Addressing Alcohol-Related Harms: A Population Level Response

Abstract

Alcohol use is the third-leading preventable cause of death in the United States, with an estimated 88,000 alcohol-related deaths annually. With alcohol consumption rising and even greater increases in heavy drinking among women, racial minorities, older adults, and the poor, there is a need to use public health strategies to address excessive alcohol consumption (defined as binge drinking, heavy drinking, and any drinking among pregnant women or individuals under age 21). This policy statement provides a comprehensive review of the evidence documenting the health and economic burdens of alcohol and guidance for public health professionals and communities on the most effective population-level interventions to prevent excessive alcohol consumption and related harms. Evidence-based interventions, informed by a health equity lens, should be foundational to a comprehensive public health approach. However, research assessing how alcohol use and harms are associated with social determinants of health and inequities is limited. Where research exists, evidence is incorporated here. Reviewed evidence-based population-level interventions include increasing alcohol taxes, reducing alcohol promotions, limiting alcohol outlet density, maintaining limits on hours and days of sale, avoiding privatization of alcohol sales, enacting dram shop liability laws, retaining the minimum legal drinking age of 21 years, enforcing laws prohibiting sales to individuals under age 21, restricting alcohol marketing, adopting responsible beverage service training laws, and adopting a 0.05% blood alcohol content limit for driving.

Relationship to Existing APHA Policy Statements

Existing APHA alcohol policy statements are broad in scope, specific to substance abuse, the war on drugs, or a call for a framework convention on alcohol control. Other statements relate to specific populations (underage youth, homeless individuals, minorities) or to specific interventions (e.g., individual level, environmental level), alcohol use disorder treatment, access and availability, advertising across different mediums, taxation, and products and labeling. Additional statements are combined with tobacco, and although there are interventions applicable to both drugs, there are distinct differences, particularly around advertising and promotion restrictions based on the Tobacco Master Settlement Agreement. The following historical snapshot of alcohol-related APHA policy statements demonstrates changes to the understanding of alcohol’s epidemiological harms and the advancement of scientific analyses on effective interventions to address alcohol-related harms.

• APHA Policy Statement 200615: A Call for a Framework Convention on Alcohol Control
• APHA Policy Statement 20041: Reducing Underage Alcohol Consumption
• APHA Policy Statement 9409: Limiting Youth Access to Alcohol
• APHA Policy Statement 9410: Local Control of Alcohol and Tobacco Availability
• APHA Policy Statement 9213: Advertising and Promotion of Alcohol and Tobacco Products to Youth
• APHA Policy Statement 9119: Implementation of Essential Alcohol and Tobacco Objectives from Healthy People 2000
• APHA Policy Statement 8921: Alcohol and Tobacco Outdoor Advertising in Minority Communities
• APHA Policy Statement 8920: Alcohol and Tobacco Industry Product Placement in Feature Films
• APHA Policy Statement 8932(PP): Alcohol and Other Drug Problems among the Homeless Population
• APHA Public Policy Statement 8817(PP): A Public Health Response to the War on Drugs: Reducing Alcohol, Tobacco, and Other Drug Problems among the Nation’s Youth
• APHA Policy Statement 8613(PP): Alcohol Tax Policy Reform
• APHA Policy Statement 8512: Alcohol Advertising on Radio and Television
• APHA Policy Statement 7121: Substance Abuse as a Public Health Problem

Problem Statement

Alcohol use is a leading risk factor for premature death and disability among individuals 15 to 59 years of age.[1] This policy statement reviews the research documenting the health and economic burdens of alcohol in the United States. It also provides guidance for public health professionals and communities on the most effective population-level interventions to address excessive alcohol consumption—defined as binge drinking (typically consumption of five or more drinks among men and four or more drinks among women in about 2 hours), heavy drinking (consumption of eight or more drinks per week among women and 15 or more drinks per week among men), and any drinking among pregnant women or individuals under age 21—and its related harms. In 2016, 5.3% of all deaths and 5.1% of the global burden of disease were attributable to alcohol use, despite a minority of individuals being current drinkers and a smaller percentage classified as heavy episodic drinkers.[2] While alcohol-attributable deaths and disability are most prevalent in high-income countries, alcohol-attributable harm per liter of pure alcohol consumed is generally higher in low- and middle-income countries, partially due to a higher prevalence of risky consumption patterns.[2]

