Relationships between US state alcohol policies and alcohol outcomes: differences by gender and race/ethnicity

Alcoholic beverage types consumed by population subgroups in the United States: Implications for alcohol policy to address health disparities

INTRODUCTION

We aimed to identify alcoholic beverage types more likely to be consumed by demographic subgroups with greater alcohol-related health risk than others, mainly individuals with low socio-economic status, racial/ethnic minority status and high drinking levels.

METHODS

Fractional logit modelling was performed using a nationally representative sample of US adult drinkers (analytic N = 37,657) from the National Epidemiologic Survey on Alcohol and Related Conditions Waves 2 (2004-2005) and 3 (2012-2013). The outcomes were the proportions of pure alcohol consumed as beer, wine, liquor and coolers (defined as wine-/malt-/liquor-based coolers, hard lemonade, hard cider and any prepackaged cocktails of alcohol and mixer).

RESULTS

Adults with lower education and low or medium income were more likely to drink beer, liquor and coolers, while those with a 4-year college/advanced degree and those with high income preferred wine. Excepting Asian adults, racial/ethnic minority adults were more likely to drink beer (Hispanics) and liquor (Blacks), compared with White adults. High- or very-high-level drinkers were more likely to consume liquor and beer and less likely to consume wine (and coolers), compared with low-level drinkers. High-level and very-high-level drinkers, who were less than 10% of all drinkers, consumed over half of the total volume of beer, liquor and coolers consumed by all adults.

DISCUSSION AND CONCLUSIONS

Individuals with low socio-economic status, racial/ethnic minority status or high drinking level prefer liquor and beer. As alcohol taxes, sales and marketing practices all are beverage-specific, targeted approaches to reduce consumption of these beverages, particularly among individuals with these profiles, are warranted.

Associations between alcohol taxes and varied health outcomes among women of reproductive age and infants

OBJECTIVE

No studies have examined whether alcohol taxes may be relevant for reducing harms related to pregnant people's drinking.

METHOD

We examined how beverage-specific ad valorem, volume-based, and sales taxes are associated with outcomes across three data sets. Drinking outcomes came from women of reproductive age in the 1990-2020 US National Alcohol Surveys (N = 11 659 women $\le$ 44 years); treatment admissions data came from the 1992-2019 Treatment Episode Data Set: Admissions (N = 1331 state-years; 582 436 pregnant women admitted to treatment); and infant and maternal outcomes came from the 2005-19 Merative Marketscan® database (1 432 979 birthing person-infant dyads). Adjusted analyses for all data sets included year fixed effects, state-year unemployment and poverty, and accounted for clustering by state.

RESULTS

Models yield no robust significant associations between taxes and drinking. Increased spirits ad valorem taxes were robustly associated with lower rates of treatment admissions [adjusted IRR = 0.95, 95% CI: 0.91, 0.99]. Increased wine and spirits volume-based taxes were both robustly associated with lower odds of infant morbidities [wine aOR = 0.98, 95% CI: 0.96, 0.99; spirits aOR = 0.99, 95% CI: 0.98, 1.00] and lower odds of severe maternal morbidities [wine aOR = 0.91, 95% CI: 0.86, 0.97; spirits aOR = 0.95, 95% CI: 0.92, 0.97]. Having an off-premise spirits sales tax was also robustly related to lower odds of severe maternal morbidities [aOR = 0.78, 95% CI: 0.64, 0.96].

CONCLUSIONS

Results show protective associations between increased wine and spirits volume-based and sales taxes with infant and maternal morbidities. Policies that index tax rates to inflation might yield more public health benefits, including for pregnant people and infants.

Multilevel Effects of Environmental and Neighborhood Factors on Sober Living House Resident 12-Month Outcomes

OBJECTIVE

Sober living houses (SLHs) are abstinence-based environments designed for individuals in recovery to live with others in recovery. Research shows that SLHs help some individuals maintain recovery and that certain SLH-related factors may be particularly protective. Here we assess how SLH housing and neighborhood characteristics are related to abstinence and psychiatric symptoms over time.

