Alcohol Tax Policy Reform

  • Date: Jan 01 1986
  • Policy Number: 8613(PP)

Key Words: Alcohol

I. Statement of the Problem

A. Alcohol Problems in Society and the Role of American Public Health Association  

Alcohol-related problems have a serious impact on our nation's public health. According to the National Academy of Sciences and the National Institute on Alcohol Abuse and Alcoholism, 80,000 to 100,000 deaths annually are directly attributable to alcohol consumption.1,2 The US Surgeon General reports that an additional 100,000 deaths have alcohol involvement, although these deaths are not necessarily directly attributable to the ingestion of the drug.3  Mortality rates tell only one part of the problem. Over 10 million, or approximately 7 percent, of all adults over age 18 who drink are estimated to have significant alcohol-related problems affecting their health, work, family, and social life.1,4 Morbidity statistics are not available, but their magnitude is indicated by the more than 500,000 hospital discharges for alcoholism in 1978, an increase of more than 160 percent since 1971.2 A recent report commissioned by the American Assembly estimates that 20 percent of hospital costs and 12 percent of total health care costs derive directly from alcohol.4  

The adverse consequences of alcohol use fall into many categories. Alcohol-related trauma is a major health problem in the United States. Over 20,000 traffic deaths and 650,000 traffic injuries annually are alcohol-related.5 Other types of alcohol-related trauma — including drowning, falls, recreation injuries, fires — account for an additional 15,000 deaths per year.6  Heavy drinkers have been found to be significantly more likely to suffer serious traumatic injuries.7,8 Excessive drinking also contributes to crime and suicide. Homicides are particularly likely to have alcohol involvement among both victims and perpetrators — over 50 percent according to a review of 28 studies.9 Problem drinkers and alcoholics have a suicide attempt rate two to six times greater than the general population.6  

The physiological consequences of alcohol use are also severe. Cirrhosis of the liver, a leading cause of death in the United States, accounting for over 9,000 deaths, is closely associated with heavy alcohol use.2,6 Over 12,000 cancer deaths during 1980 were related to alcohol use. Heart disease and alcohol poisoning (the second leading cause of unintentional poisoning, after carbon monoxide) are also related to alcohol use.2,4,6 Other serious effects of excessive alcohol consumption include non-carcinogenic damage to the gastrointestinal tract, muscles, pancreas, cardiovascular, and nervous systems. Alcohol can also have a negative effect on endocrine system hormones and can produce nutrition-related defects in the body, including anemia.2  

Tragically, alcohol-related problems are not limited to adults. Alcohol-related trauma is the leading cause of death among those aged 1 to 19.5 Approximately 5,000 of the 23,500 drinking-driving fatalities in 1984 were among youth aged 15 to 19.5 Of those males reaching their 15th birthday, one in 120 will die in a motor vehicle crash before his 25th birthday.5 Approximately 1,000 young children die each year in alcohol-related motor vehicle crashes.5 Fetal Alcohol Syndrome (FAS) is the third leading cause of birth defects involving mental retardation in the United States, and the only one of the top three that is completely preventable.10,11 FAS prevalence is estimated to be from one to three of every 1,000 live births; this translates into a conservative estimate of 3,600 infants per year, with the actual number probably much higher, although difficulties in diagnosis and reporting make an accurate estimate impossible.11-13,15 Further research has discovered less serious but still severe birth abnormalities associated with alcohol consumption during pregnancy, termed Fetal Alcohol Effects (FAE) which are estimated to occur at four times the rate of FAS cases.12 In recognition of the seriousness of FAS and FAE and the fact that no safe levels of alcohol consumption during pregnancy have been found, the Surgeon General, the American Medical Association, and others now recommend that pregnant women, and those seeking to become pregnant, abstain from alcohol.14,15  The National Institute on Alcohol Abuse and Alcoholism (NIAAA) reports that alcohol problems cost society over $116 billion annually.2,16 