Excessive alcohol use continues to be a major driver of mortality in the United States, contributing to approximately 88,000 deaths annually, including one in every 10 deaths among adults 20 to 64 years of age.[3] Binge drinking is the country’s most deadly, costly, and common form of excessive drinking, accounting for 54% of alcohol-related deaths, 66% of years of potential life lost, and 77% of economic costs.[3] Although nearly 90% of adults who drink excessively report binge drinking in the preceding 30 days, most binge drinkers do not meet diagnostic criteria for a severe alcohol use disorder (previously known as alcohol dependence or alcoholism).[4] Binge drinking is more common among men, 18- to 34-year-olds, and people with household incomes of $75,000 or more.[4] While half of U.S. adults do not drink alcohol, two in three of those who do drink report drinking above moderate levels (defined as up to one drink a day for women and up to two drinks a day for men).

In the United States, rates of excessive drinking have increased among middle-aged non-Hispanic White men and women.[5] A number of risk factors are correlated with adult alcohol misuse, including initiation of alcohol use at a young age, comorbid mental health conditions, and adverse childhood experiences.[6] In addition, deregulation of numerous alcohol prevention policies at the federal, state, and local levels may be contributing to changes in alcohol availability and subsequent increases in consumption levels; examples include increased alcohol outlet density, privatization of retail sales, reduced alcohol prices (taxes not tied to inflation), and more alcohol advertisements on television.[7] In fact, excessive alcohol consumption has been steadily rising over the last decade, particularly among women, older adults, members of racial and ethnic minority groups, and those of lower socioeconomic status.[8] These population increases have contributed to a spike in alcohol-related emergency room visits.[9] Also, low-income, minority communities often have a higher density of alcohol outlets than wealthier, primarily White communities, leaving people living in less resourced areas with disproportionate access to the alcohol outlets associated with the most harm.[10] As a result, individuals living in these communities often experience the greatest burden of alcohol-related harms.[10]

Excessive drinking cost the United States $249 billion ($2.05 per drink) in 2010 and is responsible for approximately 2.3 million years of potential life lost.[3] The annual cost of excessive alcohol consumption varies greatly throughout the states, with two fifths of the total costs paid by federal, state, and local governments; more than 40% of binge drinking costs in states are paid by the government.[11] The District of Columbia has the highest cost of alcohol consumption per capita ($1,526), followed by Alaska ($1,165) and New Mexico ($1,084). Alternatively, the states with the lowest costs per capita are Utah ($592), Nebraska ($639), and Iowa ($635). There are also regional differences in the prevalence of alcohol consumption. According to 2015 state-level data (the most recent data available), rates of binge drinking are highest in the northern states (e.g., Montana, Wisconsin, Michigan, and Minnesota) and lowest in the southern states (e.g., Texas, Arizona, and Alabama). However, the data are less clear with respect to intensity of binge drinking (or how much alcohol is consumed during a binge drinking session). States with the highest average number of drinks consumed per binge drinker include Louisiana, Arkansas, Missouri, Iowa, and the Dakotas. Additional states have high rates of binge drinking intensity but do not follow a clear pattern.[4]

Differences in state costs and costs per capita may reflect both social and cultural factors as well as state alcohol control policies, particularly those related to alcohol price and availability.[11] Alcohol harms human health across a number of domains; it is a causal risk factor for at least seven cancers, liver disease, infectious diseases, unintentional injuries, violent crime (including physical and sexual assault and homicide), mental health conditions (e.g., anxiety, stress, and depression), and suicide.[2] Alcohol consumption is associated with a seven-fold greater risk for suicide, and heavy alcohol use is associated with a 37-fold greater risk.[12] Experience of mental health trauma, including posttraumatic stress disorder and childhood trauma (e.g., adverse childhood events), is associated with excessive alcohol use across populations including veterans and survivors of physical and sexual abuse[13]; this association is often compounded by depression and other co-occurring mental health conditions. Women who have experienced trauma are at higher risk for excessive alcohol use than trauma-exposed men.[13]