METHOD

Baseline, 6-month, and 12-month data were collected from 557 SLH residents. Multilevel mixed models tested associations between house and neighborhood characteristics and individual-level percent days abstinent (PDA) and the number of psychiatric symptoms (measured with the Psychiatric Diagnostic Screening Questionnaire [PDSQ]) as outcomes. Final models adjusted for sex, age, and race/ethnicity; ratings of house characteristics; and objective measurements of neighborhood-level exposures.

RESULTS

Both PDA and PDSQ improved significantly (ps ≤ .05) over time in both unadjusted and adjusted models. More self-help groups and fewer alcohol outlets within one mile were significantly protective for PDA, whereas walkability was significantly related to worse PDA and PDSQ (ps ≤ .05). For house-level factors, better ratings of house maintenance were related to significantly fewer psychiatric symptoms, whereas higher scores on SLH's safety measures and personal or residence identity were related to more psychiatric symptoms (ps ≤ .05). No house-level factor was significantly related to PDA.

CONCLUSIONS

Neighborhood-level factors such as increased availability of self-help groups and fewer nearby alcohol outlets may increase abstinence among individuals living in SLHs. House-level factors related to better maintenance may also facilitate improved mental health.

Associations between state-level general population alcohol policies and drinking outcomes among women of reproductive age: Results from 1984 to 2020 National Alcohol Surveys

BACKGROUND

Policies specific to alcohol use during pregnancy have not been found to reduce risks related to alcohol use during pregnancy. In contrast, general population alcohol policies are protective for the general population. Here, we assessed whether US state-level general population alcohol policies are related to drinking outcomes among women of reproductive age.

METHODS

We conducted secondary analyses of 1984-2020 National Alcohol Survey data (N = 13,555 women ≤44 years old). State-level policy exposures were government control of liquor retail sales, heavy beer at gas stations, heavy beer at grocery stores, liquor at grocery stores, Sunday off-premise liquor sales, and blood alcohol concentration (BAC) driving limits (no law, 0.10 limit, 0.05-0.08 limit). Outcomes were past 12-month number of drinks, ≥5 drink days, ≥8 drink days, and any DSM-IV alcohol abuse/dependence symptoms. Regressions adjusted for individual and state-level controls, clustering by state, and included fixed effects for survey month and year.

RESULTS

Allowing Sunday off-premise liquor sales versus not was related to having 1.20 times as many drinks (95% CI: 1.01, 1.42), 1.41 times as many ≥5 drink days (95% CI: 1.08, 1.85), and 1.91 times as many ≥8 drink days (95% CI: 1.28, 2.83). BAC limits of 0.05-0.08 for driving versus no BAC limit was related to 0.51 times fewer drinks (95% CI: 0.27, 0.96), 0.28 times fewer days with ≥5 drinks (95% CI: 0.10, 0.75), and 0.20 times fewer days with ≥8 drinks (95% CI: 0.08, 0.47).

CONCLUSIONS

US state-level policies prohibiting Sunday off-premise liquor sales and BAC limits of 0.05-0.08 for driving are related to less past 12-month overall and heavy drinking among women 18-44 years old.

Reducing alcohol use through alcohol control policies in the general population and population subgroups: a systematic review and meta-analysis

We estimate the effects of alcohol taxation, minimum unit pricing (MUP), and restricted temporal availability on overall alcohol consumption and review their differential impact across sociodemographic groups. Web of Science, Medline, PsycInfo, Embase, and EconLit were searched on 08/12/2022 and 09/26/2022 for studies on newly introduced or changed alcohol policies published between 2000 and 2022 (Prospero registration: CRD42022339791). We combined data using random-effects meta-analyses. Risk of bias was assessed using the Newcastle-Ottawa Scale. Of 1887 reports, 36 were eligible. Doubling alcohol taxes or introducing MUP (Int$ 0.90/10 g of pure alcohol) reduced consumption by 10% (for taxation: 95% prediction intervals [PI]: -18.5%, -1.2%; for MUP: 95% PI: -28.2%, 5.8%), restricting alcohol sales by one day a week reduced consumption by 3.6% (95% PI: -7.2%, -0.1%). Substantial between-study heterogeneity contributes to high levels of uncertainty and must be considered in interpretation. Pricing policies resulted in greater consumption changes among low-income alcohol users, while results were inconclusive for other socioeconomic indicators, gender, and racial and ethnic groups. Research is needed on the differential impact of alcohol policies, particularly for groups bearing a disproportionate alcohol-attributable health burden.

