Alcohol is a favorite psychoactive substance of Canadians. It is also a leading risk factor for death and disability, playing a causal role in a broad spectrum of health and social issues. Alcohol: No Ordinary Commodity is a collaborative, integrative review of the scientific literature. This paper describes the epidemiology of alcohol use and current state of alcohol policy in Canada, best practices in policy identified by the third edition of Alcohol: No Ordinary Commodity, and the implications for the development of effective alcohol policy in Canada. Best practices - strongly supported by the evidence, highly effective in reducing harm, and relatively low-cost to implement - have been identified. Measures that control affordability, limit availability, and restrict marketing would reduce population levels of alcohol consumption and the burden of disease attributable to it.

Introduction: The Dietary Guidelines for Americans, 2020–2025 recommends non-drinking or no more than 2 drinks for men or 1 drink for women in a day. However, even at lower levels, alcohol use increases the risk for certain cancers. This study estimated mean annual alcohol-attributable cancer deaths and the number of cancer deaths that could potentially be prevented if all U.S. adults who drank in excess of the Dietary Guidelines had instead consumed alcohol to correspond with typical consumption of those who drink within the recommended limits. Methods: Among U.S. residents aged ≥20 years, mean annual alcohol-attributable cancer deaths during 2020–2021 that could have been prevented with hypothetical reductions in alcohol use were estimated. Mean daily alcohol consumption prevalence estimates from the 2020–2021 Behavioral Risk Factor Surveillance System, adjusted to per capita alcohol sales to address underreporting of drinking, were applied to relative risks to calculate population-attributable fractions for cancers that can occur from drinking alcohol. Analyses were conducted during February–April 2023. Results: In the U.S., an estimated 20,216 cancer deaths were alcohol-attributable/year during 2020–2021 (men: 14,562 [72.0%]; women: 5,654 [28.0%]). Approximately 16,800 deaths (83% of alcohol-attributable cancer deaths, 2.8% of all cancer deaths) could have been prevented/year if adults who drank alcohol in excess of the Dietary Guidelines had instead reduced their consumption to ≤2 drinks/day for men or ≤1 drink/day for women. Approximately 650 additional deaths could have been prevented annually if men consumed 1 drink/day, instead of 2. Conclusions: Implementing evidence-based alcohol policies (e.g., increasing alcohol taxes, regulating alcohol outlet density) to decrease drinking could reduce alcohol-attributable cancers, complementing clinical interventions. © 2023

Deaths from causes fully attributable to alcohol use have increased during the past 2 decades in the United States, particularly from 2019 to 2020, concurrent with the onset of the COVID-19 pandemic. However, previous studies of trends have not assessed underlying causes of deaths that are partially attributable to alcohol use, such as injuries or certain types of cancer. CDC's Alcohol-Related Disease Impact application was used to estimate the average annual number and age-standardized rate of deaths from excessive alcohol use in the United States based on 58 alcohol-related causes of death during three periods (2016-2017, 2018-2019, and 2020-2021). Average annual number of deaths from excessive alcohol use increased 29.3%, from 137,927 during 2016-2017 to 178,307 during 2020-2021; age-standardized alcohol-related death rates increased from 38.1 to 47.6 per 100,000 population. During this time, deaths from excessive alcohol use among males increased 26.8%, from 94,362 per year to 119,606, and among females increased 34.7%, from 43,565 per year to 58,701. Implementation of evidence-based policies that reduce the availability and accessibility of alcohol and increase its price (e.g., policies that reduce the number and concentration of places selling alcohol and increase alcohol taxes) could reduce excessive alcohol use and alcohol-related deaths.

BACKGROUND AND AIMS: Injuries often involve alcohol, but determining the proportion caused by alcohol is difficult. Several approaches have been used to determine the causal role of alcohol, but these methods have not been compared directly with one another. Such a comparison would be useful for understanding the strengths and comparability of different approaches. This study compared estimates of average annual alcohol-attributable deaths in the United States from injuries during 2015-19 using a blood alcohol concentration (BAC) method compared with a population attributable fraction (PAF) approach. METHODS: For the BAC method, we used a direct method involving the proportion of decedents with a high blood alcohol concentration (BAC; e.g. ≥ 0.10%). For the PAF approach, we compared the use of unadjusted survey data with average consumption data adjusted using alcohol sales data to account for underreporting and also accounting for the underreporting of binge drinking. Survey data were from the Behavioral Risk Factor Surveillance System and mortality data were from the National Vital Statistics System. RESULTS: The number of alcohol-attributable injury deaths using the direct method (48 516 deaths annually) was similar to that using PAF methods (47 879 deaths annually), but only when alcohol use measures were adjusted using alcohol sales data. Furthermore, estimates were similar for cause-specific categories of deaths, including non-motor vehicle unintentional injuries and motor vehicle crashes. Among PAF methods, excessive drinking accounted for 38.3% of injury deaths using unadjusted survey data, but 64.8% of injury deaths using adjusted data. CONCLUSIONS: Estimates of alcohol-attributable injury deaths from a direct method and from a population attributable fraction method that adjusts for alcohol use based on alcohol sales data appear to be comparable.

