Alcohol Policy Prevention
Strategies
James F. Mosher, JD
Alcohol Policy Consultations
June 9, 2013
Presentation at the Preconference Workshop entitled: Drug Use and
Excessive Alcohol Epidemiology: Surveillance, Prevention, and Emerging
Methods
2013 Council of State and Territorial Epidemiologists Conference, Pasadena,
CA
Alcohol Policy: Shifting the Focus
of Intervention
INDIVIDUALS
ENVIRONMENTS
Factors that Affect Health
Examples
Smallest
Impact
Counseling
& Education
Clinical
Interventions
Long-lasting
Protective Interventions
Changing the Context
Largest
Impact
to make individuals’ default
decisions healthy
Socioeconomic Factors
Eat healthy, be
physically active
Rx for high blood
pressure, high
cholesterol, diabetes
Immunizations, brief
intervention, cessation
treatment, colonoscopy
Fluoridation, 0g trans
fat, iodization, smokefree laws, tobacco tax
Poverty, education,
housing, inequality
Community Guide:
Recommended Strategies for
Preventing Excessive Drinking
 Regulation of Alcohol Outlet Density
 Dram Shop (Commercial Host) Liability
 Increasing Alcohol Taxes
 Privatization of Retail Alcohol Sales
 Maintaining Limits on Days and Hours of Sale
 Maintaining Minimum Legal Drinking Age (MLDA) Laws
 Enhanced Enforcement of Laws Prohibiting Alcohol Sales
to Minors
 Electronic Screening and Brief Intervention
Source: www.thecommunityguide.org/alcohol
Prevention Strategies:
Research Support for Effectiveness
Effectiveness
rating
Research
breadth
Crossnational
testing
Alcohol taxes
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***
***
Minimum legal age purchase
***
***
**
Government monopoly, retail
**
***
**
Restrict outlet density
**
***
**
Dram shop liability
**
**
**
Hours, days of sale
**
**
***
*/**
***
**
Prevention Strategy
Alcohol ad exposure restrictions
Source: Babor et al., 2010
Prevention Strategies:
Research Support for Effectiveness
Effectivene
ss rating
Research
breadth
Crossnational
testing
Industry self-regulation
0
**
**
Classroom education
0
***
**
Mass media campaigns
0
***
**
Social marketing
0
**
0
Prevention
Strategy
Source: Babor et al., 2010
Alcohol Outlet Density:
Community Guide Recommnedation
“The Task Force found sufficient evidence of a
positive association between outlet density and
excessive alcohol consumption and related harms
to recommend limiting alcohol outlet density
through the use of regulatory authority (e.g.,
licensing and zoning) as a means of reducing or
controlling excessive alcohol consumption and
related harms.”
What the Science Tells Us:
Alcohol Availability
Increased/
decreased
alcohol
availability
Increased/
decreased
alcohol
consumption
Increased/
decreased public
health/safety
problems
Retail Alcohol Outlet Density:
Key Dimensions
Outlet Density:
Number of Alcohol Outlets
Outlet Density
Location of Alcohol Outlets
Clustering
Sensitive locations
 Schools
 Playgrounds
 Churches
 Hospitals
 Alcoholism treatment
facilities
Outlet Density
Types of Alcohol Outlets
 Off-sale
 Liquor stores
 Convenience stores
 Supermarkets
 Gas stations
 On-sale
 Bars/lounges
 Restaurants
 Airplanes, trains,
etc.
 Festivals
Outlet Density
Selling and Serving Practices
 Problem
practices
 Furnishing minors
 Service to
intoxicated
persons
 Public nuisance
activities
Tools for Shaping Community
Retail Alcohol Environments
Conditional Use Permits (new outlets)
Nuisance Abatement/Deemed Approved
Ordinances
Responsible Beverage Service Programs
Dram shop liability laws
Monitoring and Enforcement
Fees
Data Collection and Analysis
 Alcohol outlet density
 Place of last drink reports
 Compliance checks
 Law enforcement incident reports
 Enforcement costs
 GIS mapping
Mean Number of Alcohol Outlets Near Residences
by Race/Ethnicity & Income
Mean # of Alcohol Outlets
(California, 2003)
Income Quartile
Truong & Sturm 2009
The State Preemption Doctrine:
A Potential Barrier to Local Action
 Some States “preempt” or limit the ability of local
governments to regulate community alcohol
availability through CUPs, DAOs, and fees.