Funding

Research reported in this publication was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under Award Number R01AA028009.

Effective alcohol policies are associated with reduced consumption among demographic groups who drink heavily

BACKGROUND

Alcohol policies stand out among other noncommunicable disease-relevant policies for the lack of uptake. Composite indicators have been developed to measure the effects of alcohol control policy. We investigated whether drinking patterns among demographic groups from general population samples of drinkers from diverse countries are associated with alcohol control policy as measured by the International Alcohol Control (IAC) Policy Index.

METHODS

Representative samples of adult drinkers from 10 countries (five high-income and five middle-income) were surveyed about alcohol consumption, using beverage and location-specific questions.

MEASUREMENTS

The IAC Policy Index was analyzed with frequency, typical occasion quantity, and volume consumed. Analyses used mixed models that included interactions between country IAC Policy Index score and age group, gender, and education level.

FINDINGS

Each increase in IAC policy index score (reflecting more effective alcohol policy) was associated with a 13.9% decrease in drinking frequency (p = 0.006) and a 16.5% decrease in volume (p = 0.001). With each increase in IAC Policy Index score, both genders decreased for all three measures, but men less so than women. Women decreased their typical occasion quantity by 1.2% (p = 0.006), frequency by 3.1% (p < 0.001), and total volume by 4.2% (p < 0.001) compared to men. Low and mid-education groups decreased their typical occasion quantity by 2.6% (p < 0.001) and 1.6% (p = 0.001), respectively, compared to high education, while for drinking frequency the low education group increased by 7.0% (p < 0.001). There was an overall effect of age (F = 19.27, p < 0.0001), with 18-19 and 20-24-year-olds showing the largest decreases in typical occasion quantity with increasing IAC policy index score.

CONCLUSIONS

The IAC Policy Index, reflecting four effective policies, was associated with volume and frequency of drinking across 10 diverse countries. Each increase in the IAC Policy Index was associated with lower typical quantities consumed among groups reporting heavy drinking: young adults and less well-educated. There is value in implementing such alcohol policies and a need to accelerate their uptake globally.

Does the relationship between alcohol retail environment and alcohol outcomes vary by depressive symptoms? Findings from a U.S. Survey of Black, Hispanic and White drinkers

AIMS

To assess whether associations between alcohol availability and consumption, drinking to drunkenness, and negative drinking consequences vary among individuals with elevated depressive symptoms.

METHODS

10,482 current drinkers in 2005-2015 National Alcohol Surveys (50.0% female; 74.4% White, 8.7% Black, 11.1% Hispanic). Elevated depressive symptoms was defined as having symptoms suggestive of major depressive disorder (above CES-D8/PHQ-2 cut-offs) versus no/sub-threshold symptoms (below cut-offs). Inverse probability of treatment weighted and covariate adjusted Poisson models with robust standard errors estimated associations of ZIP-code bar density and off-premise outlet density (locations/1,000 residents), elevated depressive symptoms, and their interaction with past-year volume consumed, monthly drinking to drunkenness, and negative drinking consequences. Models were then stratified by sex and race and ethnicity.

RESULTS

Overall, 13.7% of respondents had elevated depressive symptoms. Regarding density, the only statistically significant association observed was between off-premise density and volume consumed (rate ratio = 1.3, 95% confidence interval = 1.0, 1.7). Elevated depressive symptoms were associated with higher volume consumed, prevalence of drinking to drunkenness, and prevalence of negative consequences when controlling for off-premise density or bar density. However, there was no evidence of interaction between symptoms and density in the full sample nor among subgroups.

CONCLUSION

This study suggests that, while elevated depressive symptoms do not alter associations between alcohol availability and alcohol use and problems, they remain associated with these outcomes among past-year drinkers in a U.S. general population sample even when accounting for differential availability. Addressing depressive symptoms should be considered along with other policies to reduce population-level drinking and alcohol problems.

