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Public health policy refers to laws, regulations, and other mechanisms by which government seeks to influence individual health-related behavior. The role of science in public health policy development ranges from decisive to limited, and science has the potential to serve at least three functions in relation to public health policy: 1) to reveal the existence or magnitude of a problem, 2) to facilitate the evaluation of policy options, and 3) to evaluate the effectiveness of existing policies.
Scientific research can bring a public health problem to light. Policymakers and others may develop health policies in an effort to address it. This happened when science revealed the links between alcohol and cirrhosis, drinking and traffic crashes, and alcohol consumption and fetal defects.
Alcohol-related cirrhosis. Before the 1970's, cirrhosis in the alcoholic was believed to arise from nutritional deficiencies rather than from alcohol itself. Studies showed that chronic administration of alcohol to animals in the presence of adequate nutrition can lead to signs of cirrhosis (1). It was estimated that about 30 percent of alcoholics develop cirrhosis, and that the prevalence of cirrhosis is related to the duration of heavy drinking (2).
By revealing the link between alcohol and cirrhosis, science paved the way for policies aimed at cirrhosis treatment and prevention. For example, the U.S. Public Health Service's goals for the year 2000 include a reduction of cirrhosis deaths by approximately one-third. To achieve this goal, the Public Health Service suggested a policy of intensifying efforts to reduce heavy drinking patterns (3).
Drinking and driving. In the early 1970's, there was a trend among States to lower the minimum age at which a person could legally purchase or possess alcoholic beverages (minimum legal drinking age, MLDA). Research on highway safety subsequently showed marked increases in alcohol-related traffic deaths, particularly among persons aged 16 to 24.
In 1980, traffic crashes in the United States resulted in more than 51,000 deaths, almost half of which involved persons who had consumed alcohol. About one-quarter of those alcohol-involved fatal crashes involved drivers aged 16 to 21, although this age group constitutes only 13 percent of all drivers (4). Moreover, drivers under 25 caused more than 40 percent of alcohol-involved fatal crashes. In part because of such research, legislation raising the MLDA to 21 in all States was developed, debated, and passed.
Effects of alcohol on the fetus. In 1973, the term "fetal alcohol syndrome" was introduced to describe a pattern of birth defects observed in children born to alcoholic mothers. Research confirmed that alcohol is a teratogen (5).
Educational efforts led to increased public awareness of the dangers of drinking while pregnant. In 1981, the Surgeon General recommended abstinence during pregnancy. As a result of research and education, legislation was enacted in 1988 requiring all alcoholic beverages to carry a label warning the public about health risks associated with alcohol, specifically including birth defects (Public Law 100-690).
Research can provide policymakers and others with evidence as to which policies are most likely to achieve their desired goals. For example, health care policy development may be guided by research on the influence of price on alcohol consumption, a d on the effect of insurance coverage for alcoholism treatment on the cost of health care.
Effect of price on alcohol consumption. Researchers are investigating the effect of excise taxes on alcohol consumption and associated public health problems (6). Cook (7) studied the impact of 39 changes in State taxes on distilled spirits between 1960 and 1975. In 30 of the 39 instances, sales of distilled spirits fell after the tax increase. Reduced sales were accompanied by reduced traffic fatalities.
Research on price by Grossman and colleagues (8) and Coate and Grossman (9) examined whether the young heaviest drinkers would be affected by price policies that target the population as a whole. They analyzed factors affecting beer consumption by youths based on data from nationwide health surveys. They found that higher prices for beer were associated with a lower frequency of beer consumption among youth and that the difference was more pronounced for heavier consumers (one to seven drinks per week) than for lighter consumers (less than one drink per week). Research by Laixuthai and Chaloupka (10), using computer simulation techniques, produced results consistent with these findings. These findings are significant for policy development because they provide scientific data for evaluating the effect of a policy option.
Researchers are studying the implications of such policy options as equalizing the taxes on beer, wine, and distilled spirits based on their alcohol content; setting alcohol taxes high enough to match the social costs incurred as a result of alcohol abuse; and raising taxes to offset the effects of inflation (11,6). A subject for further research is the possibility that the effects of price on alcohol consumption are not the same for all groups of drinkers.
Effect of health insurance for alcoholism treatment. Studies on the effectiveness and cost-effectiveness of alcoholism treatment can contribute to the evaluation of health care policy proposals. For example, there are generally more limitations on health insurance coverage for alcohol and other drug abuse treatment than for other illnesses (12,13). Yet research suggests that alcoholism treatment leads to reduced need for other health care services and reduced overall medical costs (14,15). One study (14) reviewed claims filed with an employee health plan from 1974 to 1987. Of 3,729 alcoholics who filed claims, 3,068 received alcoholism treatment. The total health care costs of treated alcoholics, including the cost of alcoholism treatment, declined by 23 to 55 percent from their highest pretreatment levels. The posttreatment costs for alcoholics were 24 percent lower than comparable costs for untreated aloholics.
