Policy Studies

Prevention Policies to Reduce Harmful Substance Use

Regulations on the availability of alcohol, tobacco, and other substances have been used to moderate problems in communities throughout the world for thousands of years. In the latter half of the 20th century, quantitative studies of the effects of these regulations on drinking, smoking and substance use and related problems began in earnest as public health practitioners began to recognize the full extent of the harmful consequences related to drinking and substance use. More broadly, policy approaches can be applied to a range of health-related problems, including violence, STIs, unwanted pregnancy, diabetes, and health disparities.

PRC’s research program is directed toward the development and evaluation of effective policy and environmental approaches to moderate alcohol and other substance use and related problems. Our work has always looked beyond classic economic theory and policy interventions that affect taxes and prices, to include studies of regulatory systems and modifications of drinking environments that can lead to healthy communities.

Here we present a sample of the policy concerns addressed by PRC researchers over the past decades. Click on a title to view the description.

Minimum Legal Drinking Age (MLDA)

The poster child for alcohol regulation in the US is the minimum legal drinking age (MLDA). Up until 1984, states in the US had established different minimum ages at which alcohol could be purchased from retail outlets. Among states which allowed alcohol sales, some established the MLDA at 18, others at 21, some at 18 for beer and 21 for liquor, and so forth. In general, increases in the minimum legal drinking age have been shown to reduce alcohol use and related problems among young people and moderate problems later in life. PRC's contribution to this important body of work has been to demonstrate the moderating effects of taxes on the effectiveness of minimum age constraints1 and begin to examine the impacts of MLDA laws on use of drinking contexts and related risks.2

References cited:

1. Ponicki, W.R.; Gruenewald, P.J.; and LaScala, E.A. The joint impacts of minimum legal drinking age and beer taxes on US youth traffic fatalities, 1975-2001. Alcoholism: Clinical and Experimental Research, 31:804-813, 2007. PMID:17391342
2. Treno, A.J.; Ponicki, W.R.; Huckle, T.; Yeh, L.C.; Casswell, S.; and Gruenewald, P.J. (2014) Impacts of New Zealand's lowered minimum purchase age on drinking patterns and use of drinking contexts. In review, Addiction.
Privatization and the Elimination of State Alcohol Controls

Following the end of prohibition in the US in 1933, states were allowed to establish either "monopoly" or "license" systems to regulate alcohol production, distribution and sales. Monopoly systems monopolized some aspects of the alcohol trade. License systems licensed production, distribution and sales through commercial establishments. No pure monopoly system was established in any state, but partial monopolies were established, most often monopolizing retail sales of one beverage (usually liquor) or another. As a general rule, monopoly states also had more restrictions on licensed aspects of the alcohol trade while license states had more liberal policies.3,4 Each state's regulatory apparatus must be studied separately to be understood.

After 1933, alcohol policy in the US has been characterized by successive waves of deregulation (MLDA laws are an unusual exception in this regard). Beginning in the 1980s there was a broad movement among states to privatize aspects of alcohol monopolies, reduce government involvement in alcohol sales, and increase state revenues through alcohol taxes. Early work by Canadian researchers suggested that privatization led to increases in use and related problems. This early work was given a substantial boost in the US when Holder and Blose5 demonstrated that privatized sales of liquor-by-the-drink led to greater use and problems in North Carolina. This work was followed by a landmark series of studies by Holder and colleagues6,7,8 demonstrating similar impacts of different privatization steps across five additional states. The privatization of alcohol sales has continued in Canada and the US despite evidence of negative public health effects. Returning to Canada, recent PRC studies of a recent privatization of off-premise sales in British Columbia demonstrated increases in use and problems and reductions in beverage prices.9,10,11

References cited:

3. Gruenewald, P.J. and Janes, K. The role of formal law in alcohol control systems: A comparison among states. The American Journal of Drug and Alcohol Abuse, 17(2): 199-214, 1991. PMID: 1862793
4. Gruenewald, P.J.; Madden, P.; and Janes, K. Alcohol availability and the formal power and resources of state alcohol beverage control agencies. Alcoholism: Clinical and Experimental Research 16:591-597, 1992. PMID: 1626661
5. Holder, H.D. and Blose, J.O. Impact of changes in distilled spirits availability on apparent consumption: A time series analysis of liquor-by-the-drink, British Journal of Addiction, 82:623-631, 1987.
6. Holder, H. D. and Wagenaar, A. C. Effects of the elimination of a state monopoly on distilled spirits' retail sales: A time-series analysis of Iowa. British Journal of Addiction, 85, 1615-1625, 1990. PMID:2289062
7. Wagenaar, A. C., and Holder, H. D. A change from public to private sale of wine: Results from natural experiments in Iowa and West Virginia. Journal of Studies on Alcohol, 52:162-173, 1991. PMID:2016877
8. Wagenaar, A. C., and Holder, H. D. Changes in alcohol consumption resulting from elimination of retail wine monopolies: Results from five U.S. states. Journal of Studies on Alcohol, 56:566-572, 1995. PMID:7475038
9. Stockwell, T. and Chikritzhs, T. Do relaxed trading hours for bars and clubs mean more relaxed drinking? A review of international research on impacts of changes to permitted hours of drinking. Crime Prevention and Community Safety 11:153-170, 2009.
10. Stockwell, T.; Zhao, J.; Macdonald, S.; Vallance, K.; Gruenewald, P.J.; Ponicki, W.R.; Holder, H.D.; and Treno, A. (2011). Impact on alcohol-related mortality of a rapid rise in the density of private liquor outlets in British Columbia: A local area multi-level analysis. Addiction, 106(4):768-776, 2011 PMID: 21244541
11. Treno, A.J.; Ponicki, W.R.; Stockwell, T.; MacDonald, S.; Gruenewald, P.J., Zhao, J.; Martin, G. and Greer, A. Alcohol outlet densities and alcohol price: The British Columbia experiment in the partial privatization of alcohol sales off-premise. Alcoholism: Clinical and Experimental Research, 37, 854-859, 2013. PMC Journal - In Process.
Retail Availability - Alcohol Outlet Density

Three aspects of alcohol availability that are regulated to some extent by all states are the type, number and permissible locations of alcohol outlets. In general, on-premise outlets, those that permit use at the point of purchase, are regulated somewhat differently than off-premise outlets, those that allow take-away sales and do not typically permit use at point of purchase. Historically, on-premise outlets have been the subject of more stringent regulation since they have been perceived as exposing populations to greater health risks such as heavy use, drunkenness and violence. Early international work indicated that, short of prohibition, regulations on outlet densities could ameliorate community problems such as public drunkenness and violence. PRC researchers performed the first state-level panel study demonstrating that outlet densities were related to alcohol sales12 and recently completed the first effective demonstration of relationships of densities to use of drinking contexts and drinking levels.13 PRC researchers have also been at the forefront developing technologies for the analysis of these data14 and demonstrating relationships between outlet densities and violent assaults,15 alcohol-related motor vehicle crashes,16 intimate partner violence,17 and child abuse and neglect.18

References cited:

12. Gruenewald, P.J.; Ponicki, W.R.; & Holder, H.D. The relationship of outlet densities to alcohol consumption: A time series cross-sectional analysis. Alcoholism: Clinical and Experimental Research 17(1):38-47, 1993. PMID: 8452207
13. Gruenewald, P.J. and Remer, L.R. (2013) A social ecological model of alcohol use: The California 50 city study. In press, Addiction. NIHMSID #548255 PMC Journal - In Process.
14. Banerjee, A.; LaScala, E.A.; Gruenewald, P.J.; Freisthler, B.; Treno, A.; and Remer, L.G. "Social disorganization, alcohol, and drug markets and violence: A space-time model of community structure." In Thomas, Y.F.; Richardson, D.; and Cheung, I. (eds.) Geography and Drug Addiction. New York, NY: Springer Science and Business Media, 2008, pp. 119-132.
15. Mair, C.; Gruenewald, P.J.; Ponicki, W.R.; & Remer, L.G. Varying impacts of alcohol outlet densities on violent assaults: Explaining differences across neighborhoods. Journal of Studies on Alcohol and Drugs, 74:50-58, 2013. PMCID: PMC3517264
16. Ponicki, W.R.; Gruenewald, P.J.; & Remer, L.R. Spatial panel analyses of alcohol outlets and motor vehicle crashes in California: 1999-2008. Accident Analysis and Prevention, 55:135-143, 2013.
17. Cunradi, C.B., Mair, C., Ponicki, W.R., & Remer, L.G. Alcohol outlet density and intimate partner violence-related emergency department visits. Alcoholism: Clinical and Experimental Research, 36(5), 847-853, 2012.
18. Freisthler B.; Midanik L.T.; & Gruenewald P.J. Alcohol outlets & child physical abuse & neglect: Applying routine activities theory to the study of child maltreatment. J Stud Alc, 65:586-592, 2004.
Retail Availability of Alcohol - Hours and Days of Sale