These costs break down as follows: $71 billion in reduced productivity; $18 billion in early mortality; $15 billion in treatment and support expenses; $2.5 billion in costs related to alcohol-related motor vehicle crashes; $2.5 billion in costs related to alcohol-related crime; and $1 billion in costs related to alcohol-related fires. These figures do not adequately reflect the costs in human tragedy — the emotional and psychological distress for drinkers and nondrinkers alike, resulting from alcohol-related death, injury, disease, and family and emotional disturbance that cannot be measured in monetary figures.  In recognition of these tragic figures, the US Surgeon General has listed alcohol-related problems as one of the most serious health problem facing us today.3 Ethyl alcohol is a potentially dangerous drug. Yet it is also a drug that is widely used and accepted in our society. It is associated with many positive events and activities, and is clearly going to remain a part of our social fabric. Prohibition of alcohol is not, nor should it be, a policy goal now or in the future. Alcohol also brings economic benefits to many, with $60 billion in retail sales annually. The challenge then, from a public health perspective, is to support the development of social norms, practices, and policies which will minimize the health risks associated with alcohol consumption.  

In recognition of the need for a public health approach to the prevention and treatment of alcohol-related problems, the American Public Health Association (APHA), in 1985, created its Section on Alcohol and Drugs. By providing section status, APHA recognizes this serious public health concern and the need to address alcohol problems from a public health perspective. The public health movement has a tradition of advocating and implementing progressive social policies that address environmental and societal factors which adversely impact on the individual citizen's health. APHA, through its new Section on Alcohol and Drugs, is bringing this tradition to the alcohol field.  

B. Alcohol Tax Policy  

1. Impact of Alcohol Prices on Alcohol Consumption and Alcohol-Related Problems  Perhaps the single most important, and most easily administered, strategy for preventing alcohol-related problems is through the appropriate use of alcohol tax policy. This conclusion, endorsed by scholars,17-30 economists,17,23-27,31 and policy-making bodies,32 including the American Assembly33 and the National Academy of Sciences, 1 is based on scientific research on the impact of price changes on alcohol consumption and related problems.  Research on the impact of alcohol tax policies and alcohol prices on alcohol consumption and related problems is not without controversy. Some researchers have found that intervening variables (e.g., other alcohol control measures, industry marketing tactics, income levels, consumer preferences, etc.) may limit the effect of prices on consumption patterns.34-36 Differing elasticities have been found for different geographic regions and in different periods, reflecting these intervening variables and differing methodologies.34,35 Price elasticities for different types of beverages may vary, with beer prices being relatively less elastic.35 Most studies have focused on price increases for only one of the three alcoholic beverage types, making estimates of cross-elasticities difficult or impossible.  Nevertheless, despite these caveats and gaps in the research, the overwhelming evidence, both in the United States and internationally, is that levels of alcohol consumption and alcohol-related problems are price sensitive and that alcohol taxation policies are an appropriate and critical element of a comprehensive approach to the prevention of alcohol-related problems.1,17-33 An expert panel of the National Academy of Sciences (NAS), after conducting a thorough review of the literature, concluded: 

"Even relatively small changes in prices may influence not only the quantity of consumption but also the most serious health effects as well…  

"Taxes affect prices, prices affect the quantity of consumption, and the quantity of consumption affects the health and safety of drinkers. An increased tax on alcoholic beverages has the particular effect of improving the chronic health picture (as indexed by liver failure) of the heavier drinkers — who are, it can be added, paying most of the tax increase. Therefore, we see good grounds for incorporating an interest in the prevention of alcohol problems into the setting of tax rates on alcohol."1  

Two recent studies conducted in the United States (one after the NAS report) are particularly noteworthy. Dr. Philip Cook, an economist at Duke University, and his colleagues conducted a series of studies during the last six years on the topic, the first of which was sponsored by the NAS expert panel.17,25,26 This description of Cook's research is based on a report by Olson and Gerstein.37 Cook examined the effects of 38 different increases in state liquor taxes in 30 states between 1961 and 1975. These increases ranged from 4 cents to 28 cents on a fifth of 80 proof liquor (the federal tax during this time stayed constant at $1.68). After taking into account potentially compounding variables, Cook found not only a direct link between these price increases and consumption but also a connection between these price increases and two of the most serious consequences of alcohol use — cirrhosis of the liver, and highway fatalities.  Whenever a state increased its liquor tax, Cook compared the change in that state's per capita consumption of alcohol with the changes in per capita consumption for all other states during that year. If the price of alcohol had an effect on consumption, the state in which the tax increased would be likely to have a relatively negative change in consumption. In 30 out of 38 cases, Cook found this to be true.  

