Jason G. Blanchette

A new scale of the U.S. Alcohol policy environment and its relationship to binge drinking

BACKGROUND Of outcomes related to excessive drinking, binge drinking accounts for approximately half of alcohol-attributable deaths, two thirds of years of potential life lost, and three fourths of economic costs. The extent to which the alcohol policy environment accounts for differences in binge drinking in U.S. states is unknown. PURPOSE The goal of the study was to describe the development of an Alcohol Policy Scale (APS) designed to measure the aggregate state-level alcohol policy environment in the U.S. and assess the relationship of APS scores to state-level adult binge drinking prevalence in U.S. states. METHODS Policy efficacy and implementation ratings were developed with assistance from a panel of policy experts. Data on 29 policies in 50 states and Washington DC from 2000-2010 were collected from multiple sources and analyzed between January 2012 and January 2013. Five methods of aggregating policy data to calculate APS scores were explored; all but one was weighted for relative policy efficacy and/or implementation. Adult (aged ≥18 years) binge drinking prevalence data from 2001-2010 was obtained from the Behavioral Risk Factor Surveillance System surveys. APS scores from a particular state-year were used to predict binge drinking prevalence during the following year. RESULTS All methods of calculating APS scores were significantly correlated (r >0.50), and all APS scores were significantly inversely associated with adult binge drinking prevalence. Introducing efficacy and implementation ratings optimized goodness of fit in statistical models (e.g., unadjusted beta=-3.90, p<0.0001, R(2)=0.31). CONCLUSIONS The composite measure(s) of the alcohol policy environment have internal and construct validity. Higher APS scores (representing stronger policy environments) were associated with less adult binge drinking and accounted for a substantial proportion of the state-level variation in binge drinking among U.S. states.

The Alcohol Policy Environment and Policy Subgroups as Predictors of Binge Drinking Measures Among US Adults

OBJECTIVES We examined the relationships of the state-level alcohol policy environment and policy subgroups with individual-level binge drinking measures. METHODS We used generalized estimating equations regression models to relate the alcohol policy environment based on data from 29 policies in US states from 2004 to 2009 to 3 binge drinking measures in adults from the 2005 to 2010 Behavioral Risk Factor Surveillance System surveys. RESULTS A 10 percentage point higher alcohol policy environment score, which reflected increased policy effectiveness and implementation, was associated with an 8% lower adjusted odds of binge drinking and binge drinking 5 or more times, and a 10% lower adjusted odds of consuming 10 or more drinks. Policies that targeted the general population rather than the underage population, alcohol consumption rather than impaired driving, and raising the price or reducing the availability of alcohol had the strongest independent associations with reduced binge drinking. Alcohol taxes and outlet density accounted for approximately half of the effect magnitude observed for all policies. CONCLUSIONS A small number of policies that raised alcohol prices and reduced its availability appeared to affect binge drinking.

Comment on “binge drinking and alcohol prices”

To the editors of health economics review: There is ample evidence on the effects of prices and taxes on heavy drinking, including binge drinking [1]. Experiments on “Happy Hour” discounts in barroom settings have shown that when the price of alcohol decreases, consumption increases, and vice versa [2, 3]. A well-cited meta-analysis of 112 studies (Wagenaar et al., [4]) identified ten studies on heavy drinking and estimated a significant elasticity of −0.28. Another systematic review by Elder and colleagues [5] concluded that alcohol tax levels were inversely associated with excessive drinking. This is consistent with the conclusion from a widely-cited review by Cook and Moore [6] that “an increase in price results in reduced consumption”, and this applies to drinking by youth, heavy drinkers, and alcoholics who develop cirrhosis due to chronic consumption. Xuan and colleagues [7] showed that an improved comprehensive measure of alcohol taxes including specific excise tax and value-based taxes resulted in more negative tax elasticity and price elasticity predicting binge drinking, as compared to a conventional measure that relies only on beer excise tax. Another meta-analysis by Wagenaar and colleagues [8] showed that increased taxes and prices were associated with reduced alcohol-related disease and injury outcomes that are attributable to binge drinking. Nevertheless, in an issue of Health Economics Review, Dr. Jon Nelson published a “systematic” review article with the following conclusion: “Increased alcohol taxes or prices are unlikely to be effective as a means to reduce binge drinking, regardless of gender or age group.” [9]. We have reviewed this paper based on its methodology, study interpretation, and conclusion.

