Alcohol and Public Health: Failure and Opportunity.

Policy Points Public health science regarding alcohol consumption and problems, alcohol's role in equity and social justice, and identification of effective policy interventions has grown steadily stronger in the past 30 years. Progress on effective alcohol policies has stalled or gone backward in the United States and much of the world. Because alcohol influences at least 14 of the 17 sustainable development goals, as well as more than 200 disease and injury conditions, reducing alcohol problems should offer a platform for collaboration across public health silos but will require that public health itself respect and follow its own science.

Improving Campus Alcohol Policies Through Assessment and Scoring.

Excessive alcohol consumption is responsible for more than 1,500 deaths annually among college students, of whom more than one in three report having been drunk during the past 30 days. Campus alcohol policies offer a first line of defense against excessive alcohol use but have received little systematic attention in the research literature. The research team previously developed a taxonomy of campus alcohol policies and sanctions, ranked in order of effectiveness, and assessed the accessibility, clarity, and effectiveness of policies at 15 post-secondary educational institutions. Herein we describe the process of reporting those assessments back to the 15 institutions, providing them with recommendations and technical assistance on how to improve their policies, and then re-assessing school alcohol policies for effectiveness and clarity. Conversations with primary points of contact at each school provided further insight into the process of assessing and improving campus alcohol policies. Of the 15 schools assessed, 11 added more effective policies, and four added more effective consequences during the 2 years following receipt of reports on the assessment. Campuses have control over their own policies, and greater attention to them from researchers and practitioners could better maximize their potential for enhancing student health and safety and supporting student success.

Identities, drinking behaviors and cancer beliefs among African-American and White American adults: A qualitative analysis.

BACKGROUND: Alcohol consumption is causally linked to multiple cancers. African-Americans are at greater risk of cancer than other demographic groups and suffer more serious consequences. Awareness and knowledge of the alcohol-cancer link are low, especially among African-Americans compared to other racial/ethnic groups. This study built on the theory of identity-based motivation (TIBM) to explore how people think about alcohol consumption in relation to their social identities and beliefs about cancer. METHODS: Data come from 20 in-depth interviews with current drinkers (10 White and 10 African-American adults) in a major mid-Atlantic city in the summer of 2021, using race- and gender-concordant interviewers. An abductive and iterative approach identified salient themes about how drinkers thought about alcohol, social identities, and cancer. RESULTS: While most participants discussed alcohol use as an important part of American culture, African-American participants were more likely to discuss drinking as a way to cope with racism and other hardships. Participants also noted the need to address structural issues that would make it difficult to cut back on drinking. Both White and African-American participants talked about stressors in life that drive them to drink and make cutting back difficult, and African-American participants discussed how the location of liquor stores in their neighborhoods made alcohol too readily available. CONCLUSIONS: Insights from these interviews confirm the relevance of racial and other identities in shaping responses to alcohol-cancer messaging, and emphasize the need to consider both behavior change and policy change to create supportive environments for such changes.

Typology of Adolescents Exposed to Non-medical Cannabis Marketing and Associations with Consumption Patterns.

Latent class analysis (LCA) identified subtypes of cannabis marketing exposure among adolescents and assessed whether the classes were associated with three cannabis use outcomes: past 28-day use, poly-cannabis use, and symptoms of cannabis use disorder (CUD). Survey data were from 471 adolescents (aged 15-19 years) who lived in four states with legal non-medical cannabis in 2018. Measures included social media engagement and cannabis outcomes. LCA with robust maximum likelihood estimation identified latent classes. Chi-squared tests assessed whether empirically derived classes differed across demographics, and logistic regression tested associations with cannabis use outcomes. Three classes were identified: digitally engaged (35.5%), digitally unengaged (36.5%), and traditional (28.0%). Both digitally engaged and unengaged classes were exposed to marketing on social media platforms, but youth in the engaged class interacted with posts and brands. Class membership differed by age (χ2 = 14.89, p < 0.001) and school type, with the digitally engaged group older and not in school or in non-traditional schools (χ2 = 16.22, p=0.01). As compared to the traditional class, youth in the digitally engaged class had 10.63 times the odds of past 28-day cannabis use (95% CI: 5.25, 21.51), 7.84 times the odds of poly-cannabis use (95% CI: 3.54, 17.33), and 13.85 times the odds of symptoms of CUD (95% CI: 3.96, 48.48). Youth in the digitally engaged class had higher odds of all cannabis use behaviors than the traditional class. These findings point to the possible use of algorithmic marketing to adolescents and suggest a need for monitoring and possible restrictions on digital cannabis marketing.

