2019-Get the Facts – Alcohol – Welcome to the Massachusetts Prevention Alliance

Excessive alcohol consumption and underage drinking produces immense costs to Massachusetts in terms of health care expenses, lost productivity, and lost years of lives. Dangerous drinking cost Massachusetts over 5.6 billion dollars in 2010, equaling $861 per capita in the state – or about $1.93 for every drink sold. In 2013, underage drinking cost the citizens of Massachusetts $1.2 billion. Youth violence (homicide, suicide, aggravated assault) and traffic crashes attributable to alcohol use by underage youth in Massachusetts represent the largest costs for the state. Among teen mothers, fetal alcohol syndrome alone cost Massachusetts $20 million. Sadly, there are no taxes, fees or fines dedicated to funding underage drinking or alcohol abuse prevention in the State of Massachusetts.

According to the National Center on Addiction and Substance Abuse (CASA) at Columbia University, if substance use disorder and addiction were its own state budget category, it would rank second just behind spending on elementary and secondary education. Any revenues that stream into a state’s treasury department from alcohol sales are far dwarfed by the outcome costs of excessive alcohol consumption and underage drinking. CASA’s report constitutes “a searing indictment of the policies of government at every level that spend virtually all of the funds in this area to shovel up the wreckage of [alcoholism] and practically nothing to prevent and treat it.”

One of the most effective ways to lessen the costs associated with alcohol abuse and addiction is to prevent people from starting abusive drinking patterns. To do this, we need a paradigm shift. The products of the alcohol industry are responsible for a significant and growing proportion of the global burden of disease.

Research has shown that five key variables affect the nature and extent of alcohol problems associated with alcohol retail outlets: Number of alcohol outlets: High numbers of outlets are associated with increased alcohol problems (sometimes referred to as “outlet proliferation”). Types of alcohol outlets: Outlets such as bars and nightclubs, which have alcohol as their primary business, also create increased risks of problems. Concentration of outlets: In many communities, the total number of outlets is not excessive, but the outlets are clustered in certain neighborhoods. Over concentration is associated with increased incidence of alcohol problems, including violent assault. Locations of outlets: Retail outlets next to sensitive land uses such as schools, playgrounds or other locations where youth congregate can contribute to underage drinking problems and may detract from quality-of-life for residents nearby. Retail practices: Sales and service practices are particularly important variables. Sales to minors and intoxicated persons as well as public nuisance activities can all be reduced through responsible business practices, which can in turn be promoted through effective zoning provisions and enforcement policies. Taking comprehensive and proactive steps to plan the number and location of alcohol outlets and to regulate how they are operated, while working collaboratively with alcohol retailers, can reduce alcohol problems, enhance the community’s business environment, and contribute to overall community health and safety.

In persuading policy-makers to consider effective but unpopular alcohol policies, it might be instructive to frame the issue in terms of what we refer to here as ‘industrial epidemics’. This framing may be contrasted with more traditional approaches, which in the past have portrayed alcohol problems as the consequence of a moral failing, or as a chronic disease engendered by genetic, psychological and environmental causes. As this editorial will suggest, the notion of an industrial epidemic invites the application of public health concepts and shifts the policy focus from the ‘agent’ (i.e. alcohol) or the ‘host’ (e.g. the problem drinker) to the ‘disease vector’ (i.e. the alcohol industry and its associates), which in many ways is responsible for the exposure of vulnerable populations to the risks of alcohol.

Based on this emerging knowledge base about the nature of industrial epidemics and the self-serving tactics of many industrial corporations, what should be the public health response? First, it is clear that the response must not be limited to measures directed solely at the behavior of the affected individuals or at the health risks of the agents. It must also be directed at the corporations themselves and at the government’s authority to control exposure by limiting the supply of the agent through controls on production, delivery and availability to the individuals at risk.

Each day, our substance misuse prevention coalitions and community partners work to prevent early initiation of alcohol use and the potential for subsequent substance use disorders. I am here today to represent myself and my public health colleagues who firmly believe that public health considerations must come before business considerations when reviewing and potential creating alcohol laws in Massachusetts. Director General, Dr. Margaret Chan, of the World Health Organization, recently stated: “In the view of WHO, the alcohol industry has no role in the formulation of alcohol policies, which must be protected from distortion by commercial or vested interests.” Source: http://www.bmj.com/content/346/bmj.f1889/rr/640534

Alcohol laws and regulations have a direct effect on excessive alcohol use, including underage drinking and binge drinking rates.

Impact on health and cost to MA

Excessive alcohol use can result in harms such as motor vehicle injuries, violence, heart disease, cancer, alcohol poisoning, and poor birth outcomes. Excessive alcohol use includes binge drinking (five or more drinks per occasion for men or four or more drinks per occasion for women), heavy drinking (15 or more drinks a week for men or 8 or more drinks a week for women), and any alcohol use by pregnant women or underage youth. Source= CDC. Fact Sheets—Alcohol Use and Your Health. Accessed Nov 9, 2015

In Massachusetts, each year 1,525 deaths and 41,501 years of potential life are lost due to the harms resulting from excessive alcohol use. Source= CDC. Alcohol-Related Disease Impact (ARDI). Accessed Jun 12, 2015.

Alcohol consumption is “one of the most important known risk factors for human cancer” (source Scoccianti, C., Straif, K., & Romieu, I. (2013). Recent evidence on alcohol and cancer epidemiology. Future Oncology, 9(9), 1315-1322.) -including cancers of the female breast, head and neck, liver, stomach, and colorectum.

SOURCE International Agency for Research on Cancer (2010). “Alcohol consumption and ethyl carbamate. “ IARC Monographs on the Evaluation of Carcinogenic Risks to Humans / World Health Organization, International Agency for Research on Cancer, 96, 3–1383
Nelson, D. E., Jarman, D. W., Rehm, J., Greenfield, T. K., Rey, G., Kerr, W. C., & Naimi, T. S. (2013). Alcohol-attributable cancer deaths and years of potential life lost in the United States. American Journal of Public Health, 103(4), 641–648 Rehm, J. & Shield, K. (2014). “Alcohol consumption” in World Cancer Report 2014, Stewart, B.W. & Wild, C.P. (eds) (pp. 96-104). Lyon: IARC/World Health Organization World Cancer Research Fund/American Institute for Cancer Research (2016). Diet, nutrition, physical activity and stomach cancer. Retrieved from http://www.aicr.org/continuous-update-project/reports/stomach-cancer-report.pdf on April 21, 2016.

Prenatal alcohol exposure is the leading preventable cause of birth defects and intellectual and neurodevelopmental disabilities.source: Williams, J.F., Smith, V.C., and the Committee on Substance Abuse of the American Academy of Pediatrics (2015). Fetal Alcohol Spectrum Disorders [clinical report]. Pediatrics, 136(5).

In 2012, underage drinkers consumed 9.3% of all alcohol sold in Massachusetts, totaling $344 million in sales (in 2013 dollars). These sales provided profits of $168 million to the alcohol industry.

Produced by the Pacific Institute for Research and Evaluation (2015). Underage Drinking in Massachusetts: The Facts. Retrieved from: http://www.pire.org/documents/UDETC/cost-sheets/MA.pdf on April 18, 2017.

Annual sales of alcohol consumed by youth in Massachusetts averaged $1,370 per underage drinker. Underage drinkers were heavier consumers than adults. They drank an average of 3.7 drinks per day; in contrast, legal customers consumed only 1.8 drinks per day.

Excessive alcohol consumption cost Massachusetts over 5.6 billion dollars in 2010, equaling $861 per capita in the state – or about $1.93 for every drink sold. (source: Sacks, J. J., Gonzales, K. R., Bouchery, E. E., Tomedi, L. E., & Brewer, R. D. (2015). 2010 national and state costs of excessive alcohol consumption. American Journal of Preventive Medicine, 49(5), e73-e79

Relationship between alcohol laws, underage drinking, and the opioid epidemic

As you review the alcohol laws, you must look to the roots of opioid epidemic. Studies show a correlation between the age of first drink and and illicit drug use. Source (Hingson, R.W., Heeren, T., & Edwards, E.M. (2008). Age at drinking onset, alcohol dependence, and their relation to drug use and dependence, driving under the influence of drugs, and motor-vehicle crash involvement because of drugs. Journal of Studies on Alcohol and Drugs, Mar;69(2):192-201.) Those who began drinking earlier, were more likely to ever have used drugs or be drug dependent. Underage drinking prevention is opioid overdose prevention.

Evidenced-based laws and policies to prevent excessive and underage drinking

Years of research has shown several evidence-based alcohol policies, that if in place and enforced, would reduce excessive drinking, including underage drinking.

Tax

The most impactful is an increase of alcohol taxes. Higher cost of alcohol is associated with reduced underage drinking, and drinking and driving. Doubling alcohol taxes could reduce alcohol-related mortality by an average of 35% (source: Wagenaar AC, Tobler AL, Komro KA. Effects of alcohol tax and price policies on morbidity and mortality: a systematic review. American Journal of Public Health 2010;100(11):2270–8.)

Outlet density, hours of sale, and location

Regulating the number of places in a specific area where alcohol may be legally sold is also an effective way to prevent excessive alcohol use. Limits on number of alcohol outlets, hours of sale, and locations are all shown to reduce youth access to alcohol and excessive drinking. Source: U.S. Department of Health and Human Services. (2016) The Surgeon General’s Report on Alcohol, Drugs, and Health. Retrieved from https://addiction.surgeongeneral.gov/ on February 21, 2017.

Compliance Checks and Enforcement

Our ABCC works diligently to enforce alcohol regulations and respond to our community needs when requested. However, they are chronically underfunded. The Massachusetts ABCC has one of the lowest ratios of liquor law enforcement officers to alcohol licensees in the country. The ABCC’s lack of resources combined with multiple enforcement challenges at the local level, means that alcohol laws and regulations are consistently under-enforced. In order to effectively prevent youth access to alcohol, we need to ensure that there is enough funding to support the full-scope of the ABCC’s enforcement efforts, and to establish a consistent communication channel between local municipalities and the ABCC regarding enforcement efforts.

Mandatory responsible beverage service trainings for all alcohol servers is a common sense practice to help prevent youth access to alcohol and over-service of alcohol. Our community coalitions often work with local alcohol licensees to offer in-person RBS trainings and the alcohol servers report believing that RBS training should be a state requirement. Best practices in mandatory RBS training are in-person trainings. Mandatory RBS training is also a law, that when combined with 8 other laws, would reduce underage drinking and driving. The other two laws are: server 21 and fake id support services for the retailer. Server 21 laws would prohibit anyone under 21 to be able to serve or sell alcohol. Fake id support services would make it a requirement for licensees to report a fake id. Now, in MA, retailers cannot legally take a fake id from someone. (Source: surgeon general report)

Alcohol advertising

Years of research clearly indicates that alcohol advertising has a significant influence on youth and adult attitudes about drinking which contributes to the normalized culture of underage drinking as a “rite of passage.” The World Health Organization, the American Public Health Association, and the American Academy of Pediatrics among many others have released statements about the harms of alcohol ad exposure on youth. The statements include recommendations to monitor the alcohol industry’s practices in exposing youth to advertising, and to make policies to restrict the alcohol industry “advertising and product placement in venues in which more than 10 percent of the audience is children and adolescents.” Source: http://www.camy.org/resources/fact-sheets/policy-recommendations/

Public Health Review necessary

Finally, we ask for a Public Health Review of any and all modifications of the Massachusetts alcohol laws. While we outlined several best practice alcohol laws and practices, if other laws are either removed or put in place, there could be unintended public health implications. Therefore, we respectfully request a Public Health Review of any recommended alcohol laws.

Other policies to consider:

Minimum sales/server age of 21
Specifics of potential taxes
Requirement to ID everyone regardless of age
Keeping restrictions on volume discounts and minimum mark-ups
Limiting out-of-state licenses for those under 25 or 30 (just like the Garden and Fenway do already) in order to limit consumption by our under 21/college-age population.

Editor’s note: Information on this page is sourced in large part from the following article: https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1360-0443.2007.01900.x

Note i. Sacks, J. J., Gonzales, K. R., Bouchery, E. E., Tomedi, L. E., & Brewer, R. D. (2015). 2010 national and state costs of excessive alcohol consumption. American Journal of Preventive Medicine, 49(5), e73 e79.