Tax Policy, Adult Binge Drinking, and Youth Alcohol Consumption in the United States

BACKGROUND Prior research attributed youth alcohol consumption to the attitudes and drinking patterns among adults. Yet at a population level, few have examined the relationship between state-level adult binge drinking prevalence and youth drinking behaviors, or whether tax policy plays a role in this relationship. METHODS We analyzed 6 biennial surveys (1999 to 2009) of individual-level youth alcohol use and related behaviors from state-based Youth Risk Behavior Surveys and corresponding years of state-level adult binge drinking prevalence from the Behavioral Risk Factor Surveillance System. We employed logistic regression with generalized estimating equations method to assess the extent to which state adult binge drinking predicted individual-level youth drinking outcomes and examined the role of alcohol taxes in that relationship. RESULTS Population-aggregate analyses based on 194 state-year strata showed a positive correlation between state adult binge drinking and youth binge drinking (Pearson r = 0.40, p < 0.01). For individual-level youth drinking outcomes, a 5 percentage point increase in binge drinking prevalence among adults was associated with a 12% relative increase in the odds of alcohol use (adjusted OR = 1.12, 95% CI: 1.08, 1.16). Taxes were strongly inversely related with adult and youth drinking measures, and the effect of tax on youth drinking was attenuated after controlling for adult binge drinking. CONCLUSIONS Both tax and adult binge drinking are strong predictors of youth drinking. Tax may affect youth drinking through its effect on adult alcohol consumption. Implementing effective alcohol policies to reduce excessive drinking in the general population is an important strategy to reduce youth drinking.

The relationship between alcohol taxes and binge drinking: evaluating new tax measures incorporating multiple tax and beverage types

AIMS U.S. studies contribute heavily to the literature about the tax elasticity of demand for alcohol, and most U.S. studies have relied upon specific excise (volume-based) taxes for beer as a proxy for alcohol taxes. The purpose of this paper was to compare this conventional alcohol tax measure with more comprehensive tax measures (incorporating multiple tax and beverage types) in analyses of the relationship between alcohol taxes and adult binge drinking prevalence in U.S. states. DESIGN Data on U.S. state excise, ad valorem and sales taxes from 2001 to 2010 were obtained from the Alcohol Policy Information System and other sources. For 510 state-year strata, we developed a series of weighted tax-per-drink measures that incorporated various combinations of tax and beverage types, and related these measures to state-level adult binge drinking prevalence data from the Behavioral Risk Factor Surveillance System surveys. FINDINGS In analyses pooled across all years, models using the combined tax measure explained approximately 20% of state binge drinking prevalence, and documented more negative tax elasticity (-0.09, P = 0.02 versus -0.005, P = 0.63) and price elasticity (-1.40, P < 0.01 versus -0.76, P = 0.15) compared with models using only the volume-based tax. In analyses stratified by year, the R-squares for models using the beer combined tax measure were stable across the study period (P = 0.11), while the R-squares for models rely only on volume-based tax declined (P < 0.0). CONCLUSIONS Compared with volume-based tax measures, combined tax measures (i.e. those incorporating volume-based tax and value-based taxes) yield substantial improvement in model fit and find more negative tax elasticity and price elasticity predicting adult binge drinking prevalence in U.S. states.

The relationship between alcohol taxes and binge drinking

AIMS U.S. studies contribute heavily to the literature about the tax elasticity of demand for alcohol, and most U.S. studies have relied upon specific excise (volume-based) taxes for beer as a proxy for alcohol taxes. The purpose of this paper was to compare this conventional alcohol tax measure with more comprehensive tax measures (incorporating multiple tax and beverage types) in analyses of the relationship between alcohol taxes and adult binge drinking prevalence in U.S. states. DESIGN Data on U.S. state excise, ad valorem and sales taxes from 2001 to 2010 were obtained from the Alcohol Policy Information System and other sources. For 510 state-year strata, we developed a series of weighted tax-per-drink measures that incorporated various combinations of tax and beverage types, and related these measures to state-level adult binge drinking prevalence data from the Behavioral Risk Factor Surveillance System surveys. FINDINGS In analyses pooled across all years, models using the combined tax measure explained approximately 20% of state binge drinking prevalence, and documented more negative tax elasticity (-0.09, P = 0.02 versus -0.005, P = 0.63) and price elasticity (-1.40, P < 0.01 versus -0.76, P = 0.15) compared with models using only the volume-based tax. In analyses stratified by year, the R-squares for models using the beer combined tax measure were stable across the study period (P = 0.11), while the R-squares for models rely only on volume-based tax declined (P < 0.0). CONCLUSIONS Compared with volume-based tax measures, combined tax measures (i.e. those incorporating volume-based tax and value-based taxes) yield substantial improvement in model fit and find more negative tax elasticity and price elasticity predicting adult binge drinking prevalence in U.S. states.

Youth drinking in the United States: relationships with alcohol policies and adult drinking

BACKGROUND: The relationship between the alcohol policy environment (ie, the combined effectiveness and implementation of multiple existing alcohol policies) and youth drinking in the United States has not been assessed. We hypothesized that stronger alcohol policy environments are inversely associated with youth drinking, and this relationship is partly explained by adult drinking. METHODS: Alcohol Policy Scale (APS) scores that characterized the strength of the state-level alcohol policy environments were assessed with repeated cross-sectional Youth Risk Behavior Survey data of representative samples of high school students in grades 9 to 12, from biennial years between 1999 and 2011. RESULTS: In fully adjusted models, a 10 percentage point increase in APS scores (representing stronger policy environments) was associated with an 8% reduction in the odds of youth drinking and a 7% reduction in the odds of youth binge drinking. After we accounted for youth-oriented alcohol policies, the subgroup of population-oriented policies was independently associated with lower odds of youth drinking (adjusted odds ratio 0.94; 95% confidence interval 0.92–0.97) and youth binge drinking (adjusted odds ratio 0.96; 95% confidence interval 0.94–0.99). State-level per capita consumption mediated the relationship between population-oriented alcohol policies and binge drinking among youth. CONCLUSIONS: Stronger alcohol policies, including those that do not target youth specifically, are related to a reduced likelihood of youth alcohol consumption. These findings suggest that efforts to reduce youth drinking should incorporate population-based policies to reduce excessive drinking among adults as part of a comprehensive approach to preventing alcohol-related harms. Future research should examine influence of alcohol policy subgroups and discrete policies.

