Public Health Policy and Prevention of Alcohol, Tobacco, and Drug Problems
Abstract and Keywords
The misuse of alcohol, tobacco, and illicit drugs by youth and young adults is a major public health challenge across nations and the world. This chapter reviews the extensive international research concerning the use of public policy approaches to reducing these problems associated with the use and misuse of alcohol, tobacco, and illicit drugs. In general, wide differences arise in public policies both in the type of research undertaken and the practical application of policy approaches to reduce harm. For illegal drugs and for alcohol, research concerning public health effects has been associated with policies addressing specific control mechanisms, whereas many public health policy approaches for tobacco harm prevention have been multifaceted. Overall, the cumulative international evidence offers public health policy approaches with demonstrated potential to reduce harm from and use of alcohol, tobacco, and illicit drugs and can have specific effects for adolescents and young adults.
The misuse of alcohol, tobacco, and illicit drugs by youth and young adults is a major public health challenge across nations and the world. While alcohol and tobacco have legal standing for adults in most countries, limits or restrictions on youth purchase and consumption occur in most of them. Illicit drugs are defined as substances banned or prohibited in most countries for all ages (even though alcohol is banned in some Islamic countries), but special emphasis has been placed on children and youth. Typically, such bans include cannabis, heroin, cocaine, stimulants, and/or a host of synthetic substances, including LSD or Ecstasy. The challenge most jurisdictions face is to implement those public health approaches that have the greatest potential to reduce harm in general and for children and youth in particular. This potential is based on generalizable international research concerning effects of prevention strategies. A major strategy for reducing youth problems associated with the use and misuse of alcohol, tobacco, and illicit drugs is public policy, which is the focus here.
There are important differences in public health policies specific to substance abuse both in the manner and type of research undertaken and the practical application of policy approaches to reduce harm. For illegal drugs and for alcohol, research concerning public health effects has been associated with specific policies, for example, minimum drinking age, random breath testing for drink driving, and drug supply interdiction and punishment. In contrast, most of the public health policy approaches, besides taxation, for tobacco harm prevention have been multifaceted policy efforts, and these have been successful. Such multicomponent public health policy approaches for tobacco do not have a clear counterpart in alcohol or illegal drugs, as reflected in the summary of policy research here.
Another important difference is that deadly acute effects (especially for adolescents) accompany alcohol (p. 790) and illicit drugs, while tobacco effects are typically more long term in their lethal effects. Of course, addiction to alcohol and illicit drugs can begin in adolescence, as can dependence on tobacco, which can certainly have longer term health effects, including liver cirrhosis, physical addiction with associated health decline, and lung cancer. Such differences also shape the manner in which public health policy effects are presented and discussed in the following sections for alcohol, tobacco, and illicit drugs.
Public Policy as a Prevention Strategy
The primary goals of prevention are (a) to delay or prevent the onset of use, that is, the age at which alcohol, tobacco, or illicit drugs are first used; and (b) to reduce the associated problems related to alcohol, tobacco, and illicit drug use. The first goal is important because early initiation of substance use (illicit drugs, tobacco, or alcohol) by children or youth is both illegal in most cultures and often associated with later problems surrounding this substance. The earlier one begins to use alcohol, tobacco, or illicit drugs, the more one develops later dependency on any of these substances, and the greater the lifetime risks associated with the substance.
The second goal has two aspects. First is the prevention of acute problems or those immediately associated with the substance and uses of it, such as binge drinking. This is best illustrated by alcohol intoxication and associated problems of drunk-driving crashes, falls, and violence but also by overdose of drugs resulting in death or disablement. The second aspect relates to chronic effects—that is, the long-term exposure to the harmful toxins in substances such as tobacco or alcohol as well as the increased dependence on illicit drugs, for example, heroin or cocaine. Here the concern is to prevent physical effects of long-term (often dependent) use, including illness and early death, requiring abstinence or moderate use.