Regulations on outlet density are often supplemented by restrictions on the hours and days permitted for alcohol sales. Examples of these restrictions include Sunday "blue laws" which originally precluded alcohol sales for religious reasons and regulations on hours of sale common to all states. The impacts of these restrictions on use and problems have been much debated, with advocates claiming policy effects and opponents arguing that, at best, these restrictions serve to redistribute use and problems to other days and times. PRC researchers have related later trading hours to increased homicides in a study of one change in Brazil.19 But few other studies have been executed by PRC researchers or anyone else in the US. The particular problem in the US has been that suitable natural experiments by which to test these effects have rarely occurred. Changes in hours and days of sale typically take place as part of a bundle of other privatization steps (see above) making it very difficult to disentangle policy effects.

Reference cited:

19. Duailibi, S.; Ponicki, W.; Grube, J.W.; Pinsky, I.; Laranjeira, R.; & Raw, M. The effect of restricting opening hours on alcohol-related violence. American Journal of Public Health, 97:2276-2280, 2007. PMID: 17971559
Regulating Youth Access to Alcohol - Local regulatory policy, college drinkers and underage youth

As a general rule, regulations on availability in developed countries single out young people as specifically subject to restrictions on purchases and use. As noted above, MLDA laws are an effective although permeable barrier to alcohol use among underage drinkers. With sufficient motivation underage drinkers can and do obtain alcoholic beverages. Early PRC research indicated that between 30% and 70% of purchase attempts by underage drinkers at off-premise outlets were likely to be successful, but that consistent enforcement efforts can easily drive these figures much lower.20,21 For this reason, preventing alcohol sales to minors through enforcement efforts is a key feature of effective community-based alcohol prevention programs.22

Since the MLDA barrier is permeable, PRC researchers are also interested in the extent to which other regulations may impact underage drinking and problems.23 This area of research is of special interest because efforts to circumvent proscriptions on alcohol purchases and sales by young people are similar in many ways to efforts of the general population to circumvent many drug control laws. Thus, much like the illegal drug market, underage alcohol use is linked to access through informal familial and social networks.24 The most common sources of alcohol among underage drinkers are through the home and friends,25 underage purchases of alcohol are more likely where competition among outlets is greatest (where outlets are densely clustered)26 network effects appear to mediate or moderate effects related to outlet densities,27,28 and densities are related to drinking and drunken driving among youth.29,30

References cited:

20. Grube J.W. Preventing sales of alcohol to minors: Results from a community trial. Addiction 92(Suppl. 2):S251-S260, 1997. PMID:92311448
21. Paschall, M.J.; Grube, J.W.; Black, C.; Flewelling, R.L.; Ringwalt, C.L.; & Biglan, A. (2007). Alcohol outlet characteristics and alcohol sales to youth: Results of alcohol purchase surveys in 45 Oregon communities. Prevention Science, 8, 153-159. PMCID: PMC1933529
22. Holder H.D.; Gruenewald P.J.; Ponicki, W.R.; et al. Effect of community-based interventions on high risk drinking and alcohol-related injuries. JAMA Journal of the American Medical Association 284(18):2341-2347, 2000. PMID:11066184
23. Grube, J.W. (2009). Environmental approaches to preventing adolescent drinking. In L. Scheier (ed.), Handbook of drug use etiology: Theory, methods, and empirical findings (pp. 493-509). Washington, DC: American Psychological Association.
24. LaScala, E.A.; Freisthler, B.; and Gruenewald, P.J. Population ecologies of drug use, drinking and related problems. In: Stockwell, T.; Gruenewald, P.J.; Toumbourou, J.; and Loxley, W., Eds. Preventing harmful Substance Use: The Evidence Base for Policy and Practice. New York, NY: John Wiley, 2005, pp. 67-78.
25. Paschall, M.J.; Grube, J.W., Black, C.A; and Ringwalt, C.L. Is commercial alcohol availability related to adolescent alcohol sources and alcohol use? Findings from a multi-level study. Journal of Adolescent Health, 41:168-174, 2007. PMCID: PMC2213632
26. Freisthler B.; Gruenewald P.J.; Treno, A.J.; and Lee, J. Evaluating alcohol access and the alcohol environment in neighborhood areas. Alcoholism: Clinical and Experimental Research 27:477-484, 2003. PMID: 12658114
27. Chen, M.J.; Gruenewald, P.J.; and Remer, L.G. Does alcohol outlet density affect youth access to alcohol? Journal of Adolescent Health 44:582-589, 2009. PMID: 19465323
28. Chen, M.J.; Grube, J.W.; and Gruenewald, P.J. Community alcohol outlet density and underage drinking. Addiction 105:270-278, 2010. PMID: 20078485
29. Treno A.J.; Grube, J.W.; and Martin, S.E. Alcohol availability as a predictor of youth drinking & driving: A hierarchical analysis of survey and archival data. Alcoholism: Clinical and Experimental Research 27:835-840, 2003. PMID:12766629
30. Grube, J.W. and Stewart, K. Preventing impaired driving using alcohol policy. Traffic Injury Prevention 5:199-207, 2004. PMID:15276920
Smokefree Bar Policy Compliance

PRC has conducted three mixed-method studies of smoke-free workplace policy compliance and defiance in and around hundreds of California bars.2,5,9 Analyzing multiple highly structured qualitative and quantitative observations in a total of over 200 San Francisco, Alameda, and Los Angeles bars, indoor smoking was much more likely on nights when the bartender(s) was/were smoking, and nights when ashtrays were visible inside the bar, reflecting social control and norms-setting by authority figures.5,8 Qualitative data from 35 interviews with enforcement officials representing public health, fire, and law enforcement charged with upholding the provisions of the smoke-free workplace law include recurring themes of institutional and legal barriers to easy enforcement, while interviews with over 200 patrons, bartenders, and owner-managers of bars yielded rich information about gender and cultural norms concerning smoking in bar-centered social networks of migrants from different parts of the world to California cities. 1,3,4,6,7

References cited:

1. Antin, Tamar M.J., Juliet P. Lee, Roland S. Moore, and Travis D. Satterlund (2010) “Law in Practice: Obstacles to a Smokefree Workplace Policy in Bars serving Asian Patrons,” Journal of Immigrant and Minority Health, 12(2):221-227.
1. Antin, Tamar M.J., Juliet P. Lee, Roland S. Moore, and Travis D. Satterlund (2010) “Law in Practice: Obstacles to a Smokefree Workplace Policy in Bars serving Asian Patrons,” Journal of Immigrant and Minority Health, 12(2):221-227.
2. Lee, Juliet P., Roland S. Moore, and Scott E. Martin (2003) “Unobtrusive Observations of Smoking in Urban California Bars,” Journal of Drug Issues, 33(4):983-1000.
3. Lee, Juliet P., Tamar M.J. Antin, and Roland S. Moore (2008) “Social Organization in Bars: Implications for Tobacco Control Policy,” Contemporary Drug Problems, 35(1):59-98.
4. Moore, Roland S., Rachelle M. Annechino, and Juliet P. Lee (2009) “Unintended Consequences of Smokefree Bar Policies for Low-SES Women in Three California Counties,” American Journal of Preventive Medicine 37(2S):S138-143.
5. Moore, Roland S., Juliet P. Lee, Scott E. Martin, Michael Todd, and Bong-Chul Chu
(2009) Correlates of Persistent Smoking in Bars Subject to Smokefree Workplace Policy.  International Journal of Environmental Research and Public Health, 6(4), 1341-1357. Accessible online at http://www.mdpi.com/1660-4601/6/4/1341.
6. Moore, Roland S., Juliet P. Lee, and Tamar M. Antin and Scott E. Martin (2006) “Tobacco free workplace policies and low socioeconomic status female bartenders in San Francisco,” Journal of epidemiology and Community Health, 60(2):51-56.  http://jech.bmj.com/content/60/suppl_2/ii51.full.pdf
7. Satterlund, Travis D., Tamar M.J. Antin, Juliet P. Lee, and Roland S. Moore. 
(2009) “Cultural Factors Related to Smoking in San Francisco’s Irish Bars.” Journal of Drug Education, 39(2):181-193.
8. Satterlund, Travis D.; Juliet P. Lee, Roland S. Moore, and Tamar M. J. Antin
(2009) “Challenges to Implementing and Enforcing California’s Smoke-Free Workplace Act in Bars,” Drugs: Education, Prevention & Policy, 16(5):422-435.
9. Satterlund, Travis L., Juliet P. Lee and Roland S. Moore
(2012) “Changes in Smoking-Related Norms in Bars Resulting from California’s Smoke-Free Workplace Act,” Journal of Drug Education 42(3):315-326.
Regulating Youth Access to Tobacco - Policies and Adolescents' Smoking