IMPORTANCE: Alcohol consumption is a leading preventable cause of death in the US, and death rates from fully alcohol-attributable causes (eg, alcoholic liver disease) have increased in the past decade, including among adults aged 20 to 64 years. However, a comprehensive assessment of alcohol-attributable deaths among this population, including from partially alcohol-attributable causes, is lacking. OBJECTIVE: To estimate the mean annual number of deaths from excessive alcohol use relative to total deaths among adults aged 20 to 64 years overall; by sex, age group, and state; and as a proportion of total deaths. DESIGN, SETTING, AND PARTICIPANTS: This population-based cross-sectional study of mean annual alcohol-attributable deaths among US residents between January 1, 2015, and December 31, 2019, used population-attributable fractions. Data were analyzed from January 6, 2021, to May 2, 2022. EXPOSURES: Mean daily alcohol consumption among the 2 089 287 respondents to the 2015-2019 Behavioral Risk Factor Surveillance System was adjusted using national per capita alcohol sales to correct for underreporting. Adjusted mean daily alcohol consumption prevalence estimates were applied to relative risks to generate alcohol-attributable fractions for chronic partially alcohol-attributable conditions. Alcohol-attributable fractions based on blood alcohol concentrations were used to assess acute partially alcohol-attributable deaths. MAIN OUTCOMES AND MEASURES: Alcohol-attributable deaths for 58 causes of death, as defined in the Centers for Disease Control and Prevention's Alcohol-Related Disease Impact application. Mortality data were from the National Vital Statistics System. RESULTS: During the 2015-2019 study period, of 694 660 mean deaths per year among adults aged 20 to 64 years (men: 432 575 [66.3%]; women: 262 085 [37.7%]), an estimated 12.9% (89 697 per year) were attributable to excessive alcohol consumption. This percentage was higher among men (15.0%) than women (9.4%). By state, alcohol-attributable deaths ranged from 9.3% of total deaths in Mississippi to 21.7% in New Mexico. Among adults aged 20 to 49 years, alcohol-attributable deaths (44 981 mean annual deaths) accounted for an estimated 20.3% of total deaths. CONCLUSIONS AND RELEVANCE: The findings of this cross-sectional study suggest that an estimated 1 in 8 total deaths among US adults aged 20 to 64 years were attributable to excessive alcohol use, including 1 in 5 deaths among adults aged 20 to 49 years. The number of premature deaths could be reduced with increased implementation of evidenced-based, population-level alcohol policies, such as increasing alcohol taxes or regulating alcohol outlet density.

INTRODUCTION: Alcohol is a leading contributor to liver disease, however, estimating the proportion of liver disease deaths attributable to alcohol use can be methodologically challenging. METHODS: We compared three approaches for estimating alcohol-attributable liver disease deaths (AALDD), using the USA as an example. One involved summing deaths from alcoholic liver disease and a proportion from unspecified cirrhosis (direct method); two used population attributable fraction (PAF) methodology, including one that adjusted for per capita alcohol sales. For PAFs, the 2011-2015 Behavioral Risk Factor Surveillance System and per capita sales from the Alcohol Epidemiologic Data System were used to derive alcohol consumption prevalence estimates at various levels (excessive alcohol use was defined by medium and high consumption levels). Prevalence estimates were used with relative risks from two meta-analyses, and PAFs were applied to the 2011-2015 average annual number of deaths from alcoholic cirrhosis and unspecified cirrhosis (using National Vital Statistics System data) to estimate AALDD. RESULTS: The number of AALDD was higher using the direct method (28 345 annually) than the PAF methods, but similar when alcohol prevalence was adjusted using per capita sales and all alcohol consumption levels were considered (e.g. 25 145 AALDD). Using the PAF method, disaggregating non-drinkers into lifetime abstainers and former drinkers to incorporate relative risks for former drinkers yielded higher AALDD estimates (e.g. 27 686) than methods with all non-drinkers combined. DISCUSSION AND CONCLUSIONS: Using PAF methods that adjust for per capita sales and model risks for former drinkers yield more complete and possibly more valid AALDD estimates.