To force, facilitate, or encourage changes in social, economic, or physical environments to reduce substance abuse, public policies are utilized. A policy is any established process, priority, or structure that is purposefully sustained over time. Thus, policy, at whatever level it is promulgated or implemented, is an environmental response to specific substance abuse or associated problems. National, state, or provincial laws often establish the base for local policies, including legal drinking or smoking ages, regulation of alcohol and tobacco prices and retail outlets, smoking or drinking in certain public places, the legal blood alcohol level for drinking and driving, advertising restrictions, and alcohol service to obviously intoxicated persons and underage persons. In some instances, a groundswell of local laws, such as restraining smoking in public places and even in homes, has the effect of prompting state or federal laws to harmonize differences among jurisdictions or to preempt stronger laws at the local level than a state law would allow. This chapter will review policy strategies according to substances (alcohol, tobacco, and illicit drugs) as well as the major policy levers shown by international research to be effective, including price, retail availability by limiting legal age of purchase, and other limits on access or use such as hours and/or days of sale and licensing restrictions, and bans on smoking or drinking in selected environments.
Public policy effects can provide a means to fast-forward or leap-frog the incremental process; that is, what has occurred in some countries may be informative for others just beginning a similar process to streamline it. For example, alcohol or tobacco policies that stimulate the development of commercially produced alcohol and importing or manufacturing cigarettes in some less industrialized countries can be informed by the public health consequences (both positive and negative) observed from more developed countries and their policies.
Alcohol contributes to problems of public health and safety in two ways; that is, drinking can have acute or immediate as well as chronic or long-term consequences. Alcohol is a psychoactive substance that affects one’s ability to carry out complex tasks and/or to make socially appropriate or safe decisions, especially in a stressful situation. For example, an automobile driver who has been drinking, even one drink of alcohol, has a reduced ability to operate the vehicle and impaired decision-making ability. The more drinks consumed, the greater the driver’s impairment. Secondly, alcohol, consumed regularly in high amounts, can have a direct harmful effect on the body. This is the aspect of drinking that most affects adolescents.
Insofar as alcohol is a legal product in most countries, the regulation of these products through (p. 791) policies has usually, in industrialized countries, been a part of a public health approach to limit the damage associated with drinking, as well as to increase tax revenues. Government policies can in some cases actually determine the retail price of beverages, the opening hours or days for retail sales, the number and location of retail outlets, how the alcohol can be advertised and promoted, and restrictions on who may sell or purchase alcohol. Restricting alcohol availability through law has been a key policy in many parts of the world. Because all policy occurs within an individual society and reflects the unique attitudes and values of that society, the potential effectiveness of any policy is directly related to public acceptability and compliance with these policies, and the associated willingness of the jurisdiction to enforce the policy. The extreme example of an alcohol policy that exceeded public acceptability and enforceability and was eventually repealed was Prohibition in the United States. Acceptability of a minimum age of legal drinking, possession, or purchase of alcohol has also varied with regional cultures across countries, states, and municipalities while enacted in some form in every US state. Considerable evidence demonstrates the sensitivity of adolescents to their social, economic, and geographical environments (see Paschall, Lipperman-Kreda, & Grube, 2014).
Alcohol policy strategies are designed to alter these environments for drinkers, especially adolescents. These policies have been shown to be consistently effective over time and in two or more countries or cultural settings include the following general policies used in public health efforts to reduce alcohol-related harm:
(a) Economic access—the price of alcohol and its relationship to disposable income or ability to purchase. The consumption of alcohol, tobacco, and other drugs is related to the product’s retail price; that is, all other things being equal, the higher the price, the lower the consumption. This sensitivity called price elasticity differs by age, income, and country.
(b) Physical access—the ability of adolescents to obtain alcohol; that is, its convenience to purchase alcohol and the barriers (policies) that reduce retail access.
(c) Alcohol promotion and advertising restrictions—policy efforts to reduce the attractiveness of alcohol to youth and demand, which could occur through alcohol advertising.