Eye-tracking to examine differences in alcohol product appeal by sex among young people.

Background: Advertising of traditional alcopops contains elements that appeal to youth, especially females. Supersized alcopops are marketed differently than traditional alcopops and contain up to 5.5 standard alcoholic drinks. Young females are more likely to underestimate the alcohol content of supersized alcopops, putting them at higher risk of overconsumption. Similar to supersized alcopops, beer is packaged in large cans and in the same areas of store shelves.Objective: This study examined among young people whether supersized alcopops versus beer products disproportionately appealed to females.Methods: Eleven adolescents (13-17 years old) and 72 college students (21-26 years old) were recruited during 2019-2020. Participants viewed 19 photos of convenience store display cases containing both supersized alcopop and beer products. While viewing each image, participants were instructed to click on the beverage that looked the "coolest" (i.e. most appealing). Eye-tracking hardware and software measured the amount of time participants visually fixated on each product. Participants completed a survey to record demographic characteristics.Results: Compared to males (n=25), females (n=58) fixated on supersized alcopops for 6.8 seconds longer (95%CI 0.3,13.3). Females also had 3.7 times the odds of selecting a supersized alcopop as the product they found most appealing compared to males (95%CI 1.68,8.01), adjusting for amount of time visually fixating on supersized alcopops, which was also a significant predictor.Conclusions: Young females' strong preference for supersized alcopops is concerning given they disproportionately underestimate their potency, relative to males, and are more likely to obtain dangerously high BAC levels from consuming one or two supersized alcopops.

The Health Impact of Alcohol on American Cities: Modeling the Local Burden of Current Alcohol Use in One Jurisdiction.

Measurement of alcohol use and associated harms at the city level is often incomplete or non-existent even though such data are often critical to informing local prevention strategies. This paper models how to generate local estimates of the morbidity, mortality, and cost of current alcohol use instead of abstaining. Administrative data sources, including medical examiner records, hospital records, and police records, among others, were used to obtain local estimates of alcohol-attributable outcomes. In 2018, we used alcohol-attributable fractions and scaled national estimates to quantify the burden of current alcohol use in Baltimore, MD, in 2013. Fifty-two percent of Baltimore adults reported past 30-day drinking. There were 276 alcohol-attributable deaths in 2013, and 106 (38.4%) of these were persons other than the drinker. In 2013, current alcohol use cost $582.3 million in Baltimore City. This burden was distributed across drinkers (40.1%), persons other than the drinker (21.3%), and the government (38.6%). It is possible to quantify this burden at the local level, and these data could be used to inform evidence-based alcohol policy strategies at the local level.

Alcohol Outlet Clusters and Population Disparities.

Alcohol outlet clusters are an important social determinant of health in cities, but little is known about the populations exposed to them. If outlets cluster in neighborhoods comprised of specific racial/ethnic or economic groups, then they may function as a root cause of urban health disparities. This study used 2016 liquor license data (n = 1204) from Baltimore City, Maryland, and demographic data from the American Community Survey. We defined alcohol outlet clusters by combining SaTScan moving window methods and distances between outlets. We used multiple logistic regression to compare census block groups (CBGs) (n = 537) inside and outside of four types of outlet clusters: total, on-premise, off-premise, and LBD-7 (combined on-/off-premise). The most robust predictor of alcohol outlet cluster membership was a history of redlining, i.e., racially discriminatory lending policies. CBGs that were redlined had 7.32 times the odds of being in an off-premise cluster, 8.07 times the odds of being in an on-premise cluster, and 8.60 times the odds of being in a LBD-7 cluster. In addition, level of economic investment (marked by vacant properties) appears to be a key characteristic that separates CBGs in on- and off-premise outlet clusters. CBGs with racial/ethnic or socioeconomic advantage had higher odds of being in on-premise clusters and CBGs marked by disinvestment had higher odds of being in off-premise clusters. Off-premise clusters deserve closer examination from a policy perspective, to mitigate their potential role in creating and perpetuating social and health disparities. In addition to addressing redlining and disinvestment, the current negative effects of alcohol outlet clusters that have grown up in redlined and disinvested areas must be addressed if inequities in these neighborhoods are to be reversed.

