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 Prevention Strategies

INDIVIDUALSENVIRONMENTS Alcohol Policy: Shifting the Focus of Intervention

Largest Impact Smallest Impact Factors that Affect Health Examples Eat healthy, be physically active Rx for high blood pressure, high cholesterol, diabetes Poverty, education, housing, inequality Immunizations, brief intervention, cessation treatment, colonoscopy Fluoridation, 0g trans fat, iodization, smoke- free laws, tobacco tax Socioeconomic Factors Changing the Context to make individuals’ default decisions healthy Long-lasting Protective Interventions Clinical Interventions Counseling & Education

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:

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 Effectivene ss 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 availability Increased/ decreased alcohol consumption Increased/ decreased alcohol consumption Increased/ decreased public health/safety problems 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 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 (California, 2003) Mean # of Alcohol Outlets 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

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

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.

 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 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 Liability Community Guide Recommendation

Location of Reported Binge Drinking (Self Reports) 54.3% Bars/clubs/restaurants 35.7% Private residents 10.0% 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 (4):314-20Am J Prev Med. 25

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 29

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. 32

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 33

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;

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

36 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 stores States with proposals to privatize state stores Other control states Deregulating (Privatizing) State Alcohol Retail Stores

Adult Dram Shop Host Liability 50 States and District of Columbia 1989, 2011 Number of States (including DC)

Federal Excise Tax Rates Per Gallon Absolute Alcohol, 1970–2010 Adjusted for inflation: 1970 baseline U.S. Bureau of Labor Statistics Excise tax Year

Average State Beer Excise Tax Rates Per Gallon of Beer, 1975–2008 Adjusted for inflation: 1970 baseline Beer Almanac, 2009;U.S. Bureau of Labor Statistics, 2010 Excise tax

Federal tax rates and inflation 1951 rateCurrent 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 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 46