(e) Social access—the availability of alcohol to adolescents from social sources, including friends and family members, and in social settings such as parties and informal gatherings.
(f) Harm reduction—drinking and driving-specific policies to reduce harm related to drinking while driving.
The sensitivity of drinking to retail alcohol price has been demonstrated in a dozen or more countries, as shown in reviews by Gallet (2007), and Wagenaar, Salois, and Komro (2009). Furthermore, alcohol tax increases have the potential to reduce the rate of fatal car accidents involving alcohol; for example, it is estimated that a 10% increase in the price of alcoholic beverages in the United States could reduce the probability of drinking and driving by about 7% for males and 8% for females, with even larger reductions among those 21 years and under because of their lower disposable income. One example of increasing retail price as a part of policy occurred in the Northern Territory of Australia under a Living With Alcohol Program (LAP), which increased the cost of standard drinks by five cents in 1992 followed by other problem reduction strategies in 1996, including lowering the legal blood alcohol content (BAC) limit and a special levy on case wine (Stockwell et al., 2001). Over the years of this program, there were statistically significant reductions in acute conditions such as road deaths (34.5%) and other mortality (23.4%) as well as traffic crashes requiring hospitalization (28.3%).
Adolescents who drink weekly or are heavy drinkers (typically defined as five or more drinks per occasion) have more sensitivity to price than do other youth (Coate & Grossman, 1988). Tax increases may influence not only consumption but also other alcohol-related outcomes, and youth again appear to be more price responsive than adults in terms of these outcomes. Increased price appears to reduce drinking and driving among youth more than among adults (Chaloupka, Saffer, & Grossman, 1993, 2002).
Dee and Evans (2001) reported that price increases would reduce motor vehicle crash fatalities among 18- to 20-year-olds. Sorenson and Berk (2001) after statistically controlling for potential confounder variables found that beer sales and handgun sales in California (from 1972 through 1993) generally predicted homicides during one year, particularly among young men, and that reducing beer sales and handguns sold could reduce (p. 792) the number of homicides. Grossman and Markowitz (2001) examined the effect of beer price on violence among students from 191 colleges and universities from 29 states and found that higher prices for beer were associated with lower incidences of (1) getting into trouble with police or college authorities, (2) damaging property, (3) fighting or arguing, and (4) being taken advantage of or taking advantage of someone sexually. The principal finding is that the incidence of each of these four acts of violence is inversely related to the price of beer in the state in which the student attends college. Markowitz (2001) concluded that higher beer taxes would reduce the likelihood of teens engaging in physical fights. In summarizing its systematic review and weighing of the evidence, the Task Force on Community Preventive Services (2010a) and Elder et al. (2010) have recommended increasing alcohol taxes as a policy to reduce excess alcohol consumption and alcohol-associated problems.
Another class of alcohol policies particularly relevant to youth consists of policy approaches to reduce the ability of adolescents to obtain alcohol from retail sources.
Minimum Legal Drinking Age or Alcohol Purchase Age
One notable public policy has involved establishing a minimum legal drinking or retail purchase age to reduce the consumption of alcohol by youth. There are legal ages of alcohol purchase in many countries, but most often they are ignored or not enforced. One example of a national policy to reduce youth drinking using minimum age occurred in the United States in the 1980s with a minimum purchase or drinking age of 21 years for all alcoholic beverages. Wagenaar and Toomey (2002) in their extensive summary of international research on the effects of the minimum legal drinking age (MLDA) studied the effects of changes in the MLDA on incidents of drunk driving and traffic crashes (e.g., fatal crashes, drink-driving crashes, or self-reported driving after drinking); a clear majority found that raising the MLDA reduced crashes and associated problems and lowering the MLDA increased crashes. Raising the MLDA in the United States has been associated with a 47% decrease in fatal crashes involving young drivers with BACs ≥ 0.08% and a 40% decrease in such crashes involving young drivers with BACs ≥ 0.01% (Dang, 2008). Conversely, a review of research indicated that the trend to decrease the MLDA in the United States from 21 to 18 years during the 1970s was associated with a 7% increase in traffic fatalities for the affected age groups (Cook, 2007). The US National Highway Traffic Safety Administration (NHTSA) estimated that with a drinking age of 21 years across all 50 states cumulatively through 2000, over 20,000 lives have been saved (US Department of Transportation, 2001). In Australia, Smith (1986) and Smith and Burvill (1987) found that the lowering of the drinking age from 21 to 18 years in three Australian states resulted in increases in traffic-related hospital admissions, other accident-related hospital admissions, and rates of juvenile crime. More recently, the lowering of the drinking age in New Zealand from 20 to 18 years was related to increases in traffic injuries among 15- to 19-year-olds (Kypri et al., 2006) and in prosecutions for disorder offences among 14- to 15-year-olds (Huckle, Pledger, & Casswell, 2006). A systematic review of 33 evaluations of MLDA laws in the United States, Canada, and Australia found a median decline of 16% in crash-related outcomes for the targeted age groups following passage of laws to increase the MLDA (Shults et al., 2001).