Electronic cigarette explosion/burn and poisoning related emergency department visits, 2018-2019.

BACKGROUND: Electronic cigarette (ECIG) use has increased dramatically in recent years. Negative ECIG-related acute health effects have included explosion/burn injuries from battery failure and child ingestion/poisoning of liquid nicotine. However, there is an urgent need for continued surveillance of ECIG health effects to determine whether these outcomes change as ECIG devices and liquids rapidly evolve. This study updates national estimates of ECIG-related emergency department (ED) visits and describes the context of these injuries. METHODS: A keyword search of case narrative text was used to identify ECIG-related ED visits in the National Electronic Injury Surveillance System (NEISS) data. These cross-sectional data are designed to be weighted to provide national estimates of consumer product-related injuries treated in EDs. ECIG-related injuries were described and categorized, and sampling weights applied to model national estimates. RESULTS: From 2015 to 2019 there were an estimated 3369 ED visits from ECIG explosion/burn injuries (95% CI = 2020, 4718), and an estimated 676 visits from 2019 alone (95% CI = 315, 1036). In 2018-2019, there were an estimated 1550 cases of children <5 years old ingesting ECIG liquids (95% CI = 778, 2322). CONCLUSIONS: Despite a notable shift in the US market towards ECIG devices that use lower electrical power and disposable "pods" (e.g., JUUL), liquid chemical ingestion among young children and ECIG explosion/burn injuries persist. Improved product regulations are urgently needed to prevent negative health effects caused by ECIGs, as well as prevent their ingestion and use by children.

Underage drinkers' first experience consuming a popular brand of supersized alcopop.

BACKGROUND: Supersized alcopops are sugar sweetened beverages with high alcohol concentration; Four Loko is the most commonly consumed brand among underage drinkers. OBJECTIVES: The current study examined the prevalence and correlates of Four Loko consumption, as well as drinking location, beverage source, quantity consumed, and alcohol-related consequences among students who consumed the product before age 21. METHODS: Undergraduate drinkers (n = 1,019; 53.5% female) attending public universities in Florida, Montana, and Virginia completed a classroom survey. Multivariable logistic regression models examined first-time Four Loko experiences among students under age 21 at the time of the drinking episode (n = 336). RESULTS: Among drinkers, 46% had consumed Four Loko. The vast majority (93%) drank the product before age 21. During their first Four Loko drinking episode, 57% consumed at least one can and 10% drank two or more cans. Among underage drinkers, being male (AOR = 6.8), paying for the Four Loko (AOR = 3.1), and earlier age of alcohol initiation (AOR = 0.8) were associated with greater odds of drinking at least one can. Among underage drinkers who finished at least one can, 36% blacked out and 21% vomited. The odds of blacking out and vomiting were greater if the participant drank at least one can (AOR = 6.0, AOR = 4.0). Students in states that sold Four Loko with higher alcohol-by-volume were more likely to blackout (AOR = 2.0) and vomit (AOR = 2.5). CONCLUSIONS: Delaying the age of first alcohol use may have protective effects on supersized alcopop consumption. Increased enforcement of existing laws is needed to prevent underage access to Four Loko. Further, laws that reduce the alcohol content of Four Loko may reduce negative consequences associated with its consumption.

The Federal Trade Commission's mandated Four Loko labeling fails to facilitate accurate estimation of alcohol content by college students.