OBJECTIVE: Self-reported alcohol consumption in U.S. public health surveys covers only 30%-60% of per capita alcohol sales, based on tax and shipment data. To estimate alcohol-attributable harms using alcohol-attributable fractions, accurate measures of total population consumption and the distribution of this drinking are needed. This study compared methodological approaches of adjusting self-reported survey data on alcohol consumption to better reflect sales and assessed the impact of these adjustments on the distribution of average daily consumption (ADC) levels and the number of alcohol-attributable deaths. METHOD: Prevalence estimates of ADC levels (i.e., low, medium, and high) among U.S. adults who responded to the 2011-2015 Behavioral Risk Factor Surveillance System (BRFSS; N = 2,198,089) were estimated using six methods. BRFSS ADC estimates were adjusted using the National Alcohol Survey, per capita alcohol sales data (from the Alcohol Epidemiologic Data System), or both. Prevalence estimates for the six methods were used to estimate average annual alcohol-attributable deaths, using a population-attributable fraction approach. RESULTS: Self-reported ADC in the BRFSS accounted for 31.3% coverage of per capita alcohol sales without adjustments, 36.1% using indexed-BRFSS data, and 44.3% with National Alcohol Survey adjustments. Per capita sales adjustments decreased low ADC prevalence estimates and increased medium and high ADC prevalence estimates. Estimated alcohol-attributable deaths ranged from approximately 91,200 per year (BRFSS unadjusted; Method 1) to 125,200 per year (100% of per capita sales adjustment; Method 6). CONCLUSIONS: Adjusting ADC to reflect total U.S. alcohol consumption (e.g., adjusting to 73% of per capita sales) has implications for assessing the impact of excessive drinking on health outcomes, including alcohol-attributable death estimates.

Complementary foods and beverages (CFB) are key components of an infant's diet in the second 6 months of life. This manuscript summarizes nutrition and feeding practices examined by the 2020 Dietary Guidelines Advisory Committees during the CFB life stage. Breastfeeding initiation is high (84%), but exclusive breastfeeding at 6 months (26%) is below the Healthy People 2030 goal (42%). Most infants (51%) are introduced to CFB sometime before 6 months. The primary mode of feeding (i.e., human milk fed [HMF]; infant formula or mixed formula and human milk fed [FMF]) at the initiation of CFB is associated with the timing of introduction and types of CFB reported. FMF infants (42%) are more likely to be introduced to CFB before 4 months compared to HMF infants (19%). Different dietary patterns, such as higher prevalence of consumption and mean amounts, were observed including fruit, grains, dairy, proteins, and solid fats. Compared to HMF infants of the same age, FMF infants consume more total energy (845 vs. 631 kcal) and protein (22 vs. 12 g) from all sources, and more energy (345 vs. 204 kcal) and protein (11 vs. 6 g) from CFB alone. HMF infants have a higher prevalence of risk of inadequate intakes of iron (77% vs. 7%), zinc (54% vs. <3%), and protein (27% vs. <3%). FMF infants are more likely to have early introduction (<12 months) to fruit juice (45% vs. 20%) and cow's milk (36% vs. 24%). Dietitians and nutritional professionals should consider tailoring their advice to caregivers on dietary and complementary feeding practices, taking into account the primary mode of milk feeding during this life stage to support infants' nutrient adequacy. National studies that address the limitations of this analysis, including small sample sizes and imputed breast milk volume, could further refine findings from this analysis.

Excessive alcohol use is a leading cause of preventable death in the United States (1) and costs associated with it, such as those from losses in workplace productivity, health care expenditures, and criminal justice, were $249 billion in 2010 (2). CDC used the Alcohol-Related Disease Impact (ARDI) application* to estimate national and state average annual alcohol-attributable deaths and years of potential life lost (YPLL) during 2011-2015, including deaths from one's own excessive drinking (e.g., liver disease) and from others' drinking (e.g., passengers killed in alcohol-related motor vehicle crashes). This study found an average of 95,158 alcohol-attributable deaths (261 deaths per day) and 2.8 million YPLL (29 years of life lost per death, on average) in the United States each year. Of all alcohol-attributable deaths, 51,078 (53.7%) were caused by chronic conditions, and 52,921 (55.6%) involved adults aged 35-64 years. Age-adjusted alcohol-attributable deaths per 100,000 population ranged from 20.8 in New York to 53.1 in New Mexico. YPLL per 100,000 population ranged from 631.9 in New York to 1,683.5 in New Mexico. Implementation of effective strategies for preventing excessive drinking, including those recommended by the Community Preventive Services Task Force (e.g., increasing alcohol taxes and regulating the number and concentration of alcohol outlets), could reduce alcohol-attributable deaths and YPLL.(†).