Another issue is that certain health care reform policies might narrow treatment options for individual patients. However, preliminary research (reviewed in 16) has demonstrated the importance of matching the type and setting of alcoholism treatment to the needs of individual patients. Results of this study may help determine the effect of individualized patient-treatment matching on treatment effectiveness and cost, thereby potentially influencing health policy development.
Research may provide data for evaluating public health policies after they are enacted. For example, have warning labels, an increased MLDA, and access to liver transplantation for alcoholics had the intended effects? Because research and public health policy continually influence each other, such findings may have implications for future policy and program development.
Warning labels. Research regarding the effectiveness of warning labels is inconclusive. Surveys of changes in attitudes that might be attributable to the warning labels found little evidence of change in the perceived seriousness of drinking during pregnancy. Also, the proportion of respondents perceiving that driving after five or more drinks was "very dangerous" fell from 87 percent in 1989 to 79 percent in 1991. However, the proportion of respondents who reported having seen the warning label is low, standing at 35 percent of all adults in the summer of 1991 (17,18).
Some alcohol-related behavior, as opposed to attitudes about drinking, may have changed coincident with the introduction of the warning labels. In recent studies, the proportion of respondents reporting that they had decided not to drive because they had too much to drink increased from 35 percent in 1989 to 43 percent in 1991 (17,18). Among women of childbearing age, the proportion who reported limiting their drinking because of concern about health problems rose from 18 percent in 1989 to 25 percent in 1990 and 28 percent in 1991. However, other risky behaviors related to the warning labels had not changed during this period (17,18).
Uniform minimum legal drinking age. Research examined the effects of increases in the MLDA within individual States before the MLDA was raised to 21 in all States. Most studies found that laws raising the MLDA led to declines in teenage night fatal crashes, those most likely to involve alcohol (19). These and other research results were cited in support of passage of the Federal Uniform Drinking Age Act in 1984, which encouraged all States to raise the MLDA to 21. This law was subsequently upheld by the U.S. Supreme Court based in part on scientific evidence.
A recent evaluation of the uniform MLDA by O'Malley and Wagenaar (20), using the National High School Senior Survey, found that raising the legal drinking age reduced alcohol consumption and lowered involvement in alcohol-related fatal crashes for persons under the age of 21. Moreover, lower levels of consumption persisted into the early twenties, after all respondents were of legal drinking age. These studies suggest that raising the MLDA is an effective policy in helping to prevent traffic crashes.
Liver transplantation. For terminally ill patients with cirrhosis, liver transplantation is the only effective treatment. Opponents of liver transplantation for alcoholics argued that alcoholics receiving new livers would relapse into drinking, destroying the new liver. Research showed that the survival of alcoholic cirrhosis patients 1 year after liver transplantation was equal to or better than that of transplantation patients with other liver diseases (21,22), and recidivism to drinking was quite low (23,24). Because of this research, alcoholic cirrhosis was included among conditions for which liver transplantation is reimbursable under Medicare (25). Recent research continues to demonstrate survival rates in alcoholic cirrhotic patients equal to those for nonalcoholic cirrhotic patients (26,24). Therefore, as a result of scientific policy evaluation, a life-saving therapy has been made more widely available.
Alcohol Research and Public Health Policy--
A Commentary by NIAAA Director Enoch Gordis, M.D.
Alcohol research can play an important role in policy development and decisionmaking as shown in the examples provided in this Alcohol Alert. Science by itself, however, is rarely the sole basis for policy decisions. A mix of economic, ethical, and political points also are involved in U.S. alcohol policy development and, in some cases, these other factors can be more influential than the best scientific evidence. For example, the strong scientific evidence of a link between the minimum legal drinking age and alcohol-related driving fatalities among young persons played a key role in the policy decision to establish a nationwide minimum legal drinking age of 21. However, similarly good evidence of the economic and health benefits of providing health insurance coverage for alcoholism treatment is just beginning to overcome longstanding views of alcoho lism as a moral rather than a health issue.
Whether alcohol policies result from science alone or some mix of other factors, it is important that their outcome be subjected to scientific scrutiny. By doing so we can determine where policies are successful in achieving a desired outcome and deserving of replication, where modifications may be needed to improve the success of a policy, or where policies should be discarded.