Alcohol does not have health benefits: research has shown that moderate alcohol consumption does not improve cardiovascular disease outcomes.[14] Alcohol-related harms occur through a combination of the volume of alcohol consumed and the pattern of consumption; dose-response relationships can be seen with many major disease categories (e.g., tuberculosis, certain cancers).[2] Drinking patterns such as heavy episodic drinking are linked to a greater risk of intentional and unintentional injuries, violence, and fetal alcohol spectrum disorders; however, increased risk can occur at lower levels of consumption for certain outcomes such as breast cancer and motor vehicle crashes.[2] A number of unintentional injuries are also associated with alcohol use (e.g., road traffic injuries, drownings, poisonings, falls, and burns), and these injuries are responsible for 21% of all alcohol-attributable deaths—the highest of the eight categories analyzed.[2] Alcohol consumption is the leading known preventable cause of birth defects and developmental disabilities.[15] In addition, alcohol plays a role in both perpetrating violence and being a victim of violence.[2] Each day, excessive drinking is associated with nearly half of the homicides occurring in the United States.[16] This alcohol-attributable violence carries a large price tag; in 2010, crimes that involved excessive drinking cost the country $36.7 billion.[11]

Furthermore, in 2017, nearly 11,000 people died in a motor vehicle crash involving an alcohol-impaired driver, accounting for more than 25% of all traffic deaths in the United States during that year (one death every 48 minutes, or 29 per day).[17] In 2010, the most recent year for which data are available, the United States spent more than $44 billion on alcohol-related crashes.[18]

Along with harms to the drinker, alcohol’s second-hand effects (the harms experienced through other people’s drinking) include subjective and objective harms attributable to alcohol that occur in the social environment. One U.S. study showed that reports of being harassed in public, harassed at a party, physically hurt, scolded, frightened, and kept awake due to others’ alcohol use were more frequent among individuals 15 to 24 years of age than among those in other age groups.[19] Preliminary studies among college students have uncovered a variety of harms from other people’s drinking, including being pushed, hit, or assaulted; having one’s property damaged; having one’s studying disturbed; experiencing unwanted sexual advances or rape; and being insulted or humiliated.[20]

In addition to being the leading cause of preventable birth defects and developmental disabilities in the United States, drinking alcohol while pregnant may lead to a number of childhood conditions that fall within the umbrella of fetal alcohol spectrum disorders, including small head size, low body weight, hyperactive behavior, poor memory, learning disabilities, vision or hearing problems, and poor reasoning.[14]

Finally, it is important to note that alcohol consumption and related harms have differential population effects. For example, lesbian, gay, bisexual, and transgender (LGBT) youth, particularly young LGBT men, are at increased risk for alcohol misuse.[21] In addition, excessive alcohol consumption varies by race and ethnicity. Behavioral Risk Factor Surveillance System data from 2017 show past-month binge drinking rates of 20% among American Indians/Alaska Natives, 18% among Whites and Hispanics/Latinos, 14% among Blacks/African Americans, and 12% among Asians.[4] A study from Scotland revealed that excessive drinkers who live in socioeconomically disadvantaged areas are more likely to experience alcohol-related harms than those who live in more advantaged areas[22]; however, additional research in the United States is needed. Rates of excessive alcohol use are also high in military populations. The 2015 Health Related Behaviors Survey showed that 30% of service members were current binge drinkers, as compared with approximately 25% of U.S. civilian adults overall.[23] These studies suggest that rates of excessive alcohol use are higher among individuals from minority populations (e.g., racial/ethnic, gender, sexual identity, military status) and lower socioeconomic status groups and that these individuals are more likely to experience alcohol-related harms, including both morbidity and mortality, representing a clear equity issue.