Each year, excessive drinking accounts for one in 10 deaths among U.S. adults aged 20-64 years (1), and approximately 90% of adults who report excessive drinking* binge drink (i.e., consume five or more drinks for men or four or more drinks for women on a single occasion) (2). In 2015, 17.1% of U.S. adults aged >/=18 years reported binge drinking approximately once a week and consumed an average of seven drinks per binge drinking episode, resulting in 17.5 billion total binge drinks, or 467 total binge drinks per adult who reported binge drinking (3). CDC analyzed 2011-2017 Behavioral Risk Factor Surveillance System (BRFSS) data to assess trends in total annual binge drinks per adult who reported binge drinking in the United States overall and in the individual states. The age-adjusted(dagger) total annual number of binge drinks per adult who reported binge drinking increased significantly from 472 in 2011 to 529 in 2017. Total annual binge drinks per adult who reported binge drinking also increased significantly from 2011 to 2017 among those aged 35-44 years (26.7%, from 468 to 593) and 45-64 years (23.1%, from 428 to 527). The largest percentage increases in total binge drinks per adult who reported binge drinking during this period were observed among those without a high school diploma (45.8%) and those with household incomes <$25,000 (23.9%). Strategies recommended by the Community Preventive Services Task Force( section sign) for reducing excessive drinking (e.g., regulating alcohol outlet density) might reduce binge drinking and related health risks.

Drinking alcohol during pregnancy can cause fetal alcohol spectrum disorders (FASDs), including birth defects that involve central nervous system impairment, behavioral disorders, and impaired intellectual development, which can lead to difficulties with school and employment. A recent study in four U.S. communities found a 1.1%-5.0% prevalence of FASDs among first-grade students (1). Drinking during pregnancy might also be a risk factor for other adverse pregnancy and birth outcomes, including miscarriage and stillbirth (2). CDC estimated the prevalence of self-reported current drinking (at least one alcohol drink in the past 30 days) and binge drinking (consuming four or more drinks on at least one occasion in the past 30 days) among pregnant women aged 18-44 years, using 2015-2017 data from the Behavioral Risk Factor Surveillance System (BRFSS). Current drinking and binge drinking in the past 30 days were reported by 11.5% and 3.9% of pregnant women, respectively. Among pregnant women who binge drink, the average frequency of binge drinking in the past 30 days was 4.5 episodes, and the average intensity of binge drinking (the average largest number of drinks reported consumed on any occasion among binge drinkers) was 6.0 drinks. Increased implementation of evidence-based community-level and clinic-level interventions, such as universal alcohol screening and brief counseling in primary and prenatal care, could decrease the prevalence of drinking during pregnancy, which might ultimately reduce the prevalence of FASDs and other adverse pregnancy and birth outcomes.

Limited information exists about the effectiveness of interventions to enforce laws prohibiting alcohol sales to intoxicated patrons in licensed establishments. New Mexico Behavioral Risk Factor Surveillance System data were used to evaluate an intervention on binge drinking intensity in licensed (eg, bars) versus unlicensed (eg, homes) locations. The proportion of binge drinkers in licensed locations who consumed 8 or more drinks on a binge drinking occasion decreased from 42.1% in 2004-2005 to 22.6% in 2007-2008 (adjusted odds ratio, 0.4; 95% confidence interval, 0.2-0.9), while the proportion in unlicensed locations was essentially unchanged. Enhanced enforcement of overservice laws may reduce excessive drinking in licensed establishments.

INTRODUCTION: Binge drinking (four or more drinks for women, five or more drinks for men on an occasion) accounts for more than half of the 88,000 U.S. deaths resulting from excessive drinking annually. Adult binge drinkers do so frequently and at high intensity; however, there are known disparities in binge drinking that are not well characterized by any single binge-drinking measure. A new measure of total annual binge drinks was used to assess these disparities at the state and national levels. METHODS: Behavioral Risk Factor Surveillance System 2015 data (analyzed in 2016) were used to estimate the prevalence, frequency, intensity, and total binge drinks among U.S. adults. Total annual binge drinks was calculated by multiplying annual binge-drinking episodes by binge-drinking intensity. RESULTS: In 2015, a total of 17.1% of U.S. adults (37.4 million) reported an annual average of 53.1 binge-drinking episodes per binge drinker, at an average intensity of 7.0 drinks per binge episode, resulting in 17.5 billion total binge drinks, or 467.0 binge drinks per binge drinker. Although binge drinking was more common among young adults (aged 18-34 years), half of the total binge drinks were consumed by adults aged >/=35 years. Total binge drinks per binge drinker were substantially higher among those with lower educational levels and household incomes than among those with higher educational levels and household incomes. CONCLUSIONS: U.S. adult binge drinkers consume about 17.5 billion total binge drinks annually, or about 470 binge drinks/binge drinker. Monitoring total binge drinks can help characterize disparities in binge drinking and help plan and evaluate effective prevention strategies.

