James F. Mosher, JDAlcohol 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 Prevention Strategies

INDIVIDUALS ENVIRONMENTS

Alcohol Policy: Shifting the Focus of Intervention

LargestImpact

SmallestImpact

Factors that Affect HealthExamples

Eat healthy, be physically active

Rx for high blood pressure, high cholesterol, diabetes

Poverty, education, housing, inequality

Immunizations, brief intervention, cessation treatment, colonoscopyFluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax

Socioeconomic Factors

Changing the Contextto make individuals’ default

decisions healthy

Long-lasting Protective

Interventions

ClinicalInterventions

Counseling &

Education

Community Guide: Recommended Strategies for

Preventing Excessive Drinking

Regulation of Alcohol Outlet DensityDram 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 InterventionSource: www.thecommunityguide.org/alcohol

Prevention Strategies:Research Support for Effectiveness

Prevention Strategy Effectiveness rating

Research

breadth

Cross-national testing

Alcohol taxes *** *** ***

Minimum legal age purchase

*** *** **

Government monopoly, retail

** *** **

Restrict outlet density ** *** **

Dram shop liability ** ** **

Hours, days of sale ** ** ***

Alcohol ad exposure restrictions

*/** *** **Source: Babor et al., 2010

Prevention Strategies:Research Support for Effectiveness

Prevention Strategy

Effectiveness rating

Research breadth

Cross-national testing

Industry self-regulation

0 ** **

Classroom education 0 *** **

Mass media campaigns

0 *** **

Social marketing 0 ** 0

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.”

Increased/decreased

alcohol availability

Increased/decreased

alcohol consumption

Increased/decreased

public health/safety

problems

What the Science Tells Us:Alcohol Availability

Retail Alcohol Outlet Density:Key Dimensions

Outlet Density:

Number of Alcohol Outlets

Outlet Density

Location of Alcohol Outlets

ClusteringSensitive locationsSchoolsPlaygroundsChurchesHospitalsAlcoholism

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

OrdinancesResponsible Beverage Service ProgramsDram shop liability lawsMonitoring and EnforcementFees

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

(California, 2003)

Mea

n #

of

Alc

oh

ol

Ou

tlet

s

Income QuartileTruong & 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 salesof alcohol and gasoline

A case study in the power, and peril, of State preemption

STATE AUTHORITY

Exclusive or near exclusive State authority

State licensing; local zoning & police powers

Joint State and local licensing

Local licensing, minimum State standards

LOCAL AUTHORITY

High State Preemption

Low State Preemption

Levels of State Preemption

What is Dram Shop(Commercial Host) Liability?

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.

What is Commercial Host Liability?

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.

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 LiabilityCommunity Guide Findings

“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 alcohol-related harms.”

Commercial Host LiabilityCommunity Guide Recommendation

Location of Reported Binge Drinking

(Self Reports)

54.3% Bars/clubs/restaurants35.7% Private residents10.0% 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):314-2025

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 stakesfor violating these

laws and encourage adoption

of Responsible Beverage Service

practices.

How is Commercial Host Liability Established?

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 increaseElder 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 2009Meta-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/drin

k

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

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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

States that privatized state storesStates with proposals to privatize state storesOther control states

Deregulating (Privatizing) State Alcohol Retail Stores

0

5

10

15

20

25

30

1989

2011

Adult Dram Shop Host Liability

50 States and District of Columbia1989, 2011

Nu

mb

er

of

Sta

tes

(in

clu

din

g

DC

)

Federal Excise Tax RatesPer Gallon Absolute Alcohol, 1970–

2010

1970

1975

1980

1985

1990

1995

2000

2005

2010

$0.00

$5.00

$10.00

$15.00

$20.00

$25.00

Distilled Spir-its

Beer

Wine

Adjusted for inflation: 1970 baselineU.S. Bureau of Labor Statistics

Excis

e t

ax

Year

Average State Beer Excise Tax RatesPer Gallon of Beer, 1975–2008

1975

1980

1985

1990

1995

2000

2005

2008

$0.00

$0.05

$0.10

$0.15

$0.20

$0.25

$0.30

Beer

Year

Adjusted for inflation: 1970 baselineBeer Almanac, 2009;U.S. Bureau of Labor Statistics, 2010

Excis

e t

ax

Federal tax rates and inflation

1951 rate Current rate

(1991)

Adjusted for inflation

(since 1951)

Beer $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

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 Countyalcohol 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 ChangeMaryland 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 ChangeAlcohol 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

46