183
Drug and Alcohol Dependence, 25 (1990) 183- 186 Elsevier Scientific Publishers Ireland Ltd.
Science aid to policy dilemmas: implications of alcohol research to policy formulation in U.S.A. Enoeh Gordis National
InstitzLte
on Alcohol Abuse
and Alcoholism,
Rockuille, MD 20857 KL9.A.)
Introduction
Alcohol abuse and alcoholism are serious problems for the United States. An estimated 10.5 million U.S. adults exhibit some symptoms of alcoholism or alcohol dependence and an additional ‘7.2 million abuse alcohol, but do not show symptoms of dependence. Alcohol use is associated with a wide variety of diseases and disorders, including liver disease, cancer and cardiovascular problems. In the U.S., 20-40% of all hospital admissions are estimated to be related to the consequences of alcohol abuse and alcoholism. Although deaths from liver cirrhosis, the principal cause of which is alcohol abuse, have been declining among all U.S. population groups, cirrhosis of the liver caused more than 26,000 deaths and was the ninth leading cause of death in the United States in 1986. Throughout U.S. history, various public policies have been enacted by Federal, State, and local governments to prevent and reduce these and other serious consequences of alcohol abuse and alcoholism. The following is a general discussion of the types of alcohol-related policies that have been implemented in the U.S., the different factors involved in alcohol policy formulation and the contributions of scientific evidence to U.S. alcohol policy development. In addition, the role of science in the enactment of a major U.S. alcohol-related law will be discussed as an example of how scientific evidence can assist in policy decisions. 0376.8716~0/$03.50 OElsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
U.S. alcohol policies generally fall into two areas: policies that are intended to influence individual drinking practices and policies aimed at regulating the supply of alcoholic beverages. Policies to influence individual drinking patterns have included mandatory school prevention and education programs, publicly financed mass media campaigns, and State and local laws that require mandatory sentences for persons convicted of drinking and driving offenses. One recent example of a policy that is designed to increase public awareness of several specific health risks of alcohol consumption is a requirement for the placement of a health warning label on alcoholic beverage containers sold in the U.S. Recently, there has been increased interest in policies that are designed to limit access to alcohol. Policies in this category include raising the minimum drinking age; restricting the number, location, and hours of sale of alcoholic beverage sales outlets; and prohibiting the promotion of alcoholic beverages on college campuses. ‘Dram shop’ laws, or laws that hold drinking establishments and, in some cases, private hosts liable for damages resulting from a person to whom they have served alcoholic beverages, have gained attention as a means to prevent alcohol-related consequences by influencing the drinking environment. In addition, laws in some States mandate health insurance coverage for alcoholism treatment.
184
In most cases, U.S. alcohol-related policy implementation has resulted from a convergence of many factors, including scientific evidence, public perception of the extent and impact of a problem, and public advocacy for specific policies to address specific problems. By itself, science is rarely the sole basis for policy development and implementation, and should not be in a society as complex as that in the U.S. A mix of economic, religious, and political pressures also affects U.S. alcohol policy development, and in many cases these factors may be more persuasive than the best scientific evidence. However, science can contribute valuable information to the policy formulation and decision-making process. Therefore, the NIAAA has developed an ongoing role in supporting research on alcohol-related public policies to provide additional information to policymakers to aid them in deciding among policy options. Current alcohol policy research initiatives Assessing the impact of public policies on alcohol-related problems is a challenging area of alcohol research and an essential component of NIAAA’s research portfolio. Among the policy areas on which research has been undertaken or planned are changes in Federal, State and local laws and regulations governing such matters as alcohol’s availability, its price, and the minimum legal drinking age, hours and other conditions of sale, and drinking and driving. Studies that relate to public and private sector health care financing for alcoholism treatment also are a part of our research agenda. One group of policy-related studies currently underway had its genesis in the previously referred to legislation requiring health warning labels on alcoholic beverage containers. This law, passed in 1988, requires that all alcoholic beverages (beer, wine and distilled spirits) bottled on or after November 18.1989 carry a label warning the public of several significant health risks associated with alcohol use: birth defects (if alcohol is consumed during pregnancy), impairment of ability to drive a care or operate