Excessive alcohol use accounted for an average of one in 10 deaths among working-age adults (aged 20-64 years) in the United States each year during 2006-2010, and cost the United States $223.5 billion in 2006. Binge drinking, defined as consuming four or more drinks for women or five or more drinks for men on an occasion, was responsible for more than half of these deaths and three fourths of the economic costs. Binge drinking also is responsible for many health and social problems, including alcohol poisoning. Yet, approximately 38 million U.S. adults report binge drinking an average of four times per month, and consume an average of eight drinks per binge episode. Most binge drinkers (90%) are not alcohol dependent.

INTRODUCTION: Excessive alcohol consumption is responsible for 88,000 deaths annually and cost the United States $223.5 billion in 2006. It is often assumed that most excessive drinkers are alcohol dependent. However, few studies have examined the prevalence of alcohol dependence among excessive drinkers. The objective of this study was to update prior estimates of the prevalence of alcohol dependence among US adult drinkers. METHODS: Data were analyzed from the 138,100 adults who responded to the National Survey on Drug Use and Health in 2009, 2010, or 2011. Drinking patterns (ie, past-year drinking, excessive drinking, and binge drinking) were assessed by sociodemographic characteristics and alcohol dependence (assessed through self-reported survey responses and defined as meeting ≥3 of 7 criteria for dependence in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). RESULTS: Excessive drinking, binge drinking, and alcohol dependence were most common among men and those aged 18 to 24. Binge drinking was most common among those with annual family incomes of $75,000 or more, whereas alcohol dependence was most common among those with annual family incomes of less than $25,000. The prevalence of alcohol dependence was 10.2% among excessive drinkers, 10.5% among binge drinkers, and 1.3% among non-binge drinkers. A positive relationship was found between alcohol dependence and binge drinking frequency. CONCLUSION: Most excessive drinkers (90%) did not meet the criteria for alcohol dependence. A comprehensive approach to reducing excessive drinking that emphasizes evidence-based policy strategies and clinical preventive services could have an impact on reducing excessive drinking in addition to focusing on the implementation of addiction treatment services.

BACKGROUND: Binge drinking (≥4 drinks for women; ≥5 drinks for men, per occasion) is responsible for more than half of the estimated 80,000 U.S. deaths annually and three-quarters of the $223.5 billion in costs in 2006. Binge drinking prevalence is assessed more commonly than binge drinking intensity (i.e., number of drinks consumed per binge episode). Risk of binge drinking-related harm increases with intensity, and thus it is important to monitor. The largest number of drinks consumed is assessed in health surveys, but its usefulness for assessing binge intensity is unknown. PURPOSE: To assess the agreement between two potential measures of binge drinking intensity: the largest number of drinks consumed by binge drinkers (maximum-drinks) and the total number of drinks consumed during their most recent binge episode (drinks-per-binge). METHODS: Data were analyzed from 7909 adult binge drinkers from 14 states responding to the 2008 Behavioral Risk Factor Surveillance System (BRFSS) binge drinking module. Mean and median drinks-per-binge from that module were compared to mean and median maximum-drinks. Analyses were conducted in 2010-2011. RESULTS: Mean (8.2) and median (5.9) maximum-drinks were strongly correlated with mean (7.4) and median (5.4) drinks-per-binge (r=0.57). These measures were also strongly correlated across most sociodemographic and drinking categories overall and within states. CONCLUSIONS: The maximum-drinks consumed by binge drinkers is a practical method for assessing binge drinking intensity and thus can be used to plan and evaluate Community Guide-recommended strategies for preventing binge drinking (e.g., increasing the price of alcoholic beverages and regulating alcohol outlet density).