Hours and Days of Retail Sale
The number of hours and days of a week in which alcohol is available for retail sales is a policy that affects both drinking and associated harm. Thus, reducing the days and hours of retail alcohol availability restricts the opportunities for alcohol purchases both in bars and restaurants as well as alcohol outlets. A recent study by Rossow and Norström (2012) analyzed the effects of local policy in18 Norwegian cities that extended or restricted the closing hours for on-premise alcohol sales. Outcomes suggested that each 1-hour extension of closing hours was associated with an assault increase of about 17% or 5.0 assaults per 100,000 inhabitants and that the effects were symmetrical; that is, assaults change proportionally up or down whether hours were increased or decreased. One policy change in Western Australia permitted extended trading permits (ETPs), which enabled longer opening hours. It was found that these extended hours, which stimulated greater sales of high-alcohol-content beer, wine, and spirits, also significantly increased monthly assault rates associated with those hotels with ETPs (Chikritzhs & Stockwell, 2002, 2006). Kelly-Baker et al. (2000) found temporary bans on the sales of alcohol from midnight Friday through 10 a.m. Monday because (p. 793) of federal elections in Mexico reduced cross-border drinking in Mexico by young Americans. A local policy in Diadema, Brazil, limited opening hours for alcohol sales and produced a significant decrease in murders (Duailibi et al., 2007). Stockwell and Chikritzhs (2009) completed a review of 48 international studies of the effects of changes in hours and days of sale and concluded that the balance of reliable evidence suggests that extended late-night trading hours leads to increased consumption and related harms. Thus, from a policy perspective, restricting hours and specific days of sale can have considerable impact on acute alcohol-related problems such as traffic crashes, violence, and heavy drinking, which is also the conclusion reached by the Hahn et al. (2010) and the Task Force on Community Preventive Services (2010b).
Retail alcohol government-operated monopolies are a public policy means to reduce drinking. Elimination of a private profit interest typically facilitates the enforcement of rules against selling to minors. Rossow, Karlsson, and Raitasalo (2008), in a study in Norway and Finland in which underage-appearing 18-year-olds attempted to purchase alcohol in off-premise outlets, found that they were more likely to be requested to present an ID and less likely to succeed in purchasing alcohol in alcohol retail monopoly outlets as compared to other types of outlets. They concluded that such monopoly outlets can facilitate enforcement of minimum legal age for purchase of alcohol. Miller et al. (2006) found that underage drinking rates, including heavy drinking as well as youth-involved traffic crashes, were lower in US states that had retail sale monopolies controlling for other factors. The Task Force on Community Preventive Services (2012a) also concluded that sufficient evidence supports policies that should discourage jurisdictions from ending retail alcohol government monopolies.