BACKGROUND: Four Loko, the leading supersized alcopop brand, is a pre-mixed alcoholic beverage containing up to 5.5 standard alcoholic drinks in a can. In 2013, the Federal Trade Commission (FTC) mandated the addition to Four Loko cans of a label indicating its alcohol content in standard drinks, presented as "alcohol per serving" and "servings per container." OBJECTIVE: The current study investigated whether college students accurately estimate the alcohol content in cans of Four Loko bearing the FTC mandated labels. METHOD: Undergraduate student drinkers (n = 833; 51.6% women) in three states (Florida, Montana, and Virginia) were provided an empty Watermelon Four Loko can and asked to determine the number of standard drinks it contained, using 12-ounce regular beer (Budweiser) equivalents. In Florida and Virginia, Watermelon Four Loko contains 4.70 standard alcoholic drinks; in Montana, it contains 3.13. RESULTS: More than 60% of Florida students and more than 70% of Virginia students underestimated Four Loko's alcohol content by one or more standard drinks, compared to 45% of Montana students. Multivariable logistic regression analysis found the following variables were associated with greater odds of underestimating Four Loko's alcohol content by one or more standard alcoholic drinks: being female (AOR = 2.2), having never seen nor heard of Four Loko (AOR = 1.9), and residing in Florida (AOR = 1.7) or Virginia (AOR = 2.8) versus Montana. CONCLUSIONS: Students were far less likely to underestimate alcohol content for 8% alcohol-by-volume (abv) cans compared to those with higher alcohol concentrations. Thus, policies restricting supersized alcopops' abv may help consumers better estimate their alcohol content.

Assessing Campus Alcohol Policies: Measuring Accessibility, Clarity, and Effectiveness.

BACKGROUND: Excessive alcohol consumption poses significant hazards to health and safety on college campuses. While substantial research exists regarding effective policies for preventing alcohol-related problems in the communities surrounding campuses, on-campus alcohol policies have received far less attention. METHODS: Official campus alcohol policies (CAPs) were retrieved from the websites of the 15 member schools of the Maryland Collaborative to Reduce College Drinking and Related Problems, a voluntary statewide collaborative. CAPs were assessed for accessibility, clarity, and effectiveness. In addition to assessing whether campuses were in compliance with federal regulations for comprehensiveness of policies, a measure of likely policy effectiveness was developed through the use of 2 Delphi panels drawing on alcohol policy researchers and on-campus and community practitioners, respectively. The panels rated 35 potential policies and 13 possible sanctions; lists of policies and sanctions were compiled primarily from what was already in existence at 1 or more member schools. RESULTS: For most campuses, the CAPs could be located within 30 seconds, but tended to be spread across multiple web pages. Language used to communicate the policies tended to be complex and above the reading level of someone with a high school education. At least half of the schools had less than half of the possible policies rated most or somewhat effective by the Delphi panels. Schools were more likely to employ the most effective sanctions, but somewhat and ineffective sanctions were also not uncommon. CONCLUSIONS: CAPs are an important element in reducing negative consequences of alcohol consumption on college campuses. A higher level of research scrutiny is warranted to understand the extent to which CAPs are associated with excessive drinking, but this research describes an evidence- and expert-informed assessment approach that colleges can use to regularly analyze and update their CAPS.

Methods for Evaluating the Association Between Alcohol Outlet Density and Violent Crime.

BACKGROUND: The objective of this analysis was to compare measurement methods-counts, proximity, mean distance, and spatial access-of calculating alcohol outlet density and violent crime using data from Baltimore, Maryland. METHODS: Violent crime data (n = 11,815) were obtained from the Baltimore City Police Department and included homicides, aggravated assaults, rapes, and robberies in 2016. We calculated alcohol outlet density and violent crime at the census block (CB) level (n = 13,016). We then weighted these CB-level measures to the census tract level (n = 197) and conducted a series of regressions. Negative binomial regression was used for count outcomes and linear regression for proximity and spatial access outcomes. Choropleth maps, partial R2 , Akaike's Information Criterion, and root mean squared error guided determination of which models yielded lower error and better fit. RESULTS: The inference depended on the measurement methods used. Eight models that used a count of alcohol outlets and/or violent crimes failed to detect an association between outlets and crime, and 3 other count-based models detected an association in the opposite direction. Proximity, mean distance, and spatial access methods consistently detected an association between outlets and crime and produced comparable model fits. CONCLUSIONS: Proximity, mean distance, and spatial access methods yielded the best model fits and had the lowest levels of error in this urban setting. Spatial access methods may offer conceptual strengths over proximity and mean distance. Conflicting findings in the field may be in part due to error in the way that researchers measure alcohol outlet density.