CONTEXT: Excessive alcohol consumption is the third-leading cause of preventable death in the U.S. This systematic review is one in a series exploring effectiveness of interventions to reduce alcohol-related harms. EVIDENCE ACQUISITION: The focus of this review was on studies evaluating the effects of the privatization of alcohol retail sales on excessive alcohol consumption and related harms. Using Community Guide methods for conducting systematic reviews, a systematic search was conducted in multiple databases up to December 2010. Reference lists of acquired articles and review papers were also scanned for additional studies. EVIDENCE SYNTHESIS: A total of 17 studies assessed the impact of privatizing retail alcohol sales on the per capita alcohol consumption, a well-established proxy for excessive alcohol consumption; 9 of these studies also examined the effects of privatization on the per capita consumption of alcoholic beverages that were not privatized. One cohort study in Finland assessed the impact of privatizing the sales of medium-strength beer (MSB) on self-reported alcohol consumption. One study in Sweden assessed the impact of re-monopolizing the sale of MSB on alcohol-related harms. Across the 17 studies, there was a 44.4% median increase in the per capita sales of privatized beverages in locations that privatized retail alcohol sales (interquartile interval: 4.5% to 122.5%). During the same time period, sales of nonprivatized alcoholic beverages decreased by a median of 2.2% (interquartile interval: -6.6% to -0.1%). Privatizing the sale of MSB in Finland was associated with a mean increase in alcohol consumption of 1.7 liters of pure alcohol per person per year. Re-monopolization of the sale of MSB in Sweden was associated with a general reduction in alcohol-related harms. CONCLUSIONS: According to Community Guide rules of evidence, there is strong evidence that privatization of retail alcohol sales leads to increases in excessive alcohol consumption.

CONTEXT: Dram shop liability holds the owner or server(s) at a bar, restaurant, or other location where a patron, adult or underage, consumed his or her last alcoholic beverage responsible for harms subsequently inflicted by the patron on others. Liability in a state can be established by case law or statute. Overservice laws prohibit the sale of alcoholic beverages to intoxicated patrons drinking in on-premises retail alcohol outlets (i.e., premises where the alcohol is consumed where purchased); enhanced enforcement of these laws is intended to ensure compliance by premises personnel. Both of these interventions are ultimately designed to promote responsible beverage service by reducing sales to intoxicated patrons, underage youth, or both. This review assesses the effectiveness of dram shop liability and the enhanced enforcement of overservice laws for preventing excessive alcohol consumption and related harms. EVIDENCE ACQUISITION: Studies assessing alcohol-related harms in states adopting dram shop laws were evaluated, as were studies assessing alcohol-related harms in regions with enhanced overservice enforcement. Methods previously developed for systematic reviews for the Guide to Community Preventive Services were used. EVIDENCE SYNTHESIS: Eleven studies assessed the association of state dram shop liability with various outcomes, including all-cause motor vehicle crash deaths, alcohol-related motor vehicle crash deaths (the most common outcome assessed in the studies reviewed), alcohol consumption, and other alcohol-related harms. There was a median reduction of 6.4% (range of values 3.7% to 11.3% reduction) in alcohol-related motor vehicle fatalities associated with the presence of dram shop liability in jurisdictions where premises are licensed. Other alcohol-related outcomes also showed a reduction. Only two studies assessed the effects of enhanced enforcement initiatives on alcohol-related outcomes; findings were inconsistent, some indicating benefit and others none. CONCLUSIONS: According to Community Guide rules of evidence, the number and consistency of findings indicate strong evidence of the effectiveness of dram shop laws in reducing alcohol-related harms. It will be important to assess the possible effects of legal modifications to dram shop proceedings, such as the imposition of statutes of limitation, increased evidentiary requirements, and caps on recoverable amounts. According to Community Guide rules of evidence, evidence is insufficient to determine the effectiveness of enhanced enforcement of overservice laws for preventing excessive alcohol consumption and related harms.

BACKGROUND: Binge drinking accounts for more than half of the 79,000 deaths due to excessive drinking in the U.S. each year. In 2006, the Behavioral Risk Factor Surveillance System (BRFSS) lowered the threshold for defining binge drinking among women from ≥5 drinks to ≥4 drinks per occasion, in accordance with national recommendations. PURPOSE: To assess changes in binge-drinking prevalence among women. METHODS: The relative and absolute change in binge drinking among U.S. adult women was assessed using pooled BRFSS data from the 2 years before (2004-2005) and after (2006-2007) the implementation of the new gender-specific definition. Analyses were conducted in 2008-2009. RESULTS: Binge-drinking prevalence among women increased 2.6 percentage points (from 7.3% in 2004-2005 to 9.9% in 2006-2007), a 35.6% relative increase. The percentage of women who reported consuming exactly 4 drinks in 2006 (3.6%) was similar to the increase in the prevalence of binge drinking among women that was observed from 2005 to 2006 (absolute change=2.9 percentage points). CONCLUSIONS: The new gender-specific definition of binge drinking significantly increased the identification of women drinking at dangerous levels. The change in prevalence among women was primarily due to the change in the definition and not to actual changes in drinking behavior. The new gender-specific definition of binge drinking can increase the usefulness of this measure for public health surveillance and support the planning and implementation of effective prevention strategies (e.g., increasing alcohol excise taxes).

