This paper compares alcohol policies under debate in U.S. state legislatures with policies that have been the focus of research attention. We reviewed the research literature to identify empirical studies of each policy and types of outcome variables analysed. The two most evaluated alcohol control policies are the minimum legal drinking age and excise tax. Eight other policies had 20 or more studies evaluating them. The remaining alcohol policies received little attention in the research literature. Alcohol consumption and traffic crashes were the most frequent outcomes used in alcohol policy studies. Most studies evaluated policy changes at the state or national level, with few studies of local or institutional policies. During 1997 some 463 alcohol control bills were introduced at state legislatures. Many specific alcohol policies under debate in state legislatures have little research evidence to guide policy decision-making, pointing to areas where future research is needed.
The consumption of alcoholic beverages is associated with a variety of social and health problems (Baker et al., 1992; Hayward et al., 1992; Roizen, 1982, 1992; Leigh, 1990; Stall et al., 1986). Furthermore, the public reports high levels of concern about such problems and supports a wide range of regulatory and programmatic efforts to reduce alcohol-related damage (Wagenaar & Streff, 1990; Giesbrecht & Greenfield, in press; Wagenaar et al., in press). As a result, cities, states or provinces, and national governments regularly debate, enact, and implement numerous changes in alcohol policy. Although there is a sizable literature on the effects of certain alcohol policies, such as minimum drinking age and alcohol taxes, many other dimensions of alcohol policy have rarely been studied. The objective of the current study was to compare alcohol policy topics under debate in state legislatures across the U.S. with alcohol policy topics that have been the focus of research attention. Gaps between the extant research literature and current legislative debates illustrate research opportunities for further studies needed to meet the information needs of policymakers.
Dimensions of alcohol policy
We categorized 36 specific categories of alcohol control policies by the mechanism by which they affect drinking behavior, such as whether they affect: (1) how, when, and where alcohol is sold, (2) where and when alcohol is consumed, (3) the price of alcohol, (4) the broader social environment surrounding alcohol use, (5) how existing policies are enforced, and (6) how underage youths obtain alcohol (see Table 1). The 36 policy areas may also be differentiated by whether they can be implemented at national, state, local, or institutional levels. Some policies, such as warning labels on alcohol products, can be implemented only on a national level, since alcohol products are produced in a variety of states and transported across state lines. Other policies, such as server training, can occur at all four levels. National, state, and local governments can mandate that all alcohol servers in their jurisdictions participate in a server-training program. An individual alcohol establishment could have an institutional policy requiring all servers in that establishment to participate in a training program, even without any public policy requiring such training.
Identification of policy studies
We identified policy evaluation studies by: (1) reviewing five previous research reviews (Ashley & Rankin, 1988; Moskowitz, 1989; Toomey et al., 1993; Wagenaar, 1993; Edwards et al., 1994) and (2) searching the ETOH and Current Contents electronic databases of alcohol literature for empirical studies using key alcohol policy terms.^ The review articles included many studies conducted and published in journals in the 1960s, 1970s, and early 1980s. The search of the ETOH bibliographic database included studies published since the early 1960s and was restricted to journal articles only; searches on Current Contents included all journal articles since 1994. We acknowledge that some relevant studies may have been missed in this search process; however, we believe the identified studies are indicative of the overall literature. The literature search produced 506 policy evaluation studies across the 36 policy categories. Some individual papers reported evaluations of multiple alcohol policies and thus were counted multiple times in this total. Some studies also assessed multiple outcomes. We categorized study outcome measures into seven categories, including: (1) mediating factors or process components of specific policies, (2) attitudes, knowledge, or awareness, (3) alcohol consumption, (4) traffic crashes and related drink-driving indicators, (5) other unintentional injuries, (6) intentional injuries such as those resulting from homicides, suicides, and assaults, and (7) other alcohol-related problems such as alcohol dependence and liver cirrhosis.