Patterns of change in implementation of state alcohol control policies in the United States, 1999–2011

AIMS To examine state alcohol control policy implementation by policy efficacy and intent. DESIGN A descriptive longitudinal analysis of policy implementation. SETTING The United States, 1999-2011. PARTICIPANTS Fifty states and the District of Columbia. MEASUREMENTS Twenty-nine state-level policies were rated based on an implementation rating (IR; range = 0.0-1.0) gathered from the Alcohol Policy Information System, government and industry reports and other sources; and expert judgment about policy efficacy for addressing binge drinking and alcohol-impaired driving among the general population and youth, respectively. FINDINGS On average, implementation of the most effective general population policies did not change [mean IR = 0.366 in 1999; 0.375 in 2011; slope for annual change = 0.001; 95% confidence interval (CI) for the slope -0.001, 0.002]. In contrast, implementation increased over time for less effective policies (mean IR = 0.287 in 1999; 0.427 in 2011; slope for annual change compared with most effective policies = 0.009; slope 95% CI = 0.002-0.007), for youth-oriented policies (mean IR = 0.424 in 1999; 0.511 in 2011; slope for annual change compared with most effective policies = 0.007; slope 95% CI = 0.005-0.009), and for impaired driving policies (mean IR = 0.493 in 1999; 0.608 in 2011; slope for annual change compared with most effective policies = 0.0105; slope 95% CI = 0.007-0.014). CONCLUSIONS Implementation of politically palatable state alcohol policies, such as those targeting youth and alcohol-impaired driving, and less effective policies increased during 1999-2011 in the United States, while the most effective policies that may maximally protect public health remained underused.

Alcohol Policies and Alcoholic Cirrhosis Mortality in the United States

Introduction Stronger alcohol policies predict decreased alcohol consumption and binge drinking in the United States. We examined the relationship between the strength of states’ alcohol policies and alcoholic cirrhosis mortality rates. Methods We used the Alcohol Policy Scale (APS), a validated assessment of policies of the 50 US states and Washington DC, to quantify the efficacy and implementation of 29 policies. State APS scores (theoretical range, 0–100) for each year from 1999 through 2008 were compared with age-adjusted alcoholic cirrhosis death rates that occurred 3 years later. We used Poisson regression accounting for state-level clustering and adjusting for race/ethnicity, college education, insurance status, household income, religiosity, policing rates, and urbanization. Results Age-adjusted alcoholic cirrhosis mortality rates varied significantly across states; they were highest among males, among residents in states in the West census region, and in states with a high proportion of American Indians/Alaska Natives (AI/ANs). Higher APS scores were associated with lower mortality rates among females (adjusted incidence rate ratio [IRR], 0.91 per 10-point increase in APS score; 95% confidence interval [95% CI], 0.84–0.99) but not among males (adjusted IRR, 0.97; 95% CI, 0.90–1.04). Among non-AI/AN decedents, higher APS scores were also associated with lower alcoholic cirrhosis mortality rates among both sexes combined (adjusted IRR, 0.89; 95% CI, 0.82–0.97). Policies were more strongly associated with lower mortality rates among those living in the Northeast and West census regions than in other regions. Conclusions Stronger alcohol policy environments are associated with lower alcoholic cirrhosis mortality rates. Future studies should identify underlying reasons for racial/ethnic and regional differences in this relationship.

Who Would Pay for State Alcohol Tax Increases in the United States

Introduction Despite strong evidence that increasing alcohol taxes reduces alcohol-related harm, state alcohol taxes have declined in real terms during the past 3 decades. Opponents of tax increases argue that they are unfair to “responsible” drinkers and those who are financially disadvantaged. The objectives of this study were to assess the impact of hypothetical state alcohol tax increases on the cost of alcohol for adults in the United States on the basis of alcohol consumption and sociodemographic characteristics. Methods The increased net cost of alcohol (ie, product plus tax) from a series of hypothetical state alcohol tax increases was modeled for all 50 states using data from the 2011 Behavioral Risk Factor Surveillance System, IMPACT Databank, and the Alcohol Policy Information System. Costs were assessed by drinking pattern (excessive vs nonexcessive) and by sociodemographic characteristics. Results Among states, excessive drinkers would pay 4.8 to 6.8 times as much as nonexcessive drinkers on a per capita basis and would pay at least 72% of aggregate costs. For nonexcessive drinkers, the annual cost from even the largest hypothetical tax increase (