Local, state, and national laws and policies that limit the days of the week on which alcoholic beverages may be sold may be a means of reducing excessive alcohol consumption and related harms. The methods of the Guide to Community Preventive Services were used to synthesize scientific evidence on the effectiveness for preventing excessive alcohol consumption and related harms of laws and policies maintaining or reducing the days when alcoholic beverages may be sold. Outcomes assessed in 14 studies that met qualifying criteria were excessive alcohol consumption and alcohol-related harms, including motor vehicle injuries and deaths, violence-related and other injuries, and health conditions. Qualifying studies assessed the effects of changes in days of sale in both on-premises settings (at which alcoholic beverages are consumed where purchased) and off-premises settings (at which alcoholic beverages may not be consumed where purchased). Eleven studies assessed the effects of adding days of sale, and three studies assessed the effects of imposing a ban on sales on a given weekend day. The evidence from these studies indicated that increasing days of sale leads to increases in excessive alcohol consumption and alcohol-related harms and that reducing the number of days that alcoholic beverages are sold generally decreases alcohol-related harms. Based on these findings, when the expansion of days of sale is being considered, laws and policies maintaining the number of days of the week that alcoholic beverages are sold at on- and off-premises outlets in local, state, and national jurisdictions are effective public health strategies for preventing excessive alcohol consumption and related harms.

Local, state, and national policies that limit the hours that alcoholic beverages may be available for sale might be a means of reducing excessive alcohol consumption and related harms. The methods of the Guide to Community Preventive Services were used to synthesize scientific evidence on the effectiveness of such policies. All of the studies included in this review assessed the effects of increasing hours of sale in on-premises settings (in which alcoholic beverages are consumed where purchased) in high-income nations. None of the studies was conducted in the U.S. The review team's initial assessment of this evidence suggested that changes of less than 2 hours were unlikely to significantly affect excessive alcohol consumption and related harms; to explore this hypothesis, studies assessing the effects of changing hours of sale by less than 2 hours and by 2 or more hours were assessed separately. There was sufficient evidence in ten qualifying studies to conclude that increasing hours of sale by 2 or more hours increases alcohol-related harms. Thus, disallowing extensions of hours of alcohol sales by 2 or more should be expected to prevent alcohol-related harms, while policies decreasing hours of sale by 2 hours or more at on-premises alcohol outlets may be an effective strategy for preventing alcohol-related harms. The evidence from six qualifying studies was insufficient to determine whether increasing hours of sale by less than 2 hours increases excessive alcohol consumption and related harms.

AIMS: Assess long-term trends of the correlation between alcohol sales data and survey data. DESIGN: Analyses of state alcohol consumption data from the US Alcohol Epidemiologic Data System based on sales, tax receipts or alcohol shipments. Cross-sectional, state annual estimates of alcohol-related measures for adults from the US Behavioral Risk Factor Surveillance System using telephone surveys. SETTING: United States. Participants State alcohol tax authorities, alcohol vendors, alcohol industry (sales data) and randomly selected adults aged > or = 18 years 1993-2006 (survey data). MEASUREMENTS: State-level per capita annual alcohol consumption estimates from sales data. Self-reported alcohol consumption, current drinking, heavy drinking, binge drinking and alcohol-impaired driving from surveys. Correlation coefficients were calculated using linear regression models. FINDINGS: State survey estimates of consumption accounted for a median of 22% to 32% of state sales data across years. Nevertheless, state consumption estimates from both sources were strongly correlated with annual r-values ranging from 0.55-0.71. State sales data had moderate-to-strong correlations with survey estimates of current drinking, heavy drinking and binge drinking (range of r-values across years: 0.57-0.65; 0.33-0.70 and 0.45-0.61, respectively), but a weaker correlation with alcohol-impaired driving (range of r-values: 0.24-0.56). There were no trends in the magnitude of correlation coefficients. CONCLUSIONS: Although state surveys substantially underestimated alcohol consumption, the consistency of the strength of the association between sales consumption and survey data for most alcohol measures suggest both data sources continue to provide valuable information. These findings support and extend the distribution of consumption model and single distribution theory, suggesting that both sales and survey data are useful for monitoring population changes in alcohol use.

