than three of them, you meet the criteria for being an alcoholic. However, Higuchi says most of his patients only seek his help once they meet five or six categories. By then, he says, most addicts are at rock bottom.

“The later alcoholics are treated, the more serious their health condition is,” he says. “In fact, by that stage they’re usually involved in all sorts of trouble, both socially and psychologically. It’s imperative to seek help as early as possible.”

Doctors treat alcoholism by first targeting the physical symptoms and chronic diseases a person may be suffering from. They then use cognitive behavioral therapy to help patients identify and solve problematic behavior as well as learn to strengthen self-control.

A new type of medicine called Regtect went on sale in 2013, the first alcohol-dependence drug to enter the domestic market in 30 years. Unlike traditional drugs for alcoholism, which cause symptoms such as nausea and headaches after consuming alcohol, Regtect works in the brain by suppressing cravings. A clinical test of Regtect found that almost half of the 320 trial patients were able to quit alcohol after six months, compared to 36 percent of those using a placebo.

Once you become an alcoholic, Higuchi says, total abstinence is a must — there is no going back and certainly no half-measures. “Your brain will always remember how to drink uncontrollably,” he says. “Even if you’ve been sober for five or 10 years, your brain will return to what it knows best: drinking uncontrollably. ”

Higuchi says it is important for recovering alcoholics to attend support groups after leaving institutionalized care because the encouragement they receive from others in such situations can help prevent a relapse.

The All Nippon Abstinence Association is the country’s largest network of support groups for recovering alcoholics, boasting a membership of around 8,000 spread across 650 local chapters. Alcoholics Anonymous in Japan, by comparison, has about 5,700 members.

Founded in 1963, the All Nippon Abstinence Association was initially influenced by Alcoholics Anonymous, which was inaugurated in the United States in 1935. However, the association wanted to distance itself from the strong Christian influences that are prevalent in Alcoholics Anonymous, and so created its own set of rules to suit Japanese conditions.

Rather than replicate the 12 steps used by Alcoholics Anonymous, the association created its own vow of abstinence (danshu no chikai) that is read out before each meeting. Alcoholics Anonymous is also funded by donations, while the association charges annual membership fees.

Perhaps the biggest difference between the association and Alcoholics Anonymous, however, is that none of the people who attend support sessions is anonymous. Everyone registers upon arrival at the meetings, and the person chairing the session calls on the participants by name when it is their turn to speak.

“This is a place to come out in the open by using your real name, and to build relationships based on that,” Otsuki says. “You cannot hide your true self here.”

Otsuki is a recovering alcoholic who has been sober for more than 20 years. He once held down a good job at a leading trading company and was in constant competition with his colleagues to succeed. It was this desire to succeed, however, that drove him to drink. He started drinking heavily after work and woke up each day with a monstrous hangover. He was hospitalized several times and was forced to quit his job when he was 48 years old.

“I felt as if my life was over,” Otsuki says. “I was caught between the past — the good ol’ days of working for 25 years with a successful firm — and the present. It wasn’t until I joined the association that I realized I had to let go of my past in order to move forward in life.”

Discrimination against addicts struggling with a drinking problem in Japan remains strong, and most people don’t even know that alcoholism is a disease.

“People don’t like inebriated drinkers because they are generally slovenly and disorganized, and alcoholics are viewed as being the most extreme form of that. No one ever thinks they are an alcoholic,” Otsuki says. “We have no other option but to show what we are really like as recovering alcoholics.”

Lawmakers are ever so slowly taking note of the problem, finally passing legislation that is aimed at reducing health problems caused by alcohol last December.

The legislation recognizes that alcohol abuse is closely related to social issues such as drunken driving, domestic violence and suicide. The new law also states that local and central governments should draft and implement measures to prevent health problems caused by alcohol. Once done, medical professionals and alcohol manufacturers across the country are required to cooperate with the measures to stop dependency.

Tomomi Imanari, chairwoman of the nonprofit group Alcohol Yakubutsu Mondai Zenkoku Shimin Kyokai (ASK), is pleased to see that some responsibility is now being put on manufacturers.

“Before this law, they were absolved of responsibility,” Imanari says. “By passing this legislation, however, alcohol manufacturers now have a duty to refrain from encouraging inappropriate drinking. They now have the responsibility to prevent health problems caused by alcohol.”

According to research conducted by ASK, France bans beverages that have an alcohol content of more than 1.2 percent from being advertised on television and prohibits manufacturers from sponsoring sports and cultural events. In the United States, producers do not advertise spirits on television, and refrain from showing scenes of drinking and featuring models that are less than 25 years old. In Japan, meanwhile, alcohol manufacturers are required to follow a set of self-regulatory guidelines. They must, among other things, refrain from airing commercials between 5 a.m. and 6 p.m., include warnings for pregnant women about likely health risks and refrain from using under-aged models in advertisements.