Enforcement of Alcohol Laws and Policies
The systematic checking by law enforcement of whether a licensed establishment actually sells alcohol to underage persons or “underage-looking persons” represents a key factor in policy effectiveness. Even moderate increases in enforcement can reduce sales of alcohol to minors by as much as 35% to 40%, especially when combined with media and other community and policy activities (Grube & Nygaard, 2001). There is some evidence that enforcement primarily affects the specific establishments targeted in compliance checks with limited diffusion and that any effects on sales may decay relatively quickly (Wagenaar, Toomey, & Erickson, 2005a, b). In one study, enforcement of underage sales laws increased compliance with alcohol sales laws from 11% to 39% (Scribner & Cohen, 2001). Dent, Grube, and Biglan (2005) found that perceived compliance and enforcement of underage drinking laws at the community level was inversely related to individual heavy drinking, drinking at school, and drinking and driving and to the use of commercial sources for alcohol by adolescents. Similarly, compliance rates as determined by surveys in which youth attempted to purchase alcohol have been found to be inversely related to frequency of use of commercial sources for alcohol by minors (Paschall, Grube, Black, Flewelling, et al., 2007). Paschall, Grube, Black, and Ringwalt (2007) found that the alcohol sales rate was positively related to students’ use of commercial alcohol sources and perceived alcohol availability. Another policy version of enforcement is establishing legal liability for providing alcohol to underage persons, especially if alcohol-involved harms occur; for example, when an intoxicated minor is involved in a traffic crash. Sloan et al. (2000) analyzed traffic fatalities across all US states and found that imposing legal liability on commercial services resulted in reduced fatality rates for those drivers 15 to 20 years, controlling for other dependent variables.
Results from a randomized community trial in one US state (Oregon) found significant associations between the level of law enforcement of underage drinking in the intervention communities and reductions in both 30-day use of alcohol and binge drinking. The enforcement level included all types of enforcement, including drunk driving, youth possession of alcohol, underage age purchase violations, and provision of alcohol to minors (Flewelling et al., 2013). This is further explored in Paschall et al. (2012) and Paschall, Lipperman-Kreda, and Grube (2014).
Number and Densities of Alcohol Outlets
Adolescents, like adults, can potentially obtain alcohol from any retail alcohol outlets that sell alcohol. The geographical concentration of outlets in neighborhoods and communities can either enhance or reduce total alcohol availability. Gruenewald, Ponicki, and Holder (1993), using a time-series cross-sectional analysis of alcohol consumption and density of alcohol outlets over 50 US states, found a 10% reduction in the density (p. 794) of alcohol outlets would reduce consumption of spirits from 1% to 3% and consumption of wine by 4% across all ages. Similar findings have been reported in other countries (see Babor, Caulkins, et al., 2010). Treno, Grube, and Martin (2003) found that higher density of outlets was positively related to drinking and driving among licensed youth drivers and negatively related to riding with drinking drivers among youth who did not have driver’s licenses. Alcohol outlet density was found to be related to both perceived ease of access to alcohol and to consumption among youth in 50 zip codes in California (Treno et al., 2008). There is consistent evidence that outlet density is related to rates of heavy episodic drinking by youths and young adults (Huckle, Huakau, Sweetsur, Huisman, & Casswell, 2008; Scribner et al., 2008; Weitzman, Folkman, Folkman, & Wechsler, 2003). Treno et al. (2003) found evidence that outlet density was positively associated with frequency of underage drinking and driving and with riding with drinking drivers. Based on reviews of the scientific evidence, the Task Force on Community Preventive Services (2009) and Campbell et al. (2009) confirm the potential of limiting alcohol outlet density as a means to reduce excessive consumption and alcohol-related harms. Drinking context and outlet density have been associated with intimate partner violence (Mair, Cunradi, Gruenewald, Todd, & Remer, 2013) and neighborhood violence including adolescents (Mair, Gruenewald, Ponicki, & Remer, 2013).