Price of Four Loko in Large U.S. Cities, 2018.

BACKGROUND: Supersized alcopops are flavored alcoholic beverages that contain up to 5.5 standard alcoholic drinks in a single can. Limited research suggests Four Loko-the most commonly consumed supersized alcopop by underage drinkers-is among the least expensive ready-to-drink alcohol products on the U.S. market. This is a public health concern because alcohol prices are inversely associated with consumption and related harms, particularly among youth. This study investigated Four Loko's retail price per volume of alcohol in large U.S. cities. METHODS: This study used multistage random sampling to collect data in the largest city of each state and Washington, DC. A simple random sample of 5 ZIP codes from each city was selected and entered into Four Loko's website product locator. Within ZIP codes, up to 4 stores were randomly selected and contacted by telephone. Retailers were interviewed about Four Loko in regard to: availability, volume, alcohol by volume (abv), price for 1 can, and discounts for purchasing more than 1 can. RESULTS: The sample included 344 retail stores with Four Loko in stock. Average price per standard alcoholic drink (i.e., 14 g of absolute alcohol) was $0.54 for Four Loko products. Taking into account volume, price, and discounts, an average of 17 standard alcoholic drinks could be purchased via Four Loko with $10. Adjusted analysis using linear regression showed that availability of bulk price discounts and higher abv (14% vs. 12%) were associated with lower price per drink. CONCLUSION: This study verifies that Four Loko is among the least expensive ready-to-drink alcohol available for purchase in the United States. Given that consuming a single supersized alcopop constitutes binge drinking and is therefore unsafe, regulatory agencies should consider a variety of steps to reduce the availability and abv of these products and increase their retail price in order to reduce and prevent unsafe alcohol consumption.

Pathways linking intergenerational cultural dissonance and alcohol use among Asian American youth: The role of family conflict, parental involvement, and peer behavior.

A difference in degree of acculturation between immigrant parents and children, known as intergenerational cultural dissonance (ICD), is a risk factor for adolescent alcohol use. We used path analysis with 292 Vietnamese and Cambodian adolescents from immigrant families in the United States to measure potential mediators (family conflict, parental involvement/monitoring, association with deviant peers) of the ICD-alcohol use relationship. The hypothesized model was an adequate data fit among both groups. Among Cambodian adolescents, higher ICD levels significantly predicted increased family conflict, which in turn was associated with reduced parental involvement/monitoring, increased association with deviant peers, and a subsequently higher risk of alcohol use (p < .05 for all coefficients). We also found significant indirect effects of ICD on alcohol use among Vietnamese adolescents through family conflict and parental involvement/monitoring (p < .05 for all coefficients) but not through peer behavior. For both groups, there was no direct effect of ICD on alcohol use outside these pathways. Identification of significant mediators provides potential targets for preventing alcohol use among these populations. In addition, differences in path coefficients between Vietnamese and Cambodian adolescents underscore the importance of conducting analyses stratified by Asian ethnic group.

Policy Approaches for Regulating Alcohol Marketing in a Global Context: A Public Health Perspective.

Alcohol consumption is responsible for 3.3 million deaths globally or nearly 6% of all deaths. Alcohol use contributes to both communicable and noncommunicable diseases, as well as violence and injuries. The purpose of this review is to discuss, in the context of the expansion of transnational alcohol corporations and harms associated with alcohol use, policy options for regulating exposure to alcohol marketing. We first provide an overview of the public health problem of harmful alcohol consumption and describe the association between exposure to alcohol marketing and alcohol consumption. We then discuss the growth and concentration of global alcohol corporations and their marketing practices in low- and middle-income countries, as well as in higher-income societies. We review the use and effectiveness of various approaches for regulating alcohol marketing in various countries before discussing challenges and opportunities to protect public health.

College Students' Underestimation of Blood Alcohol Concentration from Hypothetical Consumption of Supersized Alcopops: Results from a Cluster-Randomized Classroom Study.