 Local powers may vary both across and within States.
Concurrent sales
of alcohol and gasoline
A case study in
the power, and
peril, of State
preemption
Levels of State Preemption
Exclusive or
near exclusive
State authority
STATE
AUTHORITY
State licensing;
local zoning &
police powers
High State
Preemption
LOCAL
AUTHORITY
Joint State and
local licensing
Local licensing,
minimum State
standards
Low State
Preemption
A Form of Tort Liability:
A party whose intentional, reckless or
negligent actions causes harm to another
may be required to compensate the injured
party.
A form of tort liability that holds retailers
responsible for alcohol-attributable harms
caused by a patron who was illegally served
alcohol because the patron was either
intoxicated (“adult liability”) or underage
(“underage liability”) at the time of service.
Commercial Host Liability
Community Guide Findings
 Dram shop liability was associated with
a substantial reductions in alcohol
problems (a median reduction of 6.4
percent in alcohol-related motor
vehicle crashes)
 Legislation that limited the scope of
dram shop liability may undercut these
positive effects
Commercial Host Liability
Community Guide Recommendation
“The Task Force on Community
Preventive Services recommends the
use of dram shop liability laws, on the
basis of strong evidence of effectiveness
in preventing and reducing alcoholrelated harms.”
Location of Reported Binge Drinking
(Self Reports)
54.3%
35.7%
10.0%
Bars/clubs/restaurants
Private residents
Elsewhere
“Drinking in bars and restaurants is strongly associated
with binge drinking and with alcohol-impaired driving
among U.S. adults who report binge drinking.”
Source: Driving after Binge Drinking, Am J Prev Med. 2009 37(4):314-20
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40% or more of alcohol-related vehicle
crashes originate in retail establishments.
Why Commercial Host Liability?
Commercial host
liability common
law rules
substantially raise
the stakes
for violating these
laws and encourage
adoption of
Responsible
Beverage Service
practices.
In the absence of legislative guidance,
courts are able to establish these
rules through their “common law”
powers.
State legislatures may establish the
parameters of tort liability using
numerous, often complex, rules for
when, how, and how much
compensation is permitted.
Alcohol Taxes:
Community Guide Findings
 Higher alcohol prices or taxes were consistently related to:
 Fewer motor vehicle crashes and fatalities (10 of 11
studies)
 Less alcohol-impaired driving (3 of 3 studies)
 Less mortality from liver cirrhosis (5 of 5 studies)
 Less all-cause mortality (1 study)
 Effects also were demonstrated for measures of violence,
sexually transmitted diseases, and alcohol dependence.
 Reductions in excessive alcohol consumption are
proportional to the size of the tax increase
Elder et al. Am J Prev Med 2010;38(2):17–29
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Alcohol Taxes:
Community Guide Recommendation
“The Task force on Community Preventive
Services recommends increasing the unit
price of alcohol by raising taxes based on
strong evidence of effectiveness for
reducing excessive alcohol consumption
and related harms. Public health effects
are expected to be proportional to the size
of the tax increase.”
Alcohol Taxes: Meta-Analysis
Wagenaar et al. Addiction 2009
Meta-analysis of 110 studies containing 1,003
estimates of relationship between tax and price of
alcohol and alcohol consumption
“A large literature establishes that beverage alcohol
prices and taxes are related inversely to drinking.
Effects are large compared to other prevention policies
and programs. Public policies that raise prices of
alcohol are an effective means to reduce drinking.”