A systematic review of the literature to assess the effectiveness of alcohol tax policy interventions for reducing excessive alcohol consumption and related harms was conducted for the Guide to Community Preventive Services (Community Guide). Seventy-two papers or technical reports, which were published prior to July 2005, met specified quality criteria, and included evaluation outcomes relevant to public health (e.g., binge drinking, alcohol-related crash fatalities), were included in the final review. Nearly all studies, including those with different study designs, found that there was an inverse relationship between the tax or price of alcohol and indices of excessive drinking or alcohol-related health outcomes. Among studies restricted to underage populations, most found that increased taxes were also significantly associated with reduced consumption and alcohol-related harms. According to Community Guide rules of evidence, these results constitute strong evidence that raising alcohol excise taxes is an effective strategy for reducing excessive alcohol consumption and related harms. The impact of a potential tax increase is expected to be proportional to its magnitude and to be modified by such factors as disposable income and the demand elasticity for alcohol among various population groups.

BACKGROUND: Binge drinking (consuming five or more drinks during a drinking occasion) is responsible for more than half of the 79,000 annual deaths due to excessive drinking in the U.S. Although studies show a strong dose-response relationship between the intensity of binge drinking (i.e., the number of drinks consumed per binge episode) and adverse outcomes, there are no population-based studies assessing this measure. PURPOSE: This study aims to analyze population-based data from a module of questions on binge drinking among U.S. adults to assess the number of drinks consumed by binge drinkers and the associated independent risk factors for consuming more drinks. METHODS: Data were analyzed from 14,143 adult binge drinkers who responded to the Behavioral Risk Factor Surveillance System binge drinking module in 2003 and 2004. Total drinks were calculated by summing the total number of beer, wine, and liquor-containing drinks consumed during a respondents' most recent binge drinking episode. RESULTS: Binge drinkers consumed an average of 8.0 drinks (median 6) during their most recent binge drinking episode; 70.0% of binge drinkers consumed six or more drinks, and 38.4% consumed eight or more drinks. Men consumed more drinks during their last binge episode than women (M=8.3 vs 7.0, median=7 vs 6), and those aged 18-34 years consumed more drinks than those aged >34 years for both men and women. Independent risk factors for consuming eight or more drinks included being male; being aged <35 years; being other than white race/ethnicity; having less education; not being married; binge drinking three or more times in the past 30 days; and drinking mostly beer. CONCLUSIONS: Most adult binge drinkers drink in excess of the five-drink threshold defining this risky behavior. The intensity of binge drinking should be monitored regularly by health agencies to improve surveillance and to better assess the impact of interventions designed to reduce binge drinking and its consequences.

The density of alcohol outlets in communities may be regulated to reduce excessive alcohol consumption and related harms. Studies directly assessing the control of outlet density as a means of controlling excessive alcohol consumption and related harms do not exist, but assessments of related phenomena are indicative. To assess the effects of outlet density on alcohol-related harms, primary evidence was used from interrupted time-series studies of outlet density; studies of the privatization of alcohol sales, alcohol bans, and changes in license arrangements-all of which affected outlet density. Most of the studies included in this review found that greater outlet density is associated with increased alcohol consumption and related harms, including medical harms, injury, crime, and violence. Primary evidence was supported by secondary evidence from correlational studies. The regulation of alcohol outlet density may be a useful public health tool for the reduction of excessive alcohol consumption and related harms.

BACKGROUND: Although binge drinking is strongly associated with alcohol-impaired driving, little is known about the prevalence of or risk factors for driving after binge drinking. PURPOSE: The purpose of this study was to assess the prevalence of, and risk factors for, driving during or shortly after a specific binge drinking episode. METHODS: The data were analyzed in 2007 and 2008 from 14,085 adults from 13 states in 2003 and 14 states in 2004 who reported binge drinking and answered an additional series of questions about binge drinking behaviors as part of the Behavioral Risk Factor Surveillance System survey. Binge drinking was defined as the consumption of five or more drinks during a drinking occasion. RESULTS: Overall, 11.9% of binge drinkers drove during or within 2 hours of their most recent binge drinking episode. Those drinking in licensed establishments (bars, clubs, and restaurants) accounted for 54.3% of these driving episodes. Significant independent risk factors for driving after binge drinking included male gender (AOR = 1.75); being aged 35-54 or > or = 55 years compared to 18-34 years (AOR = 1.58 and 2.37, respectively); and drinking in bars or clubs compared to drinking in the respondent's home (AOR = 7.81). Drivers who drank most of their alcohol in licensed establishments consumed an average of 8.1 drinks, and 25.7% of them consumed > or = 10 drinks. CONCLUSIONS: Because binge drinking and subsequent driving were common in establishments licensed to sell alcohol, and because licensing is conditional on responsible beverage service practices (i.e., not selling to intoxicated people), efforts to prevent impaired driving should focus on enforcing responsible beverage service in licensed establishments.