Cook next applied this analysis to the death rates from cirrhosis for each of the states. Cirrhosis is a disease that generally develops after many years of heavy drinking. Because it is to some extent an interruptible disease, a decline in drinking could have an immediate effect on cirrhosis mortality. At any given time, there is a reservoir of people who are within one year of dying from cirrhosis. If some of these people reduce their drinking because of a tax increase, the progress of their disease will slow and the death rate from cirrhosis will go down.  

Cook found that states with increased liquor taxes tended to have decreased cirrhosis mortality, a statistical result that could happen by chance just one time in 14. He concluded that there is considerable statistical evidence that a liquor tax increase causes an immediate and substantial reduction in cirrhosis mortality. Cook also applied this analysis to the rate of highway fatalities in each state. Again, after controlling for other variables that might have affected the analysis, he found that mortality was linked to changes in the price of alcohol, an outcome that could result by chance just 4 percent of the time.  

A more recent study by Cook and Tauchen further quantified the link between tax increases and cirrhosis mortality by use of an analysis of covariance estimated by generalized least squares regression.26 Based on 1981 prices and analyzing the same 38 data points of their previous study, their study estimated that an increase in the federal liquor tax of 16 cents on a fifth of 80 proof spirits would reduce the nation's cirrhosis mortality rate by 1.9 percent; a doubling of the US federal liquor tax would result in a 20 percent decline in the cirrhosis death rate.  Cook's findings have been substantiated by Saffer and Grossman,24 who set out to test the hypothesis that youth alcohol consumption is negatively related to the price of alcohol, and that therefore the youth motor vehicle mortality rate is negatively related to the price of alcohol. In testing this hypothesis, price is defined broadly as the sum of the direct and indirect cost of alcohol. In particular, the indirect cost of obtaining alcohol for a person under the age of 21 should be lower in states where the legal drinking age is 18 as opposed to 21. Thus the price of alcohol and the legal drinking age play similar roles in determining youth consumption and, as postulated by the hypothesis, motor vehicle mortality.  

The data set used to test the hypothesis was a time series of cross sections for the 48 contiguous states of the US. Motor vehicle mortality data were used to estimate the probability of being killed in a motor vehicle crash for males and females ages 15-17, 18-20, and 21-24 between 1975 and 1981. The key independent variables in the researchers' equations contained additional variables, including: the legal drinking age for beer in border states, per capita income, vehicle miles driven, ratio of young drivers, motor vehicle inspection, drinking sentiment, and the percentage of the population residing in "wet" counties.  

By substituting different values for the legal drinking age for beer and the price of beer, the same basic equations were used to estimate the effect on mortality during the same six-year period of raising the legal drinking age to 21 and increasing excise taxes on beer. The impacts of three different tax policy options were estimated: the first option indexes the federal excise tax on beer to inflation from 1951; the second equalizes the tax on beer to that on distilled spirits; and the third combines the first two.  

The results of the policy simulations are as follows: A uniform legal drinking age of 21 between 1975 and 1981 would have reduced the motor vehicle mortality rate for both females and males 18-20 years of age by 7 percent. More dramatic declines were produced by the three excise tax policies: for males 18-20 years of age, the mortality rate was estimated to fall by 15 percent when federal excise taxes are indexed to inflation; equalizing the tax on beer to the level applied to distilled spirits was estimated to reduce the mortality rate for the same age cohort by 21 percent; and the combination of both tax policies reduces mortality for 18-20 year old males by 44 deaths per 100,000, a 55 percent reduction. Comparing the three tax policy options for females 18-20 years of age, the number of lives lost falls by 12 percent, 16 percent, and 45 percent, respectively.  