Evidence-Based Strategies to Address the Problem

Addressing excessive alcohol consumption using individual-, community-, and population-level strategies simultaneously can create a comprehensive response at all levels. Population-level approaches can complement, enhance, and mutually inform individual-level approaches in responding to trauma, socioeconomic stress, and access to care (including care for substance use disorders) and in exploring potential genetic predispositions. While evidence-based, individual-level strategies (e.g., screening, brief intervention, referral to treatment) are an important component of a comprehensive effort, population-level interventions offer greater protection for more people at less cost. Given that the majority of adults who report current binge drinking do not meet diagnostic criteria for severe alcohol use disorder,[4] prioritization of population-level, evidence-based strategies is paramount to adequately address the wide range of harms associated with excessive alcohol consumption across populations and locations, and these strategies should focus on the social determinants in which consumption occurs. Furthermore, interventions centered on the individual have limited population-level impact. Assessing how alcohol interventions address social determinants and inequities should be a foundational element of a comprehensive public health approach to addressing alcohol consumption and related harms; however, research is limited.[24]

Roche et al.[24] reviewed the evidence base regarding inequities in alcohol consumption and related health outcomes in Australia and found that social determinants (i.e., the conditions in which people are born, work, grow, live, and age) can strongly influence these inequities. The authors called for the implementation of multiple evidence-based interventions that are appropriate for particular groups and settings to address the complexity of social determinants and how they affect different populations; however, they acknowledged a need for more research in this area to better understand how alcohol adversely affects different groups.[24]

In 1933, following the repeal of federal prohibition, states were granted the explicit authority to tax and regulate alcohol. What has emerged in the subsequent decades is a tapestry of different rules, regulations, and laws designed to reflect the will of the people in each jurisdiction. These variations have given researchers opportunities to identify the most effective strategies to mitigate alcohol-related harms. A number of strategies target specific conditions of the alcohol environment; however, the most effective way to safeguard against alcohol-related harm is through a combination of policies and regulations coupled with appropriate levels of enforcement.[7] Major public health resources such as the book Alcohol: No Ordinary Commodity,[7] along with the Surgeon General’s Report on Alcohol, Drugs, and Health[6]; the World Health Organization’s global alcohol strategy[2]; and the guidelines of the Centers for Disease Control and Prevention (CDC) Task Force on Community Preventive Services, have identified the interventions that are most effective in addressing alcohol-related harms, including pricing and taxation policies, regulation of alcohol retail access, and drinking context (e.g., marketing restrictions, lowering of blood alcohol content [BAC] limits).

These strategies have far-reaching population-level effects that involve not only those who consume the greatest amount of alcohol but also those at greatest risk of harm, whether from their own consumption or other people’s drinking. In addition, many of the strategies may have even greater benefits for the low-income and minority communities that experience greater harms. This policy statement summarizes research findings to provide public health professionals and communities with an overview of the most effective population-level interventions to address and prevent excessive alcohol consumption and its related harms. Evidence on how social determinants and inequities are addressed as they pertain to specific strategies is included where research is available.

The strategies are organized in three categories: (1) pricing and taxes, (2) retail access, and (3) drinking context. In addition to strong evidence on the effectiveness of these policy strategies in reducing alcohol-related harms, they have been shown to be highly cost effective.

