Place

Alcohol regulation in the US is largely based on the blueprint outlined in the book Toward Liquor Control, which summarizes several basic public policy principles aimed at protecting public health and safety. One of these guiding principles is curtailing public order problems by adopting restrictions on outlet density (i.e., preventing high concentrations of retail alcohol outlets in a small area) and limits on hours and days of sale. Alcohol outlet density is a recognized environmental risk factor for excessive alcohol consumption and is associated with adverse health and safety outcomes, such as underage drinking, drunk driving^{Reference Chen, Gruenewald and Remer1} and violence,^{Reference Trangenstein2} including homicide.^{Reference Naimi3} Limiting the hours and days of sale are also known to play a role in shaping the environmental conditions around retail alcohol outlets. A 2015 systematic review concluded that decreasing the physical availability of alcohol by reducing density of outlets and reducing hours of sale for off-premise consumption (e.g., take-out stores) decreases per capita consumption and as a result reduces alcohol-related harms.^{Reference Sherk, Stockwell, Chikritzhs and Andreasson4}

The Community Preventive Services Task Force (CPSTF), an independent, nonfederal panel of public health and prevention experts, reviewed the evidence on interventions to prevent excessive alcohol consumption and recommended limiting the availability of alcohol through regulatory authority, including licensing — typically through state alcohol regulatory agencies — and local zoning processes.⁵ Additionally, the CPSTF also recommended maintaining limits on hours of sale finding that increasing hours of sale by two or more hours, particularly for on-sale establishment (i.e., bars and restaurants), was associated with increased consumption, violent crime offenses, and motor vehicle crash injuries.^{Reference Hahn, Kuzara and Elder6} Similarly, the CPSTF found harms resulting from the removal of limits on days of sale for both on- and off-premise outlets and recommended maintaining these limits to mitigate harm.⁷ However, before developing alcohol regulations and zoning policies, localities should ensure that their rules and regulations do not violate state preemption (limitation of local authority). Although limited by this doctrine, many local governments throughout the US are permitted to use their licensing and zoning/land use powers to regulate alcohol outlet density by ensuring that the placement and operations of alcohol retail outlets align with their local conditions.⁸ To assist communities, the Center on Alcohol Marketing and Youth at The Johns Hopkins Bloomberg School of Public Health created an interactive web tool that outlines each state's preemption level.^{Reference Mosher and Treffers9}

Additionally, states and localities must ensure that their rules and regulations are not arbitrary or capricious. Establishing a nexus between the regulation and the documented harm, backed by scientific evidence, is one way to mitigate legal challenges and establish fair and balanced alcohol regulations. To help communities conduct public health surveillance to assess the nexus between alcohol outlet density and related public health and safety harms, the Centers for Disease Control and Prevention created the Guide for Measuring Alcohol Outlet Density. ¹⁰

Product

Youth are more likely than adults to consume lower priced, high alcohol content products that taste sweet or flavored.^{Reference Fortunato, Siegel, Ramirez, Ross, DeJong and Albers11} Policymakers have been and should continue to regulate and restrict products with high youth appeal. “Palcohol” — a powdered alcohol approved by the Alcohol Tobacco Tax and Trade Bureau (TTB) in 2015 — is an example of successful product restriction. It was to be sold in one ounce packages with 10 percent alcohol by volume (ABV) and in four approved flavors: Rum, Vodka, Cosmopolitan, and Powderita. Palcohol was designed to be added to water to create a standard mixed drink. However, public health professionals expressed concerns that youth would be attracted to the different flavors and to the ease with which these packets could be concealed and transported.^{Reference Naimi and Mosher12} Consequently, as of September 2018, 37 states have enacted laws banning powdered alcohol.