Alcohol Promotion and Advertising Restrictions
Restrictions and outright bans of alcohol promotion and commercial advertising have been employed as part of public health policy. The evidence of the effects of advertising bans has been mixed, but recent research suggests that limits on point-of-purchase advertising and promotion could have specific effects on youth drinking. Promotion of alcohol and its effect on youth drinking has been a significant public health issue. Studies have examined the relationship between exposure to different forms of alcohol advertising and subsequent drinking among adolescents and youth. Erickson et al. (2014) examined the relationship to subsequent drinking among US adolescents. They found that for seventh-grade nondrinkers, exposure to in-store beer displays predicted drinking onset by grade 9; for seventh-grade drinkers, exposure to magazines with alcohol advertisements and to beer concession stands at sports or music events predicted frequency of grade 9 drinking, and that for 12-year-old children exposure to in-store beer displays predicted drinking onset by age 14 years. Similar research concluded that exposure to magazines with alcohol advertisements and to beer concession stands at sports or music events for 12-year-olds predicted frequency of drinking at age 14 years (see also Ellickson, Collins, Hambarsoomians, & McCaffrey, 2005). Snyder et al. (2006) found that youth who saw more alcohol advertisements drank more on average (each additional advertisement seen increased the number of drinks consumed by 1%). These researchers found that restrictions on point-of-purchase price advertising at liquor stores reduced the probability of drinking and driving among all drinkers and when price advertising is permitted, prices may be expected to fall, thereby leading to increases in overall consumption. They found that drinkers who lived in locations with policies permitting grocery stores to sell beer and wine had a significantly higher probability of drinking and driving and concluded that advertising and availability of alcohol promote drinking.
Around the world, a substantial amount of alcohol obtained by underage persons is not directly from retail sources but from social sources (friends, parties, homes, etc.) and other persons who purchase alcohol and provide it to underage persons (both persons themselves under the legal purchase age and persons who themselves are of legal age) (Harrison, Fulkerson, & Park, 2000).
Curfews for Youth
Curfews establish a time when children and young people below certain ages must be home. While this policy was not initially considered an alcohol-problem prevention strategy, research has shown positive effects in reducing alcohol-involved traffic crashes for adolescents as a result of reducing social access to alcohol away from home (Preusser, Williams, Zador, & Blomberg, 1984; Williams, Lund, & Preusser, 1984).
Social Host Liability
Under social host liability, adults who provide alcohol to a minor or serve intoxicated adults in social settings can be sued through civil action for damages or injury caused by that minor or intoxicated adult (Grube & Nygaard, 2005). In one study in the United States, social host liability laws were associated with decreases in alcohol-related traffic (p. 795) fatalities among adults, but not among minors (Whetten-Goldstein, Sloan, Stout, & Liang, 2000). In a second study, social host liability laws were associated with decreases in reported heavy drinking and in decreases in drinking and driving by lighter drinkers (Stout et al., 2000). Although social host liability may send a powerful message, that message must be effectively disseminated, implemented, and enforced before it can have a deterrent effect.
Third-Party Provision of Alcohol to Youth
Adults or young adults of legal age can purchase alcohol on behalf of an underage person who approaches a stranger outside of an alcohol establishment and asks this person to purchase alcohol for him or her. Toomey et al. (2007) in one US study found that 19% of young males over the age of 21 years were willing to purchase alcohol for youth who appeared to be underage when “shoulder-tapped” outside a convenience or liquor store. Refusal of sales to adults who are believed to be purchasing alcohol for underage persons is enforced in many retail monopoly stores, including in Norway, Iceland, Finland, and Sweden (see Rossow et al., 2008).
Social Availability Enforcement
Key aspects of potential effectiveness of policies to reduce social availability of alcohol include using law enforcement to (a) enforce laws prohibiting adult provision of alcohol to minors and underage drinking at private parties and (b) disrupt one of the highest risk settings for alcohol availability and misuse, that is, private drinking parties, by conducting weekend and nighttime patrols of areas known to be regular drinking locations. There is limited empirical evidence of effectiveness. One example occurred in Oregon where a local community implemented a weekend drunk driving and party patrol program. An unpublished evaluation of this program revealed that arrests of