Policies to reduce youth access to tobacco products from commercial sources include (1) compliance checks and enforcement of underage tobacco sales laws, (2) increasing taxes of tobacco products, and (3) restricting number or location of tobacco outlets. These policies aim at decreasing opportunities to obtain or use tobacco and making tobacco socially unacceptable. We have studied the associations between such policies and youth tobacco use and beliefs. For example, results of our study in California showed that tobacco outlet density was more closely related to youth smoking when clean air policies were weaker1. In another study, tobacco outlet density within 0.75-mile and 1-mile buffer of youth homes was positively associated with past-month cigarette smoking, after controlling for individual- and city-level covariates2. Using access surveys conducted by 4 confederate buyers in 997 tobacco outlets, we identified associations between a wide range of retail and community factors and youth access to cigarettes through commercial sources3. Results of our investigation can help to identify and target at-risk communities and outlets to decrease youth access to tobacco

References cited:

1. Lipperman-Kreda, S., Grube, J.W., & Friend, K.B (2012). Local tobacco policy and tobacco outlet density: Association with youth smoking. Journal of Adolescent Health, 50, 547-552. PMCID: PMC3360878
2. Lipperman-Kreda, S., Mair, C., Grube. J.W., Friend, K.B, Jackson, P., & Watson, D. (2013). Density and proximity of tobacco outlets to homes and schools: Relations with youth cigarette smoking. Prevention Science. Epub ahead of print. PMC Journal-In Process
3. Lipperman-Kreda, S., Grube, J.W., & Friend, K.B (2014). Contextual and community factors associated With youth access to cigarettes through commercial sources. Tobacco Control, 23, 39-44. PMCID: PMC3578042
Legalization of Marijuana

As of 2013, 22 U.S. states and the District of Columbia have legalized marijuana for medical use, 17 states have decriminalized marijuana possession, and two states, Colorado and Washington, have legalized marijuana for recreational use1. In a recent national opinion poll of adults, the vast majority (77%) reported that marijuana has legitimate medical uses, and more than half (52%) supported the legalization of marijuana for recreational use2.

This rapidly liberalizing environment may support increased acceptance of and use of marijuana among youths3,4,5. National survey data indicate that marijuana is the most commonly used illicit drug among U.S. teens, with 13% of 8th graders, 33% of 10th graders, and 42% of 12th graders having used marijuana in the past year6. The perceived risk of using marijuana has been declining.6

We are currently investigating the relations of policy changes regarding marijuana and adolescent’s marijuana beliefs and related behaviors. In a recent study we found that the relation between legalization of medical marijuana and youth use and beliefs may be a result of an overall normative environment that is more tolerant of marijuana use, rather than legalization per se. Interventions to prevent youth marijuana use should focus on adult norms regarding use by and provision of marijuana to youths. It is important to develop preventive interventions that are tailored to this changing environment.