Measurement of U.S. state
State legislative activity during the 1997 legislative session on each alcohol policy issue was measured through a policy tracking system developed by the University of Minnesota Alcohol Epidemiology Program in collaboration with the Health Policy Tracking Service of the National Conference oi State Legislatures. Staff of the National Conference of State Legislatures reviewed data from the StateNet electronic database of introduced bills across the 50 states and categorized the contents according to alcohol policy topics include( in the bill. Because the 1997 data reported here are based on our initial year of alcohol policy tracking, they may not include all possible alcohol policy bills introduced and enacted. More-detailed alcohol policy tracking data for 1998 1999 and 2000 are being collected by research staff at the University of Minnesota Alcohol Epidemiology Program; see www.epi.umn.edu/alcohol for the latest alcohol policy legislation database.
Number of studies by policy
The most studied alcohol policy is the minimum legal drinking age (MLDA), with 120 studies assessing this policy (Table 1). The second most studied policy is alcohol excise tax, with 92 studies. Thirty-two studies were identified that assessed amount and effects of general exposure to alcohol advertising, and 34 assessed the effects of TV/radio advertising specifically. Four other policies-warning labels on products, restricting types of alcohol outlets, privatization, and density of alcohol outlets-had more than 20 studies each.
Other than these eight alcohol policies, all other alcohol policies have received little, if any, scientific research attention. Nine policies have no research evaluations available at all: restrictions on outlet location, server licensing, consumption restrictions in public places, restrictions on open alcohol containers in cars, restrictions on alcohol sponsorship, administrative penalties for noncompliant alcohol outlets, restrictions on open house assemblies, keg registration, and enhancement of driver's license. An additional 12 policies had only one to five studies evaluating them. Seven policies were somewhat better evaluated, having six to 20 studies in the literature.
Most of the extant research literature on alcohol policy is in four of the six policy domains: affecting how, when, and where alcohol is sold; affecting the price of alcohol; affecting the social environment; and affecting underage access. Only six studies assessed policies affecting where and when alcohol is consumed or those affecting enforcement mechanisms. The dearth of studies on policy implementation and enforcement is notable, given other literature (for example, from the traffic safety area) that shows the central importance of enforcement in affecting the magnitude of policy effectiveness (Ross, 1992).
Although there was considerable research coverage of four policy domains, coverage varied considerably by specific policy within each category. For policies affecting youths' access to alcohol, evaluation was limited to a single policy: minimum legal drinking age. In contrast, multiple specific policies in the categories "how, when, and where alcohol is sold," "price of alcohol" and "social environment" have been evaluated.
Number of studies by outcome measure
Since alcohol is associated with numerous diverse health and social problems, it is important that scientists and decisionmakers understand the effects of alcohol control policies across alcohol-related problems. A given alcohol policy may be highly effective in reducing one type of problem but ineffective in addressing another problem. A policy that is effective in decreasing multiple problems (even if the decrease is modest) may be of more interest to policy makers than a policy that affects only one specific problem. Therefore we analyzed the extant research literature by outcome measure.
Alcohol consumption is the most common outcome measure examined (229 studies). Among policies that have been evaluated, most have at least a few studies that assessed effects on alcohol consumption. This is not surprising, given that alcohol control policies are often implemented in an effort to change the rate or pattern of alcohol consumption. Changes in alcohol-related problems are unlikely to occur in the absence of changes in consumption. In addition, measures of alcohol consumption are readily available through sales data and individual-level surveys.
The second most commonly analyzed outcome measure is traffic crashes and related drink-driving measures (121 studies). Because traffic crashes are one of the leading causes of death, particularly for young people, traffic crashes have been given a high priority in studies of effects of alcohol control policies. Many of the policy studies using traffic crashes as an outcome measure were evaluations of the minimum legal drinking age (48 of 121). As with consumption data, traffic crash data have been readily available to researchers. With the development of the Fatality Analysis Reporting System in 1975, researchers have been able to assess effects of policies on fatal crashes. Researchers also have available a reasonable proxy for alcohol-related crashes: single-vehicle nighttime crashes, the majority of which involve alcohol (NHTSA, 1998).
Alcohol-specific data sources or proxies have not been as readily available for other alcohol-related problems. This is reflected in the small number of studies that have assessed other types of alcohol-related problems. We identified only six policy studies using measures of unintentional injuries other than traffic crashes (e.g., falls, fires, drownings, recreational injuries). We found 34 studies that examined intentional-injury outcomes. Finally, 84 policy studies examined other alcohol-related problems, including health, crime, school, family, and other problem indicators.