Overall, negative and statistically significant effects on mortality were suggested for all six groups when the tax on beer is increased. Negative and statistically significant effects on mortality were also suggested for both males and females 18-20 years of age when the legal drinking age is raised to 21.  These and other research studies18,20,22,23,27-29 demonstrate the impact of alcohol prices on both long-term and short-term health problems. For example, Leroy and Sheflin derived a single demand equation for all alcoholic beverages and estimated that a price increase of 2.5 percent would reduce per capita consumption by 1 percent.28 Popham, et al. summarized their findings as follows: 

"The role of relative price was examined in virtually every jurisdiction for which the relevant data were available both regionally and, where possible, through time. Almost universally relative price was found to be very closely associated with indices of consumption and alcoholism: where relative price was high, consumption and live cirrhosis mortality were low and vice versa."22  

As even industry studies and spokespersons concede, alcohol prices are an important, perhaps the most important, factor capable of being manipulated by government policy and industry practice.  

2. Alcohol Price Trends  

Given this research, alcohol price trends over the last two decades are a serious cause for concern. Since 1967, alcohol beverage prices have dropped 28 percent relative to inflation.25 This is in marked contrast to nonalcoholic beverages, where prices have increased relative to inflation by 30 percent (Table 1).21                     

TABLE 1 — 

 Consumer Price Indexes for Alcoholic and Nonalcoholic Beverages (1967 = 100)    
 All Items 
 Alcoholic Beverages 
 Nonalcoholic Beverages
 SOURCE: US Bureau of Labor Statistics, Monthly Labor Review. 

The impact of these trends are well illustrated in the supermarket, where the prices of popular soft drinks are now equivalent to or higher than the costs of many beers in most locales, with wine prices not far behind, an unheard of event 20 years ago.  During this same period, the alcohol beverage industry has increasingly viewed itself in competition with other beverages, particularly soft drinks, in what is now termed the "beverage market".38 Marketing practices reflect this industry concern that soft drinks, mineral waters, and other nonalcoholic beverages will adversely affect alcoholic beverage sales. Advertising and other promotions have taken on a "soft drink" look; new, sweeter drinks have been created; and the availability of alcohol has been dramatically expanded so that it can be offered side by side with other beverages in supermarkets, gas stations, convenience stores, fast-food outlets, and other nontraditiional locales.38 The ability to offer beer and wine at prices competitive with or cheaper than most other beverages is a critical factor in the industry's ability to maintain its "beverage market share," particularly among young people. As Saffer and Grossman's research demonstrates,24,27 this subpopulation is very price-sensitive.  The primary cause of this decline in alcohol prices is the failure of state and federal governments to adjust excise tax rates to inflation.21,25 In 1951, federal excise taxes on distilled spirits, wine, and beer (per gallon of absolute alcohol) were $21, $1.21, and $44, respectively. Today, wine and beer have the same tax rates, with distilled spirits having only one tax increase, from $21 to $25 in 1985. If these taxes had been adjusted to inflation, they would be nearly four times the rate they are today (Table 2). State taxes, despite many increases over the years, also have declined significantly relative to inflation over the same period (Table 2).


Excise Tax Rates, Distilled Spirits,
Federal and License States (Average), 1953 - 1981
(Actual and Real Dollars)
 Year  State excise tax on distilled spirits 
(average per proof gallon) —license states only
 Federal excise tax on distilled spirits 
(per proof gallon)
 1.88  1.88  10.50
 1.99  1.99  10.50
 2.26  2.02  10.50
 2.48  2.04  10.50
1970  2.84  1.96  10.50
 3.21  1.60  10.50
1980  3.31  1.08  10.50
1984  3.97  1.02  10.50
1985  N.A.
 N.A.  12.50
SOURCE: Distilled Spirits Council of the United States: Public Revenues from Alcohol Beverages (Annual Publication).