Pricing and taxes: Taxes on alcoholic beverages may be imposed at the local, state, and federal levels and vary by beverage category, with lower rates for beer and wine and higher rates for liquor. Tax rates across states and localities have changed over time, and some have been evaluated as to their differing effects on various outcomes. Studies have shown that increases in alcohol prices and/or taxes are associated with reductions in alcohol consumption and related problems, including motor vehicle fatalities, violent crime, and alcohol-related diseases.[25] Tax increases have also been shown to be minimally burdensome on moderate drinkers, racial/ethnic minorities, and members of low-income households, with excessive drinkers shouldering three quarters of the overall cost.[26] Although increasing alcohol taxes is one of the most effective policies in changing alcohol consumption and related problems, U.S. alcohol taxes have failed to keep pace with inflation rates, resulting in cheaper alcohol prices over time.[27]

Price promotions, such as happy hours, ladies’ nights, and all-you-can-drink specials, are associated with increased alcohol consumption and negative consequences.[28] Local and state regulations can prohibit or restrict bars, clubs, and restaurants from offering special pricing on alcoholic beverages. Recently, some states have faced legal challenges in their efforts to restrict promotions of drink specials due to First Amendment considerations; however, under the 21st Amendment, states are within their legal authority to regulate or prohibit drink promotions such as happy hours in the interest of protecting the public.

Retail access: A substantial body of research demonstrates that communities with a greater density of alcohol outlets (e.g., outlets per roadway mile) are at higher risk of experiencing problems related to excessive alcohol consumption, including crime and motor vehicle crashes.[29] Underserved communities have been found to have a greater density of alcohol outlets, disproportionately exposing these communities to excess risk, including from outlets that are associated with the greatest amount of harm (off-premises outlets).[9] This research suggests that the greatest potential to decrease alcohol-related inequalities at the population level is in restricting retail outlets from clustering in underserved communities and implementing interventions focused on alcohol outlets. Density of alcohol outlets can be limited through statutory initiatives such as licensing or local zoning regulations.[30]

Studies have shown that increases of more than 2 hours in the time during which alcohol can be sold (e.g., extending bar closing) and increases in the number of days that alcohol retailers can be open (e.g., lifting prohibitions of liquor sales on Sundays or holidays) are associated with higher rates of alcohol use, motor vehicle crashes, crime, and alcohol-related injuries.[31] Typically, the state government has the primary authority to regulate days and hours of sales unless the state grants authority to local governments to adopt limits. To limit the days and hours that alcohol is sold, off-premises alcohol outlets (e.g., liquor stores) can be restricted to operating during specific times or days of the week, while bars can be prohibited from serving alcohol after a designated time.

States regulate alcohol through a closed three-tier system (producer, wholesaler, retailer), which creates efficient tax collection and ensures product safety.[32] While the majority of states allow private industry to participate in all three tiers, some states (known as control states) are market participants, with the government taking ownership of the product at some point in the sales cycle (wholesale and/or retail).[33] In some control jurisdictions, distilled spirits may be sold only in state-run liquor stores. Control jurisdictions can more easily adopt regulations that support moderation, such as setting alcohol prices, determining product selection and retail locations, and restricting promotions, than jurisdictions that sell alcohol exclusively through the private sector.[33] Pressure from the private sector, including large chain stores, to further privatize alcohol sales has increased in recent years with promises that this will increase competition and lead to increased consumer choice and state revenues.[34] Studies have shown that removal of government control of alcohol sales (privatization) results in more alcohol outlets, longer hours of sale, and increases in motor vehicle crashes and per capita alcohol sales, a well-established proxy for excessive alcohol consumption.[7,35] Furthermore, the revenue generated from a control jurisdiction’s participation in the market provides the state (and, in some cases, jurisdictions) with revenue for essential services (e.g., schools, treatment, enforcement) and provides dedicated funds that support the alcohol regulatory system’s infrastructure (e.g., inspections, enforcement) to maintain compliance among alcohol license holders.[34]

Dram shop liability laws allow alcohol license holders to be held legally responsible for harms resulting from selling or serving alcohol to individuals who are under age 21 or who are obviously intoxicated. For example, if a patron who is obviously intoxicated or underage is served alcohol and then drives his or her car from the premises and is involved in a crash where other individuals are killed or harmed, the alcohol license holder can be held responsible for related injuries or death. Research has shown that dram shop liability laws are associated with lower rates of motor vehicle fatalities and alcohol-related violence and disease.[36]

