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ALCOHOL AND PUBLIC POLICY Beyond the Shadow of Prohibition PANEL ON ALTERNATIVE POLICIES AFFECTING THE PREVENTION OF ALCOHOL ABUSE AND ALCOHOLISM Mark H. Moore and Dean R. Gerstein, Editors Committee on Substance Abuse and Habitual Behavior Assembly of Behavioral and Social Sciences National Research Counci I NATIONAL ACADEMY PRESS Washington, D.C. 1981

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The National Research Council was established by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and of advising the federal government. The Council operates in accordance with general policies determined by the Academy under the au- thority of its congressional charter of 1863, which establishes the Academy as a private, nonprofit, self-governing membership corporation. The Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in the conduct of their services to the government, the public, and the scientific and engineering communities. It is administered jointly by both Academies and the Institute of Medicine. The National Academy of Engineering and the Institute of Medicine were established in 1964 and 1970, respectively, under the charter of the National Academy of Sciences. Library of Congress Cataloging in Publication Data Main entry under title: Alcohol and public policy. Includes 7 studies commissioned by the panel. 1. Alcoholism~overnment policy United States- Addresses, essays, lectures. I. Moore, Mark Harrison. II. Gerstein, Dean R. III. National Research Council (U.S.~. Panel on Alternative Policies Affecting the Prevention of Alcohol Abuse and Alcoholism. [DNLM: 1. Alcoholism Prevention and control. WM 274 P19lb] HV5292.B49 362.2'9256'0973 81-11217 ISBN 0-309-03149-4 AACR2 Available from NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Printed in the United States of America First Printing, October 1981 Second Printing, October 1988

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PANEL ON ALTERNATIVE POLICIES AFFECTING THE PREVENTION OF ALCOHOL ABUSE AND ALCOHOLISM MARK H. MOORE (Chair), John F. Kennedy School of Government, Harvard University GAIL B. ALLEN. Department of Psychiatry, St. Luke s-Roosevelt Hos- pital Center, New York D A N E . B E A U C H A M P. Department of Health Administration, School of Public Health, University of North Carolina PHILIP J. COOK, Institute of Policy Sciences, Duke University JOHN KAPEAN. School of Law, Stanford University NATHAN MACCOBY Institute for Communication Research, Stanford University DAV! D MUSTO . Child Study Center and Department of History, Yale University ROBIN ROOM. Social Research Group, School of Public Health, Uni- versity of California, Berkeley THOMAS C. SCHELEING. John F. Kennedy School of Government, Harvard University WOLFGANG SCHMIDT. Social Sciences Department, Alcoholism and Drug Addiction Research Foundation, Toronto NORMAN SCOTCH. Department of Socio-Medical Sciences and Com- munity Medicine, School of Medicine Boston University DONALD J. TREIMAN. Department of Sociology, University of Cali- fornia. Los Angeles JACQUELINE P. WISEMAN Department of Sociology. University of California San Diego DEAN R. GERSTEIN. Study Director . . .

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Preface The Panel on Alternative Policies Affecting the Prevention of Alcohol Abuse and Alcoholism was charged by its sponsor, the National Institute on Alcohol Abuse and Alcoholism (NIAAA), to produce a systematic analysis of alternative policies affecting the prevention of alcohol abuse and alcoholism. Prevention is not, of course, a new idea in the alcohol field. It has turned up with increasing frequency in recent years as an attractive way to think about an intractable issue. There are a number of recent reports from committees, both domestic (Plaut 1967, Wilkinson 1970, Joint Committee of the States 1973, Medicine in the Public Interest 1979) and international (Bruun et al. 1975, World Health Organization 1980), in which prevention ideas have had a prominent place. A chapter on prevention was included in each of the last three official reports to Congress on alcohol and health (National Institute on Alcohol Abuse and Alcoholism 1974, 1978, 1981~. Despite all this attention it seemed to us- and to those at the NIAAA and on the Committee on Substance Abuse and Habitual Behavior who chartered our project that the concept of prevention policies had not been systematically developed. The particular kinds of interventions, the nature of the arguments that could be made, and the assessment of existing evidence on the effectiveness of various instruments could all profit from sustained consideration. The panel was assembled, com- prising experts in the study of alcohol problems prevention methods used in other fields and other relevant academic disciplines to lend structure and content to this inquiry. Our concerns were not entirely abstract or academics however. In formulating ideas about prevention v