Control jurisdictions within the US — market participants, meaning the government takes ownership of the product at some point in the business cycle, at the retail and/or wholesale levels — can also create internal administrative restrictions to prevent the sale of certain products. Many of these jurisdictions have used this authority to restrict grain alcohol, which has often occurred after public health professionals expressed concerns. Grain alcohol has high alcohol content, a low price, and is odorless and colorless, making it difficult to detect in cocktails or punches. One study found that of youth who reported drinking grain alcohol, 35.1% reported binge drinking.^{Reference Naimi, Siegel, DeJong, O'Doherty and Jernigan13} Therefore, as of October 2014, nine of 18 control jurisdictions created internal administrative restrictions: (a) banning grain alcohol >95% ABV (ID, ME, MI); (b) banning grain alcohol at an even lower ABV (WV, IA); (c) requiring it to be purchased through special order (NC, OH, UT); or (d) having partial shelf restrictions (OR, UT).^{Reference Grossman, Binakonsky and Jernigan14} Control jurisdictions have also banned products based on flavors (e.g., bubble gum or cotton candy), product design (e.g., Jell-O shots or alcohol-infused whipped cream), and product labeling/marketing (e.g., hollow candies or mason jars with fruit).

Public health advocates can also use the power of the states' Attorneys General (AGs) to bring litigation against alcohol manufacturers or to petition government agencies for product restrictions. For example, when companies began producing caffeinated alcoholic beverages (CABs) that looked like nonalcoholic energy drinks, a group of AGs became concerned. After reaching agreements with individual brand manufacturers to pull their CABs from the market, they petitioned the Food and Drug Administration (FDA) to stop the sale of these products. In 2010, the FDA sent letters to manufacturers of seven CABs stating that the products did not meet the legal standard of “generally recognized as safe.”¹⁵ As a result, these manufacturers removed the caffeine from their alcoholic products.

Although public health advocates have had successes in restricting powdered alcohol, grain alcohol, and CABs, vigilance is important as the alcohol industry is constantly creating new products. A current concern is “Multiple Fruit-Flavored Alcoholic Drinks in a Can” (MFAC).^{Reference Rossheim and Thombs16} These products are large (e.g., 23.5 ounces), with high alcohol content (12-14% ABV) and low prices. Given preliminary research, this product appears to be attractive and harmful to youth.¹⁷ It is important that the public health community continue to work with policymakers, regulators, and the state AGs to use all the tools available to regulate and restrict alcohol products particularly attractive to youth.

Promotion

The growing evidence that alcohol marketing promotes underage drinking,^{Reference Anderson18} and that underage youth drink only a limited number of alcohol brands,^{Reference Siegel19} is critical information for policymakers and regulators. Recently researchers, for the first time, examined the relationship between the placement of brand-specific alcohol advertisements in magazines and the underage youth readership of these magazines.^{Reference King20} They surveyed the patterns of advertising for 24 alcohol brands that are popular among underage youth (“youth brands”) and 656 brands that are consumed primarily by legal age adults (“adult brands”) in 49 national consumer magazines. After controlling for young adult and total readership, cost of advertising, advertising budgets, and magazine readership demographics, they found that in magazines with very high youth readership, youth alcohol brands were eight times more likely to advertise than the adult brands. This study provided strong evidence that underage youth are disproportionately exposed to such advertising, especially for brands that are popular among underage drinkers. As such, researchers concluded that alcohol companies target youth in their advertising.²¹ Unlike tobacco advertising, which is regulated by the FDA, alcohol advertising is essentially unregulated, subject only to self-administered, voluntary standards. The key criterion used in advertising decisions under these standards is that alcohol companies may not advertise their products in magazines with more than 28.4% youth readers.²²

Clearly, regulation of alcohol advertising is necessary to protect underage youth from targeting by alcohol brands, which results in disproportionate exposure to advertisements for those brands. Moving forward, (1) the Federal Trade Commission could establish mandatory regulatory standards that restrict advertising patterns that result in greater proportional youth exposure than adult exposure; (2) state AGs could demand that alcohol companies alter their advertising practices and pursue litigation against companies that fail to act; and (3) Congress could place jurisdiction over alcohol advertising in the hands of a federal agency, just as it has done for tobacco advertising.

Price

Given the short nature of this piece, the well-established impact of price on alcohol consumption is discussed only briefly here. Namely, researchers using a wide variety of methods, data, and outcome measures have concluded that “increases in the prices of alcoholic beverages lead to reductions in drinking and heavy drinking as well as in the consequences of alcohol use and abuse.”^{Reference Chaloupka, Grossman and Saffer23}