Hazardous drinking and alcohol use disorders

Alcohol is one of the most widely consumed psychoactive drugs globally. Hazardous drinking, defined by quantity and frequency of consumption, is associated with acute and chronic morbidity. Alcohol use disorders (AUDs) are psychiatric syndromes characterized by impaired control over drinking and other symptoms. Contemporary aetiological perspectives on AUDs apply a biopsychosocial framework that emphasizes the interplay of genetics, neurobiology, psychology, and an individual's social and societal context. There is strong evidence that AUDs are genetically influenced, but with a complex polygenic architecture. Likewise, there is robust evidence for environmental influences, such as adverse childhood exposures and maladaptive developmental trajectories. Well-established biological and psychological determinants of AUDs include neuroadaptive changes following persistent use, differences in brain structure and function, and motivational determinants including overvaluation of alcohol reinforcement, acute effects of environmental triggers and stress, elevations in multiple facets of impulsivity, and lack of alternative reinforcers. Social factors include bidirectional roles of social networks and sociocultural influences, such as public health control strategies and social determinants of health. An array of evidence-based approaches for reducing alcohol harms are available, including screening, pharmacotherapies, psychological interventions and policy strategies, but are substantially underused. Priorities for the field include translating advances in basic biobehavioural research into novel clinical applications and, in turn, promoting widespread implementation of evidence-based clinical approaches in practice and health-care systems.

Do alcohol policies affect everyone equally? An assessment of the effects of state policies on education-related patterns of alcohol use, 2011-2019

BACKGROUND

Public policies are a powerful tool to change behaviors that may harm population health, but little is known about how state alcohol policies affect different population groups. This study assesses the effects of a comprehensive measure of the state alcohol regulatory environment (the State Alcohol Policy Score or SAPS) on heavy drinking-a risk factor for premature death-on different population groups, defined by levels of educational attainment, then by race/ethnicity, and sex.

METHODS

We pool each state's Behavioral Risk Factor Surveillance Survey (BRFSS) 2011-2019 and use robust Poisson regression analyses that control for individual-level factors, state-level factors (1 year lagged SAPS score for each state, state fixed effects), and year fixed effects to assess the relationship between SAPS and heavy drinking behaviors by education group. Interaction terms test whether education moderates the relationship by race/ethnicity and gender.

RESULTS

SAPS scores increased 2010-2018, but substantial gaps persist between states. A 10 % increase in a state's alcohol policy score is associated with a 2 % lower prevalence in current drinking (APR=0.97, 95 % CI=0.97-0.97, p < 0.0011) although not for those with a high school education or less. A 10 % increase in the SAPS was associated with a 3 % lower prevalence of heavy drinking; interaction terms in models reveal that a 10 % increase in the SAPS was associated with a lower prevalence of heavy drinking among those with less than a college education.

CONCLUSION

Narrowing gaps in alcohol policies between states may reduce heavy drinking among those with lower educational attainment.

Quantifying risk of injury from usual alcohol consumption: An instrumental variable analysis

BACKGROUND

Numerous studies of roadside accidents among emergency room patients show elevated risk of injury from acute alcohol consumption, i.e., recent drinking precedes the injury event. The observed effects are large and show a dose-response relationship. In contrast, studies quantifying the association between injury risk and chronic consumption, such as past-year average volume, show lower relative risk estimates than those from acute consumption.

METHODS

Combining data from 4 waves of US National Alcohol Surveys (NAS) for years 2000-2015 (N = 29,571, 53% overall cooperation rate), we estimated the risk of any past-year injury from past-year volume using logistic regression. This was contrasted with an instrumental variable (IV) analysis utilizing a 2-stage residual inclusion (2SRI) approach to estimate injury risk from volume, which adjusted for unobserved confounders using state beer and spirits tax rates, zip code-level outlet and bar density, and control state status as instruments.

