Alcohol Policy

Thomas K. Greenfield, Ph.D.

Alcohol Research Group Public Health Institute

Emeryville, California;

Department of Psychiatry, UCSF

Editor: Jűrgen Rehm, Ph.D. University of Toronto and CAMH

(Supported in part by Center Grant P30 AA05595)

Alcohol Policies: Overall Approach Will consider first the underlying epidemiology

– Alcohol consumption; overall trends and drinking patterns– health and social consequences – clues for policy levers?

Give an overview of the range of types of policies– First identify historical and cultural backdrop for US policies – Types of alcohol policies – jurisdictional level; role of

enforcement. Emphasis will be on evidentiary basis – Treatment policies are not addressed – other than costs

Other issues– Touch on several other issues like policy development,

optimal policy mix, pragmatic versus ‘ideal’ policies

Alcohol Policies: Levels, Types, IssuesJurisdictional Level

– Federal, state, county, municipal; as well as – institutional

Type– Legislatively Based (e.g., taxation/pricing, access,

advertising regulation, transportation rules, etc.) – Law Enforcement (e.g., policing, random breath testing,

and justice system)– Institutional/Organizational policies (e.g., server

intervention, schools, workplace, military)– International Policies (e.g., trade agreements, treaties)

Issues– Cutting edge issue: what is the appropriate policy mix?– The role of science in policy development/implementation

Prevention Policies

“[Prevention policies] are all policies that operate in a non- personalized way to alter the set of contingencies affecting individuals as they drink or engage in activities that (when combined with intoxication) are considered risky.”1

“Alcohol policy is defined broadly as any purposeful effort or authoritative decision on the part of government or non-government groups to minimize or prevent alcohol-related consequences.” 2

1Moore & Gerstein (1981), p 53 Beyond the Shadow of Prohibition2Babor et al. (2003), p 95 Alcohol: No Ordinary Commodity

Reductions in Problems During Prohibition

Measure Dates Change

Cirrhosis mortality 1911–1929 29.5 to 10.7 per 100,000

Admissions for alcoholic psychosis

1919–1928 10.1 to 4.7 per 100,000

Arrests for drunk & disorderly

1916–1922 50% decline

Source: Moore & Gerstein, 1981

Prohibition took effect January 1920, lasted to December 1933Impact had two stages—first years: changed drinking patterns;second period: lawlessness, crime and loss of legitimacy.

Source: Berridge, 2003, citing Burnham, 1968-69

Repeal: Alcohol Control• 1932: Roosevelt campaigns for repeal of 18th Amendment• December 1933: 21st Amendment (Repeal) ratified by 35 states • Alcohol Control becomes “a pivotal idea” in post-Repeal era

– Federal• regulate production of spirits, wine & beer (curb illegal production)• manage product purity and labeling; impose excise taxes• Authority with Department of Justice (ATF since 1972; now ATFE)

– State• Devolved Powers including dry option, retail monopolies, taxation• Alcoholic Beverage Control (ABC Laws); outlet licensing, density, etc.

– Local• Dry Counties; Zoning regulation, policing outlets, etc.

Sources: Levine 1980; Moore & Gerstein, 1981

Sources: Lakins, Williams, Yi, & Smothers (2004); Kerr, Greenfield, Tujague, & Brown (2005)

U.S. Per Capita Consumption of Pure Alcohol from Beer, Wine and Spirits

0.00

0.25

0.50

0.75

1.00

1.25

1.50

1.75

2.00

2.25

2.50

2.75

3.00

1950

1952

1954

1956

1958

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

Ga

llon

s o

f Alc

oh

ol

SpiritsWineBeerTotal AlcoholAEDS SpiritsAEDS WineAEDS BeerAEDS Total

Optimal Policy Approaches: A Controversy Resolved?

• Single Distribution Theory (Skog improving Ledermann).Argues that a substantial decrease in a population’s mean (or per capita) consumption will be accompanied by a decrease in the prevalence of heavy drinkers; supports policy measures like taxation aimed at achieving overall reduction

• Harm Reduction: Abates Hazardous Drinking Patterns. Attention is less on trying to modify everyone’s drinking, be it light or heavy, and more on policy measures targeting heavy quantity per occasion drinking patterns; high quantity contexts

Sources: Skog, 1985; Edwards et al, 1994;Rehm et al, 1996; Stockwell et al, 1997; 1Babor et al, 2003

“Per capita alcohol consumption is … related to the prevalence of heavy use, which in turn is associated with … negative effects”1

Concentration of U.S. Alcohol Consumption

0

20

40

60

80

100

2.5 5 10 20 30 40 50 60 70 80 90 100

Highest Volume Percentile of Drinkers Lowest Volume

% T

otal

V

olum

e (g

/day

)Cumulative Percent Volume (g/day)