References cited:

1. Pew Research Center (2014). “Marijuana in America: Shifting attitudes, events and laws,” http://www.people-press.org/2013/04/04/marijuana-timeline/
2. Galston, W.A. and Dionne, E.J. (2013, May). “The new politics of marijuana legalization: Why opinion is changing,” Governance Studies at Brookings. http://www.brookings.edu/~/media/research/files/papers/2013/05/29%20politics%20marijuana%20legalization%20galston%20dionne/dionne%20galston_newpoliticsofmjleg_final.pdf
3. Cerdá, M.; Wall, M.; Keyes, K.M.; Galea, S.; and Hasin, D. "Medical marijuana laws in 50 states: Investigating the relationship between state legalization of medical marijuana and marijuana use, abuse and dependence." Drug and Alcohol Dependence, 120(1-3):22-27, 2012.
4. Friese, B., and Grube, J. “Legalization of medical marijuana and marijuana use among youths,” Drugs (Abingdon Engl), 20(1):33-39, 2013 February 1. doi: 10.3109/09687637.2012.713408 Author manuscript; available in PMC 2014 February 1. PMCID: PMC3638722
5. Friese, B. and Grube, J. “Is there a relationship between the legalization of medical marijuana and youths’ beliefs about marijuana,”? presented at Society for Prevention Research, May 31, 2013; San Francisco, California.
6. Johnston, L.D., O’Malley, P.M., Bachman, J.G., Schulenberg, J.E. and Miech, R.A. (2014). Monitoring the Future national survey results on drug use, 1975-2013: Volume I, Secondary school students. Ann Arbor: Institute for Social Research, University of Michigan.
7. ProCon (2014). “State and relevant medical marijuana laws: California.” Retrieved from: http://medicalmarijuana.procon.org/view.resource.php?resourceID=000881#California
The Role of School-Based Health Centers on Adolescent Sexual and Reproductive Health

The number of school based health centers (SBHC) across the country is increasing, with over 1900 centers open nationally. SBHC may be effective structural/contextual health promotion investments as they (1) are embedded within schools, the only public institution with the capacity to reach a majority of youth; (2) are designed to reduce barriers associated with accessing services (e.g., finances, confidentiality concerns, inconvenient hours, distance from home); and (3) directly or indirectly expose youth to medical and mental services that exist in their community. When placed in areas of high need, the potential exists for improving youth, family, and community outcomes and ultimately reducing health disparities. 

Few studies have focused on contextual or structural factors characterizing environments in which young people live and make decisions about reproduction. To date, research on SBHC with a family planning component (SBHC-FPC) and birth rates, contraceptive use, and sexual behaviors has been mixed, largely due to methodological weaknesses such as self-selection by clinic users, substitution effects, and nonequivalent comparison groups. Additionally, long-term impacts are not measured as adolescents age out of the system and become more difficult to track.  The current study aims to address these issues by conducting an impact evaluation on the role of SBHC-FPC on female adolescent and reproductive health behaviors.  Previous methodological limitations are addressed by surveying a large national sample of youth (selected through a list-assisted random sample; n = 3600), across 160 schools (including matched control schools without a SBHC), and following them for a three year period from adolescence into young adulthood.

Specifically we aim to asses 1) whether the presence of SBHC-FPCs in high school is associated with positive short-term effects in adolescence and carry-over effects into young adulthood, including effects on attitudes, beliefs, and behaviors (e.g. contraceptive use, pregnancy intentions); and 2) how access to different types of sexual and reproductive health services impacts outcomes (e.g. birth control counseling versus birth control dispensing).  Results of the proposed application will inform whether and what types of health services influence young women’s reproductive behaviors and whether exposure to school-based health services has broader impacts on health care seeking over time. Findings from the proposed study will inform research and school and state policy through (a) increased understanding of the effects of SBHC-FPCs on reproductive health-seeking behavior, planned and unplanned pregnancy, and (b) increased knowledge of which services are effective. Findings will also inform our understanding of how access to medical services more generally influences health behaviors.