(1) Lieber, C.S. Alcohol and nutrition: An overview. Alcohol Health & Research World 13(3):197-206, 1989. (2) Lelbach, W.K. Epidemiology of alcoholic liver disease. In: Popper, J., and Schaffner, F., eds. Progress in Liver Disease. Vol. 5. New York: Grune and Stratton, 1976. pp. 494-515. (3) Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS Pub. No. (PHS)91-50212. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. (4) Phelps, C.E. Death and taxes: An opportunity for substitution. Journal of Health Economics 7:1-24, 1988. (5) National Institute on Alcohol Abuse and Alcoholism. Fetal alcohol syndrome. Alcohol Alert. No. 13. PH 297. Rockville, MD: the Institute, 1991. (6) Chaloupka, F.J. Price and taxation strategies for preventing alcohol-related problems. Alcohol Health & Research World, in press. (7) Cook, P.J. The effect of liquor taxes on drinking, cirrhosis, and auto accidents. In: Moore, M.H., and Gerstein, D.R., eds. Alcohol and Public Policy: Beyond the Shadow of Prohibition. Washington, DC: National Academy of Sciences, 1981. pp. 255-285. (8) Grossman, M.; Coate, D.; & Arluck, G.M. Price sensitivity of alcoholic beverages in the United States: Youth alcohol consumption. In: Holder, H., ed. Control Issues in Alcohol Abuse Prevention: Strategies for States and Communities. Advances in Substance Abuse. Suppl. 1. Greenwich, CT: JAI Press, 1987. pp. 169-198. (9) Coate, D., & Grossman, M. Effects of alcoholic beverage prices and legal drinking ages on youth alcohol use. Journal of Law and Economics 31:145-171, 1988. (10) Laixuthai, A., & Chaloupka, F.J. "Youth Alcohol Use and Public Policy." Paper presented at the meetings of the Western Economic Association, San Francisco, July 12, 1992. (11) Saffer, H., & Grossman, M. Beer taxes, the legal drinking age, and youth motor vehicle fatalities. Journal of Legal Studies 16:351-374, 1987. (12) Jensen, G.A., & Morrisey, M.A. Employer-sponsored insurance coverage for alcohol and drug abuse treatment, 1988. Inquiry 28:393-402, 1991. (13) Kronson, M.E. Substance abuse coverage provided by employer medical plans. Monthly Labor Review 114(3):3-10, 1991. (14) Holder, H.D., & Blose, J.O. The reduction of health care costs associated with alcoholism treatment: A 14-year longitudinal study. Journal of Studies on Alcohol 53(4):293-302, 1992. (15) Holder, H.D., & Blose, J.O. Typical patterns and cost of alcoholism treatment across a variety of populations and providers. Alcoholism: Clinical and Experimental Research 15(2):190-195, 1991. (16) Mattson, M.E., & Allen, J.P. Research on matching alcoholic patients to treatments: Findings, issues, and implications. Journal of Addictive Diseases 11(2):33-49, 1991. (17) Graves, K.L. "Do Warning Labels on Alcoholic Beverages Make a Difference? A Comparison of the United States and Ontario, Canada Between 1990 and 1991." Paper presented at the 18th Annual Alcohol Epidemiology Symposium, Toronto, Ontario, Canada, June 1992. (18) Greenfield, T.K.; Graves, K.L.; & Kaskutas, L.A. "Do Alcohol Warning Labels Work? Research Findings." Paper presented at Alcohol Policy VIII, National Association for Public Health Policy, Washington, DC, Mar. 1992. (19) DuMouchel, W.; Williams, A.F.; & Zador, P. Raising the alcohol purchase age: Its effects on fatal motor vehicle crashes in twenty-six states. Journal of Legal Studies 16(1):249-266, 1987. (20) O'Malley, P.M., & Wagenaar, A.C. Effects of minimum drinking age laws on alcohol use, related behaviors and traffic crash involvement among American youth: 1976-1987. Journal of Studies on Alcohol 52(5):478-491, 1991. (21) Starzl, T.E.; Demetris, A.J.; & Van Thiel, D.H. Liver transplantation. New England Journal of Medicine 321:1014-1022, 1989. (22) Starzl, T.E.; Demetris, A.J.; & Van Thiel, D.H. Liver transplantation. New England Journal of Medicine 321:1029-1099, 1989. (23) Van Thiel, D.H.; Gavaler, J.S.; Tarter, R.E.; Dindzans, V.J.; Gordon, R.D.; Iwatsuki, S.; Makowka, L.; Todo, S.; Tzakis, A.; & Starzl, T.E. Liver transplantation for alcoholic liver disease: A consideration of reasons for and against. Alcoholism: Clinical and Experimental Research 13(2):181-184, 1989. (24) Knechtle, S.J.; Fleming, M.F.; Barry, K.L.; Steen, D.; Pirsch, J.D.; Hafez, G.R.; D'Alessandro, A.M.; Reed, A.; Sollinger, H.W.; Kalayoglu, M.; & Belzer, F.O. Liver transplantation for alcoholic liver disease. Surgery 112(4):694-703, 1992. (25) Health Care Financing Administration. Medicare program; criteria for Medicare coverage of adult liver transplants. Federal Register 56(71):15,006, Apr. 12, 1991. (26) Van Thiel, D.H.; Carr, B.; Iwatsuki, A.; Tzakis, A.; Fung, J.J.; & Starzl, T.E. Liver transplantation for alcoholic liver disease, viral hepatitis, and hepatic neoplasms. Transplantation Proceedings 23(3):1917-1921, 1991.
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