Source: adapted from Greenfield & Rogers, JSA,1999

Top 10% drinking > 3 drinks/day: 58% of Total

Top 5% drinking > 4 drinks/day: 40% of Total

Hazardous Drinking: U.S. Percentage

81%

4%

15%

Beer

Wine

Spirits

OF TOTAL OF BEVERAGE

Source: adapted from Rogers & Greenfield, JSA,1999

63%

86%

41%59%

14%

37%

0% 20% 40% 60% 80% 100%

Hazardous Nonhazardous Share

58.4%

26.7%

14.9%

(Hazardous drinking occurs more in bars, other people’s parties, and public places)

Alcohol-attributable Mortality 2002 (number of deaths) –Epidemiological Model for Americas and World

Americas

2002 best estimates

% of all alcohol-

attributable

World % of all alcohol-

attributable

Maternal perinatal condit. 203 0.1% 3,057 0.2%

Cancer 47920 16.7% 377,968 21.2%

Neuro-psychriatric condit. 28733 10.0% 113,603 6.4%

Vascular conditions -5154 -1.8% 196,646 11.0%

Oth. noncommun diseases 52557 18.4% 237,985 13.3%

Unintentional injury 92661 32.4% 585,553 32.8%

Intentional Injury 69430 24.3% 269,155 15.1%

All alcohol-related deaths 286346 100.0% 1,783,567 100.0%

% alcohol-attributable of all deaths 4.8% 3.1%

Sources: Adapted from Rehm, Room, Monteiro, et al., 2003; Rehm & Monteiro, 2005

Economic costs of alcohol abuse by type, 1998

14%

48%

20%

18%Direct Costs

Morbidity Costs

Mortality Costs

Other Costs

U.S. Data

Source: Harwood, Fountain & Livermore, 1998;NIAAA, 2000http://pubs.niaaa.nih.gov/publications/economic-2000/printing.htm

(e.g., crime, crashes)

(e.g., medical)

(lost productivity)

(lost future earnings)

•Total: $184.6 Billion

$26.3 Billion

$88.1 Billion

$36.0 Billion

$34.2 Billion

Jurisdictional Levels: Example Policies

Federal • Excise taxes• Transportation (e.g., Minimum Drinking Age, aviation)• Commercial regulation, production, advertising, marketing• Warning Labels, Dietary Guidelines, etc.

State• State alcohol taxes• Access: alcohol distribution systems, State ABCs, retail

monopolies, local options, regulating outlets, labeling, etc. • Server licensing, training, dram shop or server liability• Drinking driver laws: mandatory license actions, treatment,etc.

Price and Taxation Policies

Studies at both federal and state levels show:

• generally, significant price effect on consumption owing to taxation

• quality substitution, market, etc., may partially neutralize price effects • effects seen for heavier drinkers as well as lighter ones• Well-designed studies have found effects on population-level problem

indicators: cirrhosis mortality, vehicular crashes• not particularly regressive tax measure compared to other commodity

taxes—there is a lower burden on the poor; youth are affected

• supported by public health experts, anathema to industry

Sources: Coate & Grossman, 1988; Babor et al, 1978; Cook & Tauchen, 1982; Edwards et al, 1994; Gruenewald & Treno, 2000; Chaloupka et al, 2002

Relative Price of Alcoholic Beverages, 1970-2005

1.00

2.00

3.00

4.00

5.00

6.00

1970

1975

1980

1985

1990

1995

2000

2005

AlcoholicBeverages

Consumer PriceIndex

Non-AlcoholicBeverages

Sources: Mosher, 1997; Mosher & Cowan, 1985;Bureau of Labor Statistics, 2006 (www.bls.gov)

Relative Price, 1970 $

U.S. Drinking Driving Legislative PoliciesMinimum Drinking Age (MDA)

• Federal law required 21 year old MDA for states to receive national highway funds (incentive to comply)

• By mid 1980’s all states adopted uniform MDA of 21• Changes before and after federal law provide natural

experiments: most studies found reductions in crashes

Evidence• Crashes of drinking drivers under 21: mean decrease 16%1

• NHTSA estimates MDA of 21 prevented 21,000 traffic deaths since 1976; saves 700-1000 deaths annually 2

• 30 states with <21 zero-tolerance laws: 19% less drunk driving3

—yet low enforcement Sources: Edwards et al, 1994; Babor et al, 2003; 1Schultz et al, 2001; 2NHTSA, 2003; 3Wagenaar, 2001

Alcohol Warning Label (PL100-690, 1988)

Federal law required health warning on container labels• Government warning from credible source: Surgeon General

• Pregnant women should not drink : risk of birth defects

• Impairs ability to drive a car or operate machinery and may cause health problems; political compromises—warnings often obscure

Major Results of national study commissioned by NIAAA • By 1994, 60% of drinkers saw the label–asymptotic exposure

• Messages reach > 50% males 18-20 (drunk driving); > 65% drinkers 18-29 (pregnancy); reach heavy drinkers but may miss less educated and ethnic minority groups

• Modest associations with precautionary behavior, conversations Sources: Giesbrecht & Greenfield, 2003;Greenfield et al, 1999; Hankin et al, 1993