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V1 Preface policies, we sought to ground our thinking in the existing historical and institutional context. In view of the expansive territory of policies affecting prevention, we could hardly expect to cover intensively every possible track within it. We have therefore taken the role of scientific survey party: systemati- cally noting the lay of the land; describing the prominent features; ex- amining closely and marking for further attention conformations that seemed especially interesting and accessible. We have had to invent some of our survey equipment along the way. In particular, our typology of policies for modifying alcohol's effects did not come to us ready-made but was crafted over the course of writing, intensive discussion, and rewriting. The result, we hope, strikes a useful balance of the mandates to be systematic, analytical, disciplined and crisp. We have had considerable help in writing this report from seven studies commissioned by the panel, discussed at length during our de- liberations, revised by the authors, and published in this volume. Two of these studies were written to help get us under way by concisely summarizing the relevant historical and scientific background. The first of these, by Paul Aaron and David Musto, is an overview of drinking in U.S. political and cultural history, beginning with colonial times and concluding with some speculations about the possible impact of current social movements on drinking policies and practices. This paper was an important element in building the perspective of the first, historical chapter of this report and especially in tempering our understanding of the Prohibition experience. In the second paper, Dean Gerstein de- scribes the principal methodological and conceptual controversies that surround the measurement and evaluation of alcohol use and its con- sequences, including the interaction of drinking with a variety of envi- ronments: biological, physical, and social. This paper was a starting point in the development of our second chapter, on the structure of the alcohol problem. Dan Beauchamp's analysis of the closely studied 1969 Alcohol Act in Finland provides a general perspective on the strategic limits to al- cohol-related policy choices available to democratic governments. This analysis points toward the concerns involved in the transition from def- inition of the problem to specific policy proposals. In this sense, Beau- champ's work speaks to our third chapter, regarding perspectives on . . current po lcles. The papers written by Philip Cook, John Hochheimer, and David Reed address the efficacy of several of the better-known policy instru- ments that might be (and have been) used to prevent alcohol problems. Cook focuses on the effects of controlling alcoholic beverage market prices by taxation. Hochheimer analyzes the use of educational media

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Preface . . V11 and personnel (and the educational use of media and personnel) to reduce alcohol abuse. Reed discusses the use of deterrence, education, risk reduction, and mixed strategies for handling drinking-driving prob- lems. Finally, James Mosher and Joseph Mottl examine the surprisingly extensive roles of government agencies not specifically concerned with alcohol in affecting drinking behavior and consequences. These four papers were quite instrumental in developing the analyses of specific policy alternatives in chapters 4 through 6. In short, the commissioned papers, with their more extensive consid- eration of many of the points covered in our report, have enabled the report to be written more efficiently and with a broader understanding than might otherwise have been possible. While the panel does not necessarily concur in every detail of what the supporting papers have to say, we are pleased to include them, to indicate points of concurrence in the text of the report, and to encourage readers to turn to these studies for further insight into the specific areas covered. We are grateful to the many other people who have contributed to this venture. The participants in the panel's Workshop on Alcohol Pol- icies held May 15-17, 198~Kettil Bruun, Daniel Horn, H. Laurence Ross, Gerald Wilde, Joseph Gusfield, Klaus Makela, Phil Davies, and Irmgard Vogt helped to inform and shape the panel's report. Individ- ual reviewers read and constructively criticized drafts of the report. The library and administrative offices of the National Academy of Sciences provided needed assistance. In the Assembly of Behavioral and Social Sciences, David Goslin? executive director, and Eugenia Grohman, as- sociate director for reports, gave expert guidance; Christine McShane, editor, and Elaine McGarraugh, editorial assistant, polished the report and papers and prepared the volume for publication. And at NIAAA, the project management staff? especially David Promisel, provided sup- port and encouragement. This project has benefited from start to finish from the good judgment and dedication of the staff of the Committee on Substance Abuse and Habitual Behavior: Marie Clark' administrative secretary; Beverly Blakey and Charlotte Simpson, secretaries; Deborah Maloff, research associate; and the committee's study director? Peter Levison. It only remains for me to acknowledge the hard, essential work of the panel itself, and of the study director and coeditor of this volume, Dean Gerstein. MARK H. MOORE. Chair Panel on Alternative Policies Affecting the Prevention of Alcohol Abuse and Alcoholism