Outside of these guidelines, however, advertising for alcohol can be found everywhere. Beer ads are generally prominently displayed on the walls of trains for all to see, while many TV commercials in the evening feature scenes of drinking.

“This is what we are up against. It’s tough when there are advertisements all over the place,” Imanari says. “The self-regulatory rules in Japan are way behind the global standard.”

Unlike other countries, it’s also difficult to find high-profile people willing to talk frankly about their battle with alcohol in Japan. In the U.S., a number of celebrities have opened up about their disease, including actor Anthony Hopkins, rapper Eminem and the late Betty Ford, wife of former President Gerald Ford.

In Japan, only a few have spoken publically. The late Prince Tomohito of Mikasa, a cousin of Emperor Akihito, revealed that he was suffering from alcoholism in 2007, while Democratic Party of Japan lawmaker Yutaka Fukuma opened up about his battle with alcohol in June.

During a prefectural assembly meeting in Tottori, Fukuma recounted the times he left one psychiatric hospital after another, only to relapse. He also recalled a time he was so inebriated his own father broke down crying in front of him and handed him a rope to hang himself. His addiction had caused his wife so much grief that she had secretly aborted their second child. Affected by Fukuma’s story, Tottori Gov. Shinji Hirai earmarked an emergency budget worth ¥3 million to fight alcohol abuse.

“Japan needs a prominent recovering alcoholic to change the image of alcoholism in the country,” Imanari says, “but right now alcoholism is still considered something to be embarrassed about and covered up.”

For more than 30 years since it was founded in 1983, ASK has been active in spreading awareness of the dangers of alcohol. In the 1980s, a penguin anime character was advertising beer and vending machines with alcoholic beverages flooded the streets. Becoming a nonprofit body in 2000, ASK also has a hotline and conducts various surveys related to alcohol.

Imanari has been involved since the beginning and has headed the organization since 1984. She too has a personal story — her father was an alcoholic who eventually overcame the disease. He was four years sober before passing away with esophageal cancer, a disease often linked to alcoholism.

“The hardest thing about alcoholism is that alcoholics die a social death,” she says. “You are effectively abandoned by society and by your family. We need to change that, to create a place that supports the recovery of alcoholics and a society in which you can start all over again.”

Views from the street on drinking

Daisuke Kikuchi took to the streets of Tokyo to ask people some hard-hitting questions about their drinking habits:

1) How many days do you drink per week?

2) How much do you drink?

3) Have you ever felt pressured to drink?

4) Do you think people should feel comforable drinking a nonalcoholic drink?

5) Have you ever felt as if you drink too much?

6) Do you think you might be an alcoholic?

Toshinobu Saito (Early 50s)

1) Every day, although I try to avoid it.

2) I drink two cans a day now, but I can’t remember how much I used to drink when I was younger.

3) No, but I do think I shouldn’t be out drinking too much.

4) There are people who can’t drink, so I’d say they need a choice. However, it can be difficult sometimes.

5) Yes, people around me tell me I drink too much. I try to have at least a day off per week.

6) No, I don’t think so. I only drink at night.

Akira (Early 20s)

1) I don’t really drink that much, a day per week perhaps.

2) When I go out drinking, I drink about five or six drinks.

3) To be honest, I do. Not all of the time though.

4) Yeah, I think it’s a great idea. It’s unavoidable sometimes.

5) Yeah, I guess so.

6) No, I don’t drink that much.

Yuriko (Early 30s)

1) I guess three or four days per week.

2) I drink a lot when I go out but not at home. I only drink a little bit when I’m home.

3) No, not really.

4) Yes. There are people who can’t drink.

5) Yes.

6) No.

Keisuke (Late 20s)

1) I tend to drink when I’m off from work, so probably around three days a week.

2) I drink a lot when I go out but, on average, maybe about three cans of beer a day.

3) Yes, but only sometimes.

4) No. If your boss is drinking, you should drink as well.

5) Yeah, occasionally.

6) No, I don’t drink that much.

Mami (Late 20s)

1) Probably two days per week.

2) About three drinks each time.

3) No, I’ve never felt that way.

4) I think that should be an option.

5) Not really.

6) No, of course not.

WHO dependence guidelines

A diagnosis of dependence can be made if three or more of the following have been present together at some time during the previous year:

(a) a strong desire or sense of compulsion to take the substance;

(b) difficulties in controlling substance-taking behaviour in terms of its onset, termination or levels of use;

(c) a physiological withdrawal state when substance use has ceased or been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms;

(d) evidence of tolerance, such that increased doses of the psychoactive substances are required in order to achieve effects originally produced by lower doses;

(e) progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects;

(f) persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning.

A condensed version of the World Health Organization’s International Classification of Disease 10

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