Drinking context: All U.S. states currently have a minimum legal drinking age (MLDA) of 21 years. Research demonstrates that having an MLDA of 21 years (versus 18 or 19 years) is associated with reductions in alcohol consumption and motor vehicle deaths among youth and is estimated to save approximately 1,000 lives annually.[37]

Law enforcement personnel are responsible for enforcing prohibition of alcohol sales to individuals under age 21, and alcohol compliance checks at licensed alcohol outlets are one of the most common and effective strategies in doing so.[38] Similar to tobacco, a compliance check involves a person younger than 21 years, under supervision of law enforcement, attempting to purchase alcohol; if a sale is made, the establishment’s license holder and/or the clerk or server may receive a penalty.

Exposure to alcohol advertising is associated with an increased likelihood of young people starting to drink if they do not already, starting to drink at an earlier age, and binge drinking.[39] A recent systematic review showed that youth report greater exposure to alcohol advertising and promotional content than adults in most media, including the Internet.[39] Advertising may include advertisements on television, in magazines, or in social media; ownership of branded materials; window signage; billboards; and point-of-sale advertisements. The alcoholic beverage industry promotes self-regulation of its advertising over government regulation. Yet, a 2017 systematic review of more than 40 studies examining both content of and youth exposure to advertising concluded that the industry’s self-regulatory efforts are ineffective in protecting youth.[40]

Responsible beverage service (RBS) training laws, which can be enacted at the local or state level, mandate that all or some servers/sellers, managers, and/or license holders at alcohol outlets receive formal training on how to responsibly serve or sell alcohol. While research on the effectiveness of RBS training laws is inconclusive, some studies have shown that strong RBS laws are associated with reductions in alcohol-related motor vehicle crashes.[41] RBS training laws are most effective when combined with strong enforcement efforts.

Research has shown that lowering the BAC per se limit for driving (per se denotes that a measurable alcohol content level above the legal limit is, in itself, illegal and a crime) from 0.08% to 0.05% would have a general deterrent impact on alcohol-impaired driving rates. Fell and Scherer found that a BAC of 0.05% or lower would result in an 11.1% decline in fatal alcohol crashes and save 1,790 lives annually in the United States.[42] The National Transportation Safety Board (in 2013) and the National Academies of Sciences, Engineering, and Medicine (in 2018) recommended that U.S. states lower the legal BAC limit for driving from 0.08% to 0.05% or lower and encouraged law enforcement personnel to gather information on where impaired drivers had their last drink.[43] In December 2018, Utah became the first state to adopt a 0.05% BAC per se law. All other U.S. states have a 0.08% BAC limit.

Opposing Arguments/Evidence

Benefits to health: Some research suggests that alcohol consumption may have certain health benefits. For example, prevailing wisdom suggests that consuming one alcoholic beverage a day prevents cardiovascular disease. However, any decrease in cardiovascular disease risk seen in research studies is likely due to selection bias and abstainer bias, which occur when individuals abstain from alcohol because of prior health concerns.[15] After adjustment for such biases, there is no evidence that alcohol use prevents cardiovascular disease. Others suggest that cultural norms are the primary driver of alcohol consumption, whereby acceptance of alcohol use at early ages is thought to prevent hazardous use and binge drinking later in life; however, evidence suggests that peer and neighborhood influences may have a stronger effect.[44]

Alcohol industry prevention programs: In general, the programs created and supported by the alcohol industry to reduce alcohol consumption often lack scientific evidence and may be antithetical to public health objectives. A recent evaluation of alcohol industry actions concluded that 96.8% of these actions lacked scientific support, and 11.0% had the potential to directly harm the population by promoting alcohol use in general or alcohol use in risky situations, such as driving.[45] Alcohol producers support prevention efforts that focus on individual behavior change, industry self-regulation, and interventions that reduce the downstream consequences of alcohol consumption but not alcohol use itself.[46] These behavior change programs primarily involve a consumer education approach or a social norms approach that highlights the differences between perceived and actual peer alcohol consumption. For example, A-B InBev has committed to spending $1 billion through 2025 on social norms programs that employ a social marketing approach and commercial marketing techniques, and pilot studies have focused on drunk driving and underage alcohol use.[47] However, systematic reviews and meta-analyses have indicated that there is no scientific evidence supporting such an approach to reducing harmful alcohol consumption.[46]