Twenty-six studies assessed effects of alcohol policies on attitudes, awareness, and knowledge of the general public. Most of these studies evaluated the U.S. policy mandating warning labels on alcohol containers. Assessment of changes on these outcome measures is appropriate for this alcohol policy, since the primary goal of the warning labels was to increase awareness of alcohol-related problems.
A few studies assessing effects of server-training programs evaluated changes in servers' attitudes and knowledge following participation in a training program. However, because the ultimate goal of server-training policies is to alter the attitudes and behavior of the customers, not simply of the servers, we placed these studies in the "mediators/processes" category.
The mediators/processes category was the third largest in terms of number of studies. Studies evaluating a wide array of alcohol policies fell into this category. Studies of policy mediators and processes are critical to understanding why policies are or are not effective and to understand how the effectiveness of policies could be improved. For example, if studies find that server-training programs do not alter serving practices, it is unlikely that server-training policies will change drinking patterns or alcohol-related problems. The minimum legal drinking age is the most well-studied alcohol policy; we know it has lowered drinking rates and traffic crashes among youth (Wagenaar, 1993). Yet many youths are still drinking. Follow-up research assessed whether MLDA laws were being enforced (Wagenaar & Wolfson, 1994), the sources youths were using to obtain alcohol (Wagenaar et al., 1996), and effectiveness of community mobilization strategies to reduce youths' access to alcohol (Holder, 1997; Wagenaar et al., 1999; Wagenaar et al., 2000).
In addition to using research to improve policy and intervention effectiveness, studies of mediators/processes are critical for refinement and testing of theory. If specific links in causal models of alcohol problems and theories of change are supported by the data in one context, the foundation is built for the design and testing of more effective interventions in other areas. Ultimately, science advances by the gradual building of useful theories supported in multiple contexts by empirical tests. Understanding not only the effectiveness of alternative interventions, but also their mechanisms of effect through studies of mediators and processes, contributes directly to improved theory and improved prevention practice.
Number of studies by policy implementation level
The state of current research evidence is not equally distributed across policy implementation levels (national, state, local, institutional; Table 2). The largest number of studies were focused on state-level policies (204 of the 506 total), with national policies receiving the second most research attention (74 studies). Local and institutional policies have received little research attention. There are several possible reasons for this skewed distribution of research. The most obvious is that policies are not all equally likely to be implemented across the levels. Some policies, such as excise taxes, are typically under national or state jurisdiction, for example, and are rarely the focus of local action. Controlling for the level at which a given policy can be implemented reveals that the distribution is less skewed. Twenty-seven percent of federal policies have received some research attention, compared with 53% of state, 33% of local, and 25% of institutional policies.
Caution is warranted here. For many studies it was difficult to determine what level of policy was being assessed based on information the authors provided in their original papers or reports. As a result, many studies could not be categorized by policy level. For example, several studies relate alcohol outlet densities to outcome indicators, and the density of outlets may have been the result of a state-level or a local-level policy or, as is frequently the case in the U.S., of both.
Number of studies by level of legislative activity
In total, we identified 463 alcohol control bills that were introduced during the 1997 state legislative sessions (Table 2). Of these, 148 were enacted. The most legislative activity occurred around alcohol policies that affect how, when, and where alcohol is sold, with 229 bills introduced and 86 passed. We also observed a large amount of legislative activity for policies affecting the price of alcohol and the social environment. Little activity was observed in 1997 for policies affecting where and when alcohol is consumed, enforcement mechanisms, or underage access to alcohol.
Identification of alcohol policy legislative activity is important, since it shows that many states are taking action around a diverse set of alcohol issues, and we have little or no research evidence to guide policy decision-making. Some examples: Forty-eight states introduced and 12 enacted new legislation regarding restricting locations of alcohol outlets, yet we found no studies in the research literature addressing this topic. Twenty-one states introduced and five states passed new legislation regarding social-host provision of alcoholic beverages, yet we found only one study in the literature addressing this issue. Eleven states introduced and eight enacted legislation on administrative (as opposed to criminal) penalties for violating alcohol regulations, yet we found no studies of administrative penalties in the literature. Finally, 12 states introduced and one state enacted bills regarding keg registration, yet we found no studies in the scientific literature addressing this issue. In summary, it is clear that policy makers are currently forced to address numerous alcohol policy issues without the benefit of scientific research on their possible effects.