According to Cook, Saffer and Grossman, and other leading scholars, if the tax rates had been kept at or near the inflation rate, thousands of lives, particularly young lives, would have been saved, and the suffering of thousands more alleviated.24,26

The tax rates have an additional adverse public health impact — the unwarranted distinction between differing types of alcoholic beverages. Wine and beer are taxed at rates below that for distilled spirits, in terms of alcohol content, as noted above, although standard drink sizes for each of the three beverages contain the same amount of ethyl alcohol. There is a serious misconception in our society that beer and wine consumption poses less threat to public health than distilled spirits. In fact, because all three types of beverages contain the same drug — ethyl alcohol — they pose similar threats. For example, beer is the major contributor to drinking-driving, and alcoholism cirrhosis and other alcohol-related problems can all be contracted using any of the three beverages. The fallacy that each type of alcoholic beverage poses different risks is particularly relevant in the efforts to combat FAS. Polls were conducted in New York City both before and one year after posters were required in all alcohol outlets warning of the hazards of drinking during pregnancy. The results of the poll before warning posters were mandated showed that 23 percent of respondents thought beer and wine were "very unlikely" to cause birth defects, while only 5 percent responded similarly for distilled spirits.41 These response rates were significantly reduced one year later, after the posters were installed, but still remained much higher for beer and wine than for spirits.39

Alcohol tax policy goes beyond the excise tax issue. Numerous other tax provisions affect the production and marketing of alcoholic beverages. Typically the provisions promote cheap manufacture, widespread availability, and low prices despite the adverse public health effects. 40 Most deleterious are the provisions of the Internal Revenue Service (IRS) Code which make alcohol a tax deductible business expense. As a result of IRS policy, over $12 billion of alcohol purchases are deducted annually, costing the US Treasury more than $2-3 billion each year.41 The provisions encourage drinking during working hours, despite a wealth of literature documenting the damage this causes to the conduct of business and the contribution of such drinking to alcoholism rates. Tax benefits that encourage alcohol consumption adversely affect public health and, in addition, deprive state and federal treasuries of funds which could be used to protect public health programs facing budget cuts.

II. Purpose and Objective

The purpose of this position paper is to provide the basis for APHA to take a leadership role in the efforts to reform alcohol tax policy. A national drive is now occurring and numerous, diverse groups have joined the national Alcohol Tax Coalition. APHA can be instrumental in providing a public health perspective to the legislative debates.

APHA endorses four tax reform measures at both state and federal levels:

  1. a substantial rise in the federal alcohol excise tax rate, to at least the level, in real dollar terms, of that of 1972;
  2. the equalization of excise taxes by alcohol content for all three types of alcoholic beverages (beer, wine, and distilled spirits) to be accomplished over a phased period of time;
  3. the indexing of the alcohol tax rates to inflation; and
  4. the discontinuation of all tax deductions for the use of alcoholic beverages.

These measures have been endorsed in a report by the participants of the American Assembly for the Western Region.33 The excise tax recommendations are substantially the same as those pursued by the members of the National Alcohol Tax Coalition,32 and endorsed by more than 30 eminent economists representing the major universities of the United States31 and by the New York Times.42 Numerous other scientific and policy-making bodies including the National Academy of Sciences1 and various expert panels of the World Health Organization,30 have reached similar conclusions.

Enactment of the proposed alcohol tax reform legislation will, as research indicates, substantially reduce the incidence and severity of alcohol-related problems, including long-term health problems such as cirrhosis of the liver and short-term acute health problems such as drinking and driving. Enactment also will benefit young people in particular. In addition, the reforms will help to dispel the misconception that the varying alcohol contents of wine, beer, and distilled spirits pose different levels of health risks.

III. Action Desired and Methods to Be Used

In adopting this position paper, APHA joins numerous other individuals and scholars, as well as health, safety, and consumer organizations in calling for alcohol tax reform. APHA will inform other relevant national organizations of its tax policy recommendations, provide testimony as appropriate at federal and state legislative hearings, and send letters of support to relevant legislators and legislative committees. APHA will also inform all APHA members of the impact of alcohol tax policies on public health.

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