RESULTS

Based on the combined US population surveys and controlling for sociodemographics, using conventional logistic regression, the odds ratios of injury from an average volume of 1, 2, and 5 drinks per day were 1.12 [95% confidence interval: 1.02, 1.24], 1.10 [1.00, 1.22], and 1.04 [0.88, 1.22], respectively. These compared with 1.67 [1.00, 2.78], 2.38 [0.87, 6.54], and 6.98 [0.57, 85.89] using the IV method. The proportion of injury attributed to alcohol also increased in magnitude, from 6.2% [0.3%, 11.9%] using the conventional approach to 17.9% [8.2%, 27.7%] using the IV method.

CONCLUSIONS

The association between injury and chronic alcohol consumption may be confounded by unobserved factors, resulting in a possible downward bias of the risk estimate.

Men's decrease and women's increase in harmful alcohol use from the 2014 to 2018 national surveys in Taiwan: A harbinger for an emerging national trend in East Asia?

BACKGROUND

Gender differences in alcohol use have narrowed in Western societies, but that in Asia has been less investigated. By comparing the 2014 and 2018 waves of the national survey in Taiwan, we aimed to examine the gender differences in population trends in past-month alcohol use, binge drinking, and harmful alcohol use.

METHODS

The national survey enrolled 17,837 participants in 2014 and 18,626 participants in 2018. Binge drinking was defined as having ≥5 drinks on one occasion in the past month, and harmful alcohol use as having an Alcohol Use Disorders Identification Test score of ≥8.

RESULTS

There were significant decreases from 2014 to 2018 in the population's prevalence of past-month alcohol use, binge drinking, and harmful alcohol use. However, males and females had different trends: males showed significant reductions in all three alcohol use behaviours (a decrease of 3.79%, 1.59%, and 2.60%, respectively), while females exhibited a significant rise in harmful alcohol use (from 1.32% to 1.72%), particularly among those aged 18-29 years.

CONCLUSION

There was gender convergence in alcohol use in Taiwan, mainly due to men's decrease and women's increase in harmful alcohol use. Our findings have important implications for the intervention and prevention of the problematic use of alcohol in East Asia.

Support for Alcohol Policies in Marginalized Populations

AIM

Kingdon [(2014) Agendas, Alternatives, and Public Policies. Essex. United Kingdom: Pearson Education Limited] argues that windows of opportunity to pass policies emerge when problems, solutions and policy support co-occur. This study aims to identify a set of alcohol policies with the potential to reduce alcohol-related disparities given high levels of support from marginalized groups, such as racial/ethnic minorities and lower-income groups.

METHODS

This study used data from five US National Alcohol Surveys, which were based on household probability samples of adults in 1995 (n = 4243), 2000 (n = 5736), 2005 (n = 1445), 2010 (n = 4164) and 2015 (n = 4041). We used multiple logistic regression to determine the odds of policy support by racial/ethnic group and income level, considering price, place and marketing policies as well as individual-level interventions.

RESULTS

Overall a majority of Americans supported banning alcohol sales in corner stores (59.4%), banning alcohol advertisements on television (55.5%), and establishing universal health coverage for alcohol treatment (80.0%). Support was particularly high among Blacks, Hispanics/Latinos and lower-income persons. Multivariate models showed that compared with White people, foreign-born Hispanics/Latinos had the most robust levels of support, including raising alcohol taxes (aOR = 2.40, 95% CI: 2.00, 2.88, P < 0.0001), banning alcohol sales in corner stores (aOR = 2.85, 95% CI: 2.22, 3.65, P < 0.0001) and reducing retail sales hours (aOR = 2.91, 95% CI: 2.38, 3.55, P < 0.0001).

CONCLUSION

Of the policies examined, banning alcohol sales at corner stores is most likely to be in a "window of opportunity" for reducing alcohol-related disparities. By simultaneously reducing population-level consumption and harms from others' drinking, place-based policies have the potential to reduce harms experienced by marginalized groups.