Alcohol industry opposition to control policies: In general, the alcohol industry opposes the implementation of stronger alcohol control policies. Off-premises retailers, such as liquor and grocery stores, have advocated against increases in alcohol prices through taxation or other means,[48] yet evidence suggests that increases in the price of alcoholic beverages can reduce consumption. Price elasticities for some products (e.g., wine) exceed 1.0, suggesting that a 10% price increase may result in a maximum 10% reduction in consumption.[49] Although alcohol price increases have also been criticized as regressive, with low-income populations disproportionately impacted,[50] regressive effects are concentrated among the heaviest alcohol consumers. Low-income consumers would spend a larger proportion of their income on alcohol taxes; if alcohol consumption remained constant, however, greater price elasticities in lower income groups would suggest that reductions in alcohol use could offset increased prices.[49] Both off-premises and on-premises retailers (e.g., bars) have also advocated against decreasing the BAC limit for driving from 0.08% to 0.05%[43] despite the 0.05% limit being estimated to reduce fatal alcohol-related crashes.[50]

Alcohol industry self-regulation: Similar to many other industries,[50] the alcohol industry supports self-regulation, which involves the industry creating a set of guidelines, enforcing the implementation of those guidelines, and adjudicating violations of the guidelines without government interference.[46] Specifically, the alcohol industry promotes self-regulation of alcohol marketing; however, such systems are ineffective in reducing youth exposure to alcohol marketing or preventing the use of harmful content in alcohol advertising. According to a systematic review of 19 studies on alcohol marketing content, none of the investigations revealed self-regulation to be effective in protecting vulnerable populations.[40] Conversely, regulating alcohol marketing activities may infringe upon the industry’s commercial free speech rights, which is not a concern when implementing other alcohol control policies due to specific (e.g., the power to tax) or more general (e.g., the power to regulate) constitutional powers available to the government.

Lowering the MLDA: Finally, Choose Responsibility, a nonprofit organization, advocates for lowering the MLDA from 21 to 18 years with claims that this will lower alcohol consumption and alcohol-related harms. However, evidence suggests that the current MLDA of 21 years reduces youth alcohol consumption; protects drinkers from long-term harms such as alcohol use disorders, suicide, and homicide; and saves 1,000 lives annually.[37]

Action Steps

There are several tools available to professionals and communities to assess the strength of the local alcohol policy environment, including the National Institute on Alcohol Abuse and Alcoholism’s Alcohol Policy Information System and the CDC’s Alcohol-Related Disease Impact application. These resources can help organizations assess which strategies are best for their specific needs. The action steps described below correspond to the population-level evidence-based strategies outlined earlier. Moreover, these action steps are feasible, ethical, and equitable to undertake and are culturally appropriate for affected populations, shaping the environment of not only those who consume the greatest amount of alcohol but also those at greatest risk of harm, whether from their own consumption or other people’s drinking. Examples of the specific entities that can take each action step are included in parentheses.

Federal Action
Public health and prevention professionals, as well as similarly aligned organizations and community members, should support and advocate for:

• Increasing federal excise taxes on alcohol as part of public health’s larger fiscal health policy agenda. In addition, they should oppose efforts to reduce such taxes (nonprofit organizations, public health advocacy groups, and community volunteers).
• Increasing research funding through Congress to better understand the correlation between alcohol use and the social determinants of health—the conditions in which people are born, work, grow, live, and age (public health researchers and local/county health agencies).
• Expanding federal programs through the Department of Health and Human Services (CDC/Substance Abuse and Mental Health Services Administration [SAMHSA]), the National Highway Traffic Safety Administration (NHTSA), and the Department of Justice (DOJ) that create state and local coalitions and community efforts dedicated to the scientific prevention of excessive alcohol consumption. This should include assessment and expansion of current funding provided by Congress for initiatives to develop community and state efforts aimed toward preventing excessive alcohol consumption and its related harms (local, state, and national prevention coalitions).
• Developing a framework convention on alcohol control similar to the Framework Convention on Tobacco Control (the public health research community, public health lawyers, and national prevention organizations).