Sliding Public Support for Stronger Alcohol Policies

20

30

40

50

60

70

80

90

100

1989 1990 1991 1993 1994 2000

Warning Labels

More Prevention

Host Liability

Counter Ads

Increase Taxes

Store Hours

Drinking Age

Souce: Greenfield, Johnson & Giesbrecht, CDP, 2004

%

Alcohol Access Regulation

Access primarily regulated at state and local levels• Responsibility of State Alcoholic Beverage Control agency• Limiting Outlet Density: Possible benefits—lower crashes, less

violence

Monopoly States• By 2 years after Repeal, 15 states enacted retail monopolies• Deregulation and privatization have led to increased wine sales in

several states and a Canadian province (Quebec)

• Iowa and West Virginia increased wine and overall consumption

Sources: Babor et al, 2003; Friestheler et al, 2004; Gruenewald et al, 1993; Gruenewald et al, 1996; Gorman et al, 2001; Lipton & Gruenewald, 2002; Scribner et al, 2000; Treno et al, 2003; Trolldal, 2005; Wagenaar & Holder, 1991;1995; Weitzman et al, 2003

Case Study: Underage Drinking Enforcement

Age-of-sale Compliance Checks (e.g. underage decoys)• Can significantly reduce number of outlets selling alcohol to a minor

• Have also been shown to reduce youth’s reported ease of acquisition • In California, law enforcement conducted 291 minor decoy operations

in 1997-98, lowering violation rate to 21% from 29% in 1993-94; ABC supported effort: Grant Assistance to Law Enforcement (GALE)

“Cops in Shops” detects and cites youth purchasers—developed by Century Council, an industry group • Funding also from NHTSA, Office of Juvenile Justice;• Less often implemented by police agencies than compliance checks,

but more common in communities with large college dorm populations • Prior year: 55-74% used compliance check; 23-41% Cops in Shops

Sources: Montgomery, Foley & Wolfson, 2006; Ryan & Mosher, 2000; Grube, 1997

Server Intervention, RBS Programs

Steps servers can take to reduce chance of intoxication• One third to one half alcohol-impaired drivers drank last at

public places—bars or restaurants

• 1980-2005: RBS studies tend to show modest efficacy

• Factors enhancing effectiveness include management incentives, “house rules,” enforcement of laws banning service to intoxicated patrons; community involvement

• State mandated server training (Oregon): time series study demonstrated 23% reduction in crashes

• Training programs focused on aggressive patrons have also shown promise

Sources: Saltz, 1997; Holder, 1994; Hommel et al, 2001; Graham & Wells, 2001; Babor et al 2003;

Policies in Colleges and Schools

Colleges and Universities• Much focus on Greek system: highest volumes and amounts• Importance of clear articulation of comprehensive campus-

wide policies with consistent enforcement; community buy in• Importance of student participation in policy making

Meta-analyses of School (K–12) Programs• Programs more effective when based on sound behavioral

theory and knowledge of risk and protective factors• Importance of community and parental involvement and

consistent enforcement of school policies & access controls Sources: Weschler et al, 1995; 1998; Cohen & Rogers, 1997; Whitcomb, 1999; Pentz et al. 1996; Tobler et al, 2000; Komro & Toomey, 2002

Workplace PoliciesDrinking on the job

• Examples: Management styles in manufacturing plants predict norms & availability; barriers to policies/enforcement

Drinking off the job• Examples: Civil Aviation requirements—aircrew cannot drink

before flying; new attention to hangovers & problems on job

Policies on employee testing• Examples: Considerable variation in civil aviation; bus drivers

Policies affecting employee assistance• Examples: EAPs and parity for addictions in health plans

Sources: Ames, Grube, & Moore, 1997; 2000; Cook, 1997; Sturm et al, 1998; ASAM, 1997; Roman & Blum, 2002

Ratings of policy-relevant strategies and interventions

Policy - strategyEffectiveness Breadth of

research

support

Cross-cultural Testing

Cost to implement

Retail monopoly +++ +++ ++ Low

Restrict outlet density ++ +++ ++ Low

Increase alcohol taxes +++ +++ +++ Low

No service to intoxicated + +++ ++ Moderate

Server liability +++ + + Low

School programs 0 +++ ++ High

Warning labels 0 + + Low

Min. legal purchase age +++ +++ ++ Low

Drivers <21 ‘zero tolerance’

+++ +++ ++ Low

Brief intervention-at risk ++ +++ +++ Moderate

Source: Adapted from Babor et al, Alcohol: No ordinary commodity (Table 16.1), 2003

Summary and Conclusions• A wide range of legislative policies at various jurisdictional

levels is currently being used to regulate alcohol commerce and people’s drinking in the U.S.

• In the last 25 years, policy analyses and evaluations have demonstrated efficacy of certain model programs; implementation, effectiveness and sustainability studies needed

• We need both policies that affect all drinkers and targeted harm reduction measures aimed at heavy drinkers and settings in which drinking large quantities is promoted

• Policy development studies reveal opportunities and may improve strategies for enacting evidence-based policies

• Global burden of disease studies plus new surveys are leading to policy work for choosing practical interventions