Our review and analyses of the current state of knowledge regarding alcohol policy research reveal several clear gaps in what is known and numerous avenues where additional research could fruitfully be pursued. For only a few alcohol policy topics is the research evidence extensive-for example, excise taxes/price and legal drinking age. Even for these topics, however, many research questions remain unanswered, most notably What are their effects on alcohol-related problems beyond drinking behavior and traffic crashes? For other policy issues there is a moderate amount of evidence in the literature-for example, privatization of distribution systems, density of outlets, server training, and advertising. For other alcohol policy issues there is little or no research in the peer-- reviewed scientific literature.
There are many opportunities for further research. First, studies of the specific types of alcohol policies being adopted by nations, localities and institutions are needed. Such studies include: (1) rates and patterns of alcohol control policy and enactment across jurisdictions and across time, (2) legal analyses identifying the nature of policies enacted, (3) information on policy implementation and enforcement, and (4) the effects of other factors on policy adoption and diffusion. Second, studies of a much more diverse set of alcohol policies are needed. Most alcohol policies currently under debate and being enacted across the U.S. do not have a scientific research base available to inform public policy decision-making. Research findings can influence policy makers' decisions about policy implementation (Davis & Howdenchapman, 1996). Some policy makers may ignore research findings that do not support their positions, but if the relevant research is not available, no policy makers will even have the option of factoring in research findings during the decision-making process. Third, studies of local alcohol control policies are particularly lacking, despite growing attention to and enactment of such ordinances. Fourth, alcohol policy evaluations examining a much broader set of outcomes-beyond alcohol consumption and traffic crashes-are needed. To increase the likelihood of researchers expanding the outcomes used in their research, governments and institutions need to work together to develop systems for maintaining quality databases for other indicators of alcohol-related problems. Fifth, the scientific community needs continual encouragement to take maximum advantage of natural experiments with alternative alcohol policies, using creative research designs to obviate the limits of researcher control over policy change decisions and implementation. Funding agencies should encourage additional studies of such natural experiments using diverse methods and outcomes measures.
For Current Contents, all searches combined with [AND (alcohol* OR liquor*)]
Key: * = truncation
(tax OR taxes OR prices OR price); ((manager* OR management OR server OR servers) and (liabilit* OR practice* OR training)); (dram shop); (social host liability); (social provider*); (compliance check*); ((licens*) & (enforcement OR fee* OR youth)); administrative penalt*; privatiz* OR monopol*; distribut* & (sale* OR industry* OR ban* OR beverage control); beverage control; (outlet OR outlets OR store OR stores OR bars OR bar OR establishment* OR restaurant* OR hotel* OR pub OR pubs) and (density OR densities OR type OR types OR number* OR location*); gas* station*; ((day* OR hour* OR ban* OR restrict* OR Sunday*) & (sale* OR extend* OR closing OR trading)); (social availability); (legal availability); (open house assembl*); (warning label*); (health warning*); (content label*); (community event*); (community celebration*); (happy hour*); (liquor by the drink); stadium*; park*; (public drinking) OR (drinking in public place* OR public place*); (open container*); (home deliver*); (keg registration); (school OR schools) & (drinking OR alcohol* OR liquor) & (policy OR rule* OR regulation* OR ban* OR restrict*); classes of alcohol; beverage classes; driver* license*; advertis* & (television OR radio OR traffic OR restrict* OR children* OR ban OR bans) OR billboard* OR sponsorship*; (minimum age OR drinking age OR purchase age OR legal age OR MDA OR MLDA) OR ((teen* OR adolescen* OR young OR college* OR youth* OR student* OR underage* OR minor*) AND (sale* OR enforce* OR deterrence* OR avail* OR access* OR crackdown OR ID OR identification OR compliance)).
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BY ALEXANDER C. WAGENAAR AND TRACI L. TOOMEY
AUTHORS' NOTE: An earlier version of this paper was presented at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Extramural Scientific Advisory Board Meeting on Prevention, Washington, DC, October 21-22, 1998. We wish to thank Kathleen Lenk for assistance in identifying studies and coding data. This study was supported in part by the Robert Wood Johnson Foundation and the National Institute on Alcohol Abuse and Alcoholism.
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