Alcohol policy effects on 100% chronic alcohol-attributable mortality across racial/ethnic subgroups

In the United States, some racial/ethnic minorities suffer from higher rates of chronic alcohol problems, and alcohol-related morbidity and mortality than Whites. Furthermore, state-level alcohol policies may affect racial/ethnic subgroups differentially. We investigate effects of beverage-specific taxes and government control of spirits retail on alcohol-related mortality among non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic American Indians/Alaska Natives (AI/AN) and Hispanics using death certificate and state-level alcohol policy data for 1999-2016. Outcomes were analyzed as mortality rates (per 10,000) from 100% alcohol-attributable chronic conditions ("100% chronic AAD"). Statistical models regressed racial/ethnic-specific logged mortality rates on state-level, one-year lagged and logged beer tax, one-year lagged and logged spirits tax, and one-year lagged government-controlled spirits sales, adjusted for mortality trends, fixed effects for state, and clustering of standard errors. Government control was significantly (P < 0.05) related to 3% reductions in Overall and non-Hispanic White mortality rates, and 4% reductions in Hispanic mortality rates from 100% chronic AAD. Tax associations were not robust. Results support that government control of spirits retail is associated with significantly lower 100% AAD from chronic causes Overall and among non-Hispanic Whites and Hispanics. Government control of spirits retail may reduce both population-level 100% chronic AAD as well as racial/ethnic disparities in 100% chronic AAD.

State-Level Alcohol Environments and Sexual Identity Disparities in Binge Drinking in the Behavioral Risk Factor Surveillance System

Purpose: Binge drinking disparities by sexual identity are well documented. Stronger alcohol policy environments reduce binge drinking in the general population. We examined whether state-level alcohol policy environments have the same association with binge drinking among lesbian, gay, and bisexual (LGB) adults as among heterosexual adults. Methods: Binge drinking, sexual identity, and demographic characteristics were extracted from the 2015 to 2018 Behavioral Risk Factor Surveillance System. The strength of the alcohol policy environment was measured by using the Alcohol Policy Scale (APS) score. We estimated the association between APS score and binge drinking by using logistic regression and included an interaction term between APS score and sexual identity. Results: The interaction between APS score and sexual identity was not significant, and findings differed between women and men. Among women, a higher APS score was associated with lower odds of binge drinking (adjusted odds ratio [aOR]: 0.96, 95% confidence interval [CI]: 0.94-0.99). Differences in binge drinking by sexual identity remained after adjusting for individual and state-level factors (e.g., the percentage of LGB adults in the state). Compared with heterosexual women, the odds of binge drinking were 43% higher (aOR: 1.43, 95% CI: 1.17-1.75) among lesbian women and 58% higher (aOR: 1.58, 95% CI: 1.40-1.79) among bisexual women. A higher APS score was not associated with binge drinking among men. Conclusion: Stronger state-level alcohol policy environments were associated with lower binge drinking among women. Lesbian and bisexual women were still more likely to engage in binge drinking compared with heterosexual women even in states with stronger alcohol policy environments.

Improving the Validity of the Behavioral Risk Factor Surveillance System Alcohol Measures

BACKGROUND

Valid measurement of alcohol use can be difficult in surveys, which are subject to biases like underreporting and differential nonresponse. Still, monitoring trends, policy impacts, disparities, and related issues all require valid individual- and state-level drinking data collected over time. Here, we propose a double-adjustment approach for improving the validity of the Behavioral Risk Factor Surveillance System (BRFSS) alcohol measures.

METHODS

Validity analyses of the 1999 to 2016 BRFSS, a general population survey of U.S. adults. Measures are aggregated to state level for N = 918 observations, single-adjusted for BRFSS methodologic changes, and double-adjusted by per capita consumption. Fixed-effects models: (i) assess predictive validity using adjusted BRFSS drink volume to predict mortality outcomes and (ii) assess outcome validity using state-level alcohol taxes to predict adjusted BRFSS volume.

RESULTS

Neither the raw nor the single-adjusted BRFSS drinking measures were related to mortality in the expected direction, while double-adjusted BRFSS volume and 5+ days were significantly positively related to mortality, as expected. Spirits and beer taxes were not related to single-adjusted BRFSS drinking in the expected direction. However, spirits and beer taxes were both significantly related to double-adjusted BRFSS volume in the expected directions.

CONCLUSIONS

Future studies should consider using the double-adjusted BRFSS measures to ensure the validity of drinking survey data in analyses where variation over time is considered.