State and Local Action
Public health and prevention professionals, as well as similarly aligned organizations, local coalitions, and community members, should support and advocate for:

• Increasing state and local alcohol excise and sales taxes and tracking the evidence on other pricing interventions such as minimum unit pricing strategies. In addition, they should oppose efforts to reduce alcohol taxes (nonprofit organizations, public health advocacy groups, and community volunteers).
• Limiting the density of alcohol retail outlets and preventing the clustering of outlets in communities (particularly underserved communities) through state and local licensing and zoning regulations to better address alcohol-related inequities within communities (community coalitions, neighborhood associations, prevention organizations, and local public health organizations).
• Restricting alcohol advertising and marketing, specifically advertising targeting younger people. For example, localities may have the authority to mitigate youth exposure to alcohol advertising by limiting window signage (community coalitions, neighborhood associations, young people, parent groups, prevention organizations, and local public health organizations).
• Increasing enforcement by state and local law enforcement personnel and alcohol beverage control agencies to encourage compliance among alcohol retailers as a means of preventing illegal sale of alcohol. In addition, there is a need to increase resources provided to states and communities (through SAMHSA, DOJ, and NHTSA funding) for compliance checks, to emphasize the importance of community coalition efforts in encouraging heightened enforcement by local and state enforcement agencies, and to encourage political will (local and state law enforcement agencies, community coalitions, prevention organizations, and local and state public health and safety organizations).
• Tracking the developing evidence on place of last drink data collection as a tool to focus enforcement and regulatory compliance efforts by local law enforcement and state regulatory agencies on the outlets most likely to serve or sell to obviously intoxicated patrons (local and state law enforcement agencies, state alcohol regulatory agencies, public health agencies, prevention organizations, and community coalitions).
• Adopting 0.05% BAC per se laws for alcohol-impaired driving in all states through state legislation (community coalitions, prevention organizations, and public health and safety advocacy organizations).
• Opposing efforts to lower the MLDA of 21 years. The age 21 MLDA, which is the law in every state, is so successful in saving lives that communities should remain vigilant in maintaining it (community coalitions, prevention organizations, and public health and safety advocacy organizations).
• Opposing policies, through state legislative efforts, that further erode government controls regulating the retail sale of alcohol, including privatization; loosening of the closed three-tier alcohol control system that includes producers, wholesalers, and retailers; and other forms of deregulation (community coalitions, prevention organizations, and public health and safety advocacy organizations).
• Opposing policies that increase hours and days of alcohol retail sales, specifically policies that extend hours of sale by more than 2 hours and expand the number of days on which alcohol can be sold (e.g., holidays, Sundays) (community coalitions, prevention organizations, and public health and safety advocacy organizations).
• Opposing policies, through state legislative efforts, that further erode the effectiveness of dram shop liability laws in states where these laws are in place. Public health professionals and organizations in states that do not have dram shop liability laws should advocate for the adoption of these laws to prevent excessive alcohol consumption (community coalitions, prevention organizations, and public health and safety advocacy organizations).
• Enhancing RBS training laws and ensuring that they are enacted in conjunction with strong enforcement operations such as robust local- and state-level compliance checks and on-premises bar inspections. The required content of the training programs, the format in which training is provided (e.g., online, in person), and who is mandated to be trained are all critical elements of an effective RBS training law (community coalitions, prevention organizations, law enforcement agencies, and public health agencies).
• Encouraging inclusion of alcohol as a risk factor for cancer in state cancer control plans (community coalitions, prevention organizations, public health advocacy organizations, and medical associations).

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