Alcohol Taxes
 Local, State and federal governments impose
alcohol taxes.
 State preemption limits the extent of local
taxation.
 Taxes can be volume- or price-based (excise or
ad valorem/sales).
 Unlike alcohol outlet density and dram shop
liability, taxes are easy to implement and
enforce.
 Tax increases increase governmental revenue.
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Alcohol Taxes
 Other policy mechanisms are available to
increase alcohol prices, thereby gaining
public health benefits
 Minimum pricing
 Restrictions on happy hours
 Restrictions on wholesaler discounting
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Societal Costs vs. Alcohol Tax
Revenues
State and Federal Tax Revenues
$.12/drink
Societal Costs
All Costs:
$1.90/drink
Governmental Costs
$.80/drink
Bouchery et al. 2011; http://www.cdc.gov/alcohol/fact-sheets/binge-drinking.htm
Challenges to Developing a Public
Health Approach to Alcohol Regulation
Conflict exists between commercial interests and public
health policy reform, particularly at the state/federal levels
Challenge:
Push for Deregulation
 Increasing pressure in states to deregulate alcohol
sales to increase revenues
 Expand number, permissible locations, and types of
alcohol outlets
 Privatize retail monopoly systems
 Increase hours and days of sale
 Once instituted, deregulatory measures are hard to
reverse because new economic stakeholders are
established
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Deregulating (Privatizing) State
Alcohol Retail Stores
States that privatized state stores
States with proposals to privatize state stores
Other control states
Adult Dram Shop Host Liability
50 States and District of Columbia
1989, 2011
Number of States (including DC)
30
25
20
1989
15
2011
10
5
0
No
Restrictions
1 Restriction 2 Restrictions No Liability
Uncertain
Federal Excise Tax Rates
Per Gallon Absolute Alcohol, 1970–2010
Excise tax
$25.00
$20.00
Distilled Spirits
$15.00
Beer
$10.00
Wine
$5.00
Adjusted for inflation: 1970 baseline
U.S. Bureau of Labor Statistics
Year
2010
2005
2000
1995
1990
1985
1980
1975
1970
$0.00
Average State Beer Excise Tax Rates
Per Gallon of Beer, 1975–2008
$0.30
Excise tax
$0.25
$0.20
Beer
$0.15
$0.10
$0.05
$0.00
Year
Adjusted for inflation: 1970 baseline
Beer Almanac, 2009;U.S. Bureau of Labor Statistics, 2010
Federal tax rates and inflation
1951 rate
Current
rate
(1991)
Adjusted for
inflation (since
1951)
$9 / barrel
$18 /
barrel
$76.23
Spirits
$10.50 / proof
gallon
$12.50 /
proof
gallon
$88.94
Wine
$.17 / gallon
$1.07 /
gallon
$1.44
Beer
Opportunities for Change
Chicago and Cook County Alcohol Taxes
 Cook County doubled its alcohol taxes effective
January 1, 2012
 Four alcohol tax increases in Chicago/Cook
County since 2005
Current Chicago and Cook County
alcohol taxes/gallon
 Beer: $.38/gallon
 Other beverages (based on alcohol content)
 <14%: $.60/gallon (e.g., table wine, wine coolers)
 14%-20%: $1.34/gallon (e.g., fortified wine)
 >20%: $5.18/gallon (e.g., distilled spirits)
Opportunities for Change
Maryland Alcohol Tax
 Enacted a special 3% alcohol sales tax in 2011
 Promoted by a coalition of 1,200 health care and
social services organizations
Voter support for dime-a-drink,
Maryland 2010
Opportunities for Change
Alcohol Outlet Density Campaigns
Way Forward
 Implementation of alcohol policy reforms are
feasible and have potential for significant public
health gains
 Public health constituencies can play an
instrumental role in the process
 Assessing and disseminating scientific findings
 Educating decision makers and key constituencies
 Providing expertise to state and local coalitions
 Conducting evaluations to determine effectiveness of
interventions
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