BACKGROUND: Supersized alcopops are a class of single-serving beverages popular among underage drinkers. These products contain large quantities of alcohol. This study examines the extent to which young adults recognize how intoxicated they would become from consuming these products. METHODS: The study sample included 309 undergraduates who had consumed alcohol within the past year. Thirty-two sections of a college English course were randomized to 1 of 2 survey conditions, based on hypothetical consumption of supersized alcopops or beer of comparable liquid volume. Students were provided an empty can of 1 of the 2 beverages to help them answer the survey questions. Equation-calculated blood alcohol concentrations (BACs)-based on body weight and sex-were compared to the students' self-estimated BACs for consuming 1, 2, and 3 cans of the beverage provided to them. RESULTS: In adjusted regression models, students randomized to the supersized alcopop group greatly underestimated their BAC, whereas students randomized to the beer group overestimated it. The supersized alcopop group underestimated their BAC by 0.04 (95% confidence interval [CI]: 0.034, 0.053), 0.09 (95% CI: 0.067, 0.107), and 0.13 g/dl (95% CI: 0.097, 0.163) compared to the beer group. When asked how much alcohol they could consume before it would be unsafe to drive, students in the supersized alcopop group had 7 times the odds of estimating consumption that would generate a calculated BAC of at least 0.08 g/dl, compared to those making estimates based on beer consumption (95% CI: 3.734, 13.025). CONCLUSIONS: Students underestimated the intoxication they would experience from consuming supersized alcopops. Revised product warning labels are urgently needed to clearly identify the number of standard drinks contained in a supersized alcopop can. Moreover, regulations are needed to limit alcohol content of single-serving products.

Outlet Type, Access to Alcohol, and Violent Crime.

BACKGROUND: While there are overwhelming data supporting the association between alcohol outlet density and violent crime, there remain conflicting findings about whether on- or off-premise outlets have a stronger association. This inconsistency may be in part a result of the methods used to calculate alcohol outlet density and violent crime. This analysis uses routine activity theory and spatial access methods to study the association between access to alcohol outlets and violent crime, including type of outlet and type of crime in Baltimore, MD. METHODS: The data in this analysis include alcohol outlets from 2016 (n = 1,204), violent crimes from 2012 to 2016 (n = 51,006), and markers of social disorganization, including owner-occupied housing, median annual household income, drug arrests, and population density. The analysis used linear regression to determine the association between access to alcohol outlets and violent crime exposure. RESULTS: Each 10% increase in alcohol outlet access was associated with a 4.2% increase in violent crime exposure (ß = 0.43, 95% CI 0.33, 0.52, p < 0.001). A 10% increase in access to off-premise outlets (4.4%, ß = 0.45, 95% CI 0.33, 0.57, p < 0.001) and LBD-7 outlets (combined off- and on-premise outlets; 4.2%, ß = 0.43, 95% CI 0.33, 0.52, p < 0.001) had a greater association with violent crime than on-premise outlets (3.0%, ß = 0.31, 95% CI 0.20, 0.41, p < 0.001). CONCLUSIONS: Access to outlets that allow for off-site consumption had a greater association with violent crime than outlets that only permit on-site consumption. The lack of effective measures to keep order in and around off-premise outlets could attract or multiply violent crime.

Addressing College Drinking as a Statewide Public Health Problem: Key Findings From the Maryland Collaborative.

Excessive drinking among college students is a serious and pervasive public health problem. Although much research attention has focused on developing and evaluating evidence-based practices to address college drinking, adoption has been slow. The Maryland Collaborative to Reduce College Drinking and Related Problems was established in 2012 to bring together a network of institutions of higher education in Maryland to collectively address college drinking by using both individual-level and environmental-level evidence-based approaches. In this article, the authors describe the findings of this multilevel, multicomponent statewide initiative. To date, the Maryland Collaborative has succeeded in providing a forum for colleges to share knowledge and experiences, strengthen existing strategies, and engage in a variety of new activities. Administration of an annual student survey has been useful for guiding interventions as well as evaluating progress toward the Maryland Collaborative's goal to measurably reduce high-risk drinking and its radiating consequences on student health, safety, and academic performance and on the communities surrounding college campuses. The experiences of the Maryland Collaborative exemplify real-world implementation of evidence-based approaches to reduce this serious public health problem.