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Contents REPORT OF THE PANEL INTRODUCTION 1 SIMPLIFYING CONCEPTIONS OF ALCOHOL PROBLEMS AND POLICIES Governing Ideas, 8 Minority Conceptions? 12 Conclusion, 15 2 THE NATURE OF ALCOHOL PROBLEMS Effects of Drinking, 20 Underlying Patterns of Drinking Practices, 24 Definition of Drinking Practices, 24; Consumption: Quantity and Frequency, 27; Stability of Individual Drinking Practices, 39; Causes of Drinking Practices, 40 The Problem of Attributing Effects, 42 Conclusion: Avenues for Affecting Alcohol Problems, 44 3 6 16 3 PERSPECTIVES ON CURRENT ALCOHOL POLICIES 48 Current Alcohol Policies and Institutions, 48 The Prima Facie Case for Prevention, 50 The Definition of Prevention Policies, 52 Objections to Prevention Policies, 55 IX

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Categories of Prevention Policies, 58 Summary and Conclusion, 59 4 REGULATING THE SUPPLY OF ALCOHOElC BEVERAGES The Lessons of Prohibition, 62 Current Institutions and Policies, 64 The Single Distribution Theory, 66 Taxation and Prices, 68 Controlling Off-Premise Retail Sales, 73 Controlling On-Premise Sales, 75 Minimum Age Restrictions, 76 Conclusion, 78 SHAPING DRINKING PRACTICES DIRECTLY Concepts of Safer and More Appropriate Drinking, 81 Drinking Practices and the Law, 83 Drunken Driving and the Law, 83; Public Drunkenness, 87 Education, Information, and Training Programs, 89 School Education Programs, 90; Mass Media Informa- tion Campaigns, 92; Community-Based Health Informa- tion and Training, 93; Conclusions About Education, In- formation, and Training Programs, 96 Setting a Good Example: A Note on Symbolic Effects of Government Actions, 96 Conclusion, 98 6 REDUCING ENVIRONMENTAL RISK Damage in the Physical Environment, 102 Physical Safety Measures, 102; Social Safety Measures, 105 Damage in the Social Environment, 106 Victimization, 106; Public Drunkenness and the Urban Environment, 106; Deemphasizing Hostility, 107 Conclusion, 109 SUMMARY RE FE R EN C E S Contents 79 100 112 117

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Contents COMMISSI ONED PAPERS TEMPERANCE AND PROHIBITION IN AMERICA: A HISTORICAL OVERVIEW Paul Aaron and David Musto ALCOHOL USE AND CONSEQUENCES Dean R. Gerstein THE PARADOX OF ALCOHOL POLICY: THE CASE OF THE 1969 ALCOHOL ACT IN FINLAND Dan E. Beauchamp THE EFFECT OF LIQUOR TAXES ON DRINKING CIRRHOSIS, AND AUTO ACCIDENTS Philip J. Cook REDUCING ALCOHOL ABUSE: A CRITICAL REVIEW OF EDUCATIONAL STRATEGIES John L. Hochheimer REDUCING THE COSTS OF DRINKING AND DRIVING David S. Reed THE ROLE OF NONALCOHOL AGENCIES IN FEDERAL REG- ULATION OF DRINKING BEHAVIOR AND CONSEQUENCES James F. Mosher and Joseph R. Mottl BIOGRAPHICAL SKETCHES OF PANEL MEMBERS AND STAFF X1 127 182 225 255 286 336 388 459

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Tables 1. Distribution of Alcohol Consumption by Adults in the United States 2. Average Daily Consumption and Number of "Drunk Days" Per Year in a Sample of Air Force Men 3. "Drunk Days" Within Different Levels of Average Con- sumption in a Sample of Air Force Men 4. Changes in Apparent Consumption of Absolute Alcohol in 20 Countries by the Population Aged 15 Years and Over 5. Where, When, and With Whom People Drink (Drinking Contexts), by Age of Drinker 6. Alcohol Incidents by Total Consumption Level in a Sample of Air Force Men 7. Percentage of U.S. Population Experiencing Different Prob- lems Associated With Drinking, by Level of Consumption S. Contribution of Different Consuming Groups to Reported Experience of Problems 9. Ranking of 39 "Test Cases" of Alcohol Tax Increases by Net Percentage of Change in Rates of Liquor Consumption, Highway Deaths, and Cirrhosis Deaths . ~ X11 28 30 33 36 38 44 45 45 71

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F. 1gures 1. Schematic View of the Relationship Between Drinking and Consequences of Alcohol 2. Important Effects of Drinking and Policies for Dealing With Drinking 3. Relationship Between Average Daily Consumption and "Drunk Days" in a Sample of Air Force Men 4. Time Trends of U.S. Consumption of Absolute Alcohol, Cirrhosis Death Rate, and Alcoholism Death Rate in the Drinking Age Population, 183~1977 5. Reported Drinking Status of Men and Women in College and 25 Years Later 6. Schematic View of the Causal System Underlying Alcohol Problems . . . x~ 18 22 31 35 39 46

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