machinery, and health problems. Its passage offers a unique opportunity to study the impact of health warning labels on influencing public knowledge, attitudes and behaviors with regard to alcohol use. To take advantage of this important research opportunity, NIAAA is funding three studies to obtain prewarning label baseline data and has issued a request for applications for research on this ‘natural experiment’. Scientific inquiry about the effectiveness of policies to regulate the supply of alcohol is another vital component of alcohol policy research. An example of this type of research is the evaluation of the impact of the minimum legal drinking age on the incidence of teenage drinking and driving. (See more detailed discussion below). The involvement of alcohol in motor vehicle crashes and in crime is also being examined. Future research topics include the impact of changes in price on problem drinking, especially among youth; the impact of differences in the availability of alcoholic beverages on problem drinking; the effects of informal drinking groups on the consumption behavior of participants; and the influence of life stressors, social resources, and coping responses on remission and relapse among alcohol abusers. In addition to its own research agenda, NIAAA encourages other governmental agencies to collect information that can be useful to the policy development process. For example, NIAAA has encouraged the U.S. Department of Labor’s Bureau of Labor Statistics (BLS), to collect detailed information on health insurance coverage for treatment of alcoholism and drug abuse. Such information has been urgently needed by policymaking bodies in their deliberations on health insurance policies and as a basis for alcohol-related health services research. Data on the coverage of alcohol/drug abuse treatment in 1988 have now been gathered by BLS and are being analyzed by NIAAA. Information on coverage in 1989 is currently being gathered. Assessing the impact of alcohol-related morbidity on hospital utilization is another area for
185
which we hope to develop scientific information useful to Federal, State, and local policy formulators. The objective of this effort will be to determine the national prevalence of alcohol abuse and alcoholism among inpatients in general, short-stay hospitals; to delineate illnesses coexisting with alcohol abuse and alcoholism in this population; and to assess the impact of coexisting illnesses on hospital resource utilization. Other areas of policy-relevant studies include a review and description of public and private sector policies bearing on liver transplants for alcoholics and a critical review of research literature on the impact of drinkingand-driving laws. Over the long term, it is anticipated these and other NIAAA policy research activities will serve to clarify policy options, refine policy-relevant research questions, and contribute to the incremental and cumulative development of knowledge in policy areas. Raising the minimum drinking age: using science as a resource in policy development Although scientific evidence is rarely the only basis for the enactment of public policy, it can be an important factor in helping policymakers to arrive at conclusions about the potential effectiveness of a policy action. This was clearly the case with respect to Federal efforts to encourage all States to adopt a minimum drinking age at twenty-one. The early 1970s (1970 to 1975) brought about a trend among the States to lower the minimum age at which an individual may purchase or possess alcohol. By the mid-1970s, highway safety statistics began to show marked increases in alcohol-related traffic deaths, particularly among young people aged 16 - 24 who were heavily over-represented among those who were dying on the highways. There also was public concern over the lack of consistency among State minimum drinking age laws, which, during the mid- to late 197Os, ranged from 18 to 21. In general, there was concern that inconsistencies in the States’ laws created incentives to cross a State’s border in order to purchase and consume alcohol in a State with a
lower minimum age, which in turn increased young persons’ risks for alcohol-related injury and death. Beginning in the mid-1970s, many States began to raise their minimum drinking ages. Studies of the impact of these changes found that raising the minimum drinking age reduced alcohol-related traffic crashes among young people affected by the law. Moreover, there was evidence that these effects persisted over several years. In 1984, the Federal government, anxious to improve highway safety, especially for teenagers, passed the Federal Uniform Drinking Age Act. This Act called for all States to raise the minimum legal age at which alcoholic beverdges could be purchased or possessed to twenty-one. The Act further specified that States which failed to establish twenty-one as their minimum drinking age within a specific time-frame would be penalized by losing a portion of their federal highway construction funds. In protest, the State of South Dakota challenged the constitutionality of the Act on the grounds that the Act (11 interfered with the States’ right under the Twenty-first Amendment to regulate the sale and distribution of alcoholic beverages; and (21was inappropriately coercive through its threat to deny the full allocation of federal highway construction funds to States which did not raise their minimum drinking ages. This case eventually was heard by the U.S. Supreme Court. (South Dakota v Dole, 19871 which upheld the authority of the Government to enact the Federal Uniform Drinking Age Act and to use federal highway construction monies as an inducement for States to set a uniform minimum drinking age. The Supreme Court’s findings were based, in large part, on the solid evidence presented to it on the relationship between drinking age and alcohol-related traffic injuries and deaths. Conclusion
Alcohol research has the potential for assisting in policy development and decisionmaking.
186
This has been shown in the example provided regarding research on the relationship between the legal age for purchasing alcohol and alcoholrelated traffic accidents. As our research base on policy issues relevant to alcohol-related problems expands, public policy advocates and
policymakers will be in a strengthened position to understand the potential impact of their actions, and to plan programs and implement public policy strategies that have the greatest chance to successfully prevent and reduce alcohol-related problems.
Drug and Alcohol Dependence, 25 (1990) 183- 186 Elsevier Scientific Publishers Ireland Ltd.
Science aid to policy dilemmas: implications of alcohol research to policy formulation in U.S.A. Enoeh Gordis National
InstitzLte
on Alcohol Abuse
and Alcoholism,
Rockuille, MD 20857 KL9.A.)
Introduction
Alcohol abuse and alcoholism are serious problems for the United States. An estimated 10.5 million U.S. adults exhibit some symptoms of alcoholism or alcohol dependence and an additional ‘7.2 million abuse alcohol, but do not show symptoms of dependence. Alcohol use is associated with a wide variety of diseases and disorders, including liver disease, cancer and cardiovascular problems. In the U.S., 20-40% of all hospital admissions are estimated to be related to the consequences of alcohol abuse and alcoholism. Although deaths from liver cirrhosis, the principal cause of which is alcohol abuse, have been declining among all U.S. population groups, cirrhosis of the liver caused more than 26,000 deaths and was the ninth leading cause of death in the United States in 1986. Throughout U.S. history, various public policies have been enacted by Federal, State, and local governments to prevent and reduce these and other serious consequences of alcohol abuse and alcoholism. The following is a general discussion of the types of alcohol-related policies that have been implemented in the U.S., the different factors involved in alcohol policy formulation and the contributions of scientific evidence to U.S. alcohol policy development. In addition, the role of science in the enactment of a major U.S. alcohol-related law will be discussed as an example of how scientific evidence can assist in policy decisions. 0376.8716~0/$03.50 OElsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
U.S. alcohol policies generally fall into two areas: policies that are intended to influence individual drinking practices and policies aimed at regulating the supply of alcoholic beverages. Policies to influence individual drinking patterns have included mandatory school prevention and education programs, publicly financed mass media campaigns, and State and local laws that require mandatory sentences for persons convicted of drinking and driving offenses. One recent example of a policy that is designed to increase public awareness of several specific health risks of alcohol consumption is a requirement for the placement of a health warning label on alcoholic beverage containers sold in the U.S. Recently, there has been increased interest in policies that are designed to limit access to alcohol. Policies in this category include raising the minimum drinking age; restricting the number, location, and hours of sale of alcoholic beverage sales outlets; and prohibiting the promotion of alcoholic beverages on college campuses. ‘Dram shop’ laws, or laws that hold drinking establishments and, in some cases, private hosts liable for damages resulting from a person to whom they have served alcoholic beverages, have gained attention as a means to prevent alcohol-related consequences by influencing the drinking environment. In addition, laws in some States mandate health insurance coverage for alcoholism treatment.
184
In most cases, U.S. alcohol-related policy implementation has resulted from a convergence of many factors, including scientific evidence, public perception of the extent and impact of a problem, and public advocacy for specific policies to address specific problems. By itself, science is rarely the sole basis for policy development and implementation, and should not be in a society as complex as that in the U.S. A mix of economic, religious, and political pressures also affects U.S. alcohol policy development, and in many cases these factors may be more persuasive than the best scientific evidence. However, science can contribute valuable information to the policy formulation and decision-making process. Therefore, the NIAAA has developed an ongoing role in supporting research on alcohol-related public policies to provide additional information to policymakers to aid them in deciding among policy options. Current alcohol policy research initiatives Assessing the impact of public policies on alcohol-related problems is a challenging area of alcohol research and an essential component of NIAAA’s research portfolio. Among the policy areas on which research has been undertaken or planned are changes in Federal, State and local laws and regulations governing such matters as alcohol’s availability, its price, and the minimum legal drinking age, hours and other conditions of sale, and drinking and driving. Studies that relate to public and private sector health care financing for alcoholism treatment also are a part of our research agenda. One group of policy-related studies currently underway had its genesis in the previously referred to legislation requiring health warning labels on alcoholic beverage containers. This law, passed in 1988, requires that all alcoholic beverages (beer, wine and distilled spirits) bottled on or after November 18.1989 carry a label warning the public of several significant health risks associated with alcohol use: birth defects (if alcohol is consumed during pregnancy), impairment of ability to drive a care or operate
machinery, and health problems. Its passage offers a unique opportunity to study the impact of health warning labels on influencing public knowledge, attitudes and behaviors with regard to alcohol use. To take advantage of this important research opportunity, NIAAA is funding three studies to obtain prewarning label baseline data and has issued a request for applications for research on this ‘natural experiment’. Scientific inquiry about the effectiveness of policies to regulate the supply of alcohol is another vital component of alcohol policy research. An example of this type of research is the evaluation of the impact of the minimum legal drinking age on the incidence of teenage drinking and driving. (See more detailed discussion below). The involvement of alcohol in motor vehicle crashes and in crime is also being examined. Future research topics include the impact of changes in price on problem drinking, especially among youth; the impact of differences in the availability of alcoholic beverages on problem drinking; the effects of informal drinking groups on the consumption behavior of participants; and the influence of life stressors, social resources, and coping responses on remission and relapse among alcohol abusers. In addition to its own research agenda, NIAAA encourages other governmental agencies to collect information that can be useful to the policy development process. For example, NIAAA has encouraged the U.S. Department of Labor’s Bureau of Labor Statistics (BLS), to collect detailed information on health insurance coverage for treatment of alcoholism and drug abuse. Such information has been urgently needed by policymaking bodies in their deliberations on health insurance policies and as a basis for alcohol-related health services research. Data on the coverage of alcohol/drug abuse treatment in 1988 have now been gathered by BLS and are being analyzed by NIAAA. Information on coverage in 1989 is currently being gathered. Assessing the impact of alcohol-related morbidity on hospital utilization is another area for
185
which we hope to develop scientific information useful to Federal, State, and local policy formulators. The objective of this effort will be to determine the national prevalence of alcohol abuse and alcoholism among inpatients in general, short-stay hospitals; to delineate illnesses coexisting with alcohol abuse and alcoholism in this population; and to assess the impact of coexisting illnesses on hospital resource utilization. Other areas of policy-relevant studies include a review and description of public and private sector policies bearing on liver transplants for alcoholics and a critical review of research literature on the impact of drinkingand-driving laws. Over the long term, it is anticipated these and other NIAAA policy research activities will serve to clarify policy options, refine policy-relevant research questions, and contribute to the incremental and cumulative development of knowledge in policy areas. Raising the minimum drinking age: using science as a resource in policy development Although scientific evidence is rarely the only basis for the enactment of public policy, it can be an important factor in helping policymakers to arrive at conclusions about the potential effectiveness of a policy action. This was clearly the case with respect to Federal efforts to encourage all States to adopt a minimum drinking age at twenty-one. The early 1970s (1970 to 1975) brought about a trend among the States to lower the minimum age at which an individual may purchase or possess alcohol. By the mid-1970s, highway safety statistics began to show marked increases in alcohol-related traffic deaths, particularly among young people aged 16 - 24 who were heavily over-represented among those who were dying on the highways. There also was public concern over the lack of consistency among State minimum drinking age laws, which, during the mid- to late 197Os, ranged from 18 to 21. In general, there was concern that inconsistencies in the States’ laws created incentives to cross a State’s border in order to purchase and consume alcohol in a State with a
lower minimum age, which in turn increased young persons’ risks for alcohol-related injury and death. Beginning in the mid-1970s, many States began to raise their minimum drinking ages. Studies of the impact of these changes found that raising the minimum drinking age reduced alcohol-related traffic crashes among young people affected by the law. Moreover, there was evidence that these effects persisted over several years. In 1984, the Federal government, anxious to improve highway safety, especially for teenagers, passed the Federal Uniform Drinking Age Act. This Act called for all States to raise the minimum legal age at which alcoholic beverdges could be purchased or possessed to twenty-one. The Act further specified that States which failed to establish twenty-one as their minimum drinking age within a specific time-frame would be penalized by losing a portion of their federal highway construction funds. In protest, the State of South Dakota challenged the constitutionality of the Act on the grounds that the Act (11 interfered with the States’ right under the Twenty-first Amendment to regulate the sale and distribution of alcoholic beverages; and (21was inappropriately coercive through its threat to deny the full allocation of federal highway construction funds to States which did not raise their minimum drinking ages. This case eventually was heard by the U.S. Supreme Court. (South Dakota v Dole, 19871 which upheld the authority of the Government to enact the Federal Uniform Drinking Age Act and to use federal highway construction monies as an inducement for States to set a uniform minimum drinking age. The Supreme Court’s findings were based, in large part, on the solid evidence presented to it on the relationship between drinking age and alcohol-related traffic injuries and deaths. Conclusion
Alcohol research has the potential for assisting in policy development and decisionmaking.
186
This has been shown in the example provided regarding research on the relationship between the legal age for purchasing alcohol and alcoholrelated traffic accidents. As our research base on policy issues relevant to alcohol-related problems expands, public policy advocates and
policymakers will be in a strengthened position to understand the potential impact of their actions, and to plan programs and implement public policy strategies that have the greatest chance to successfully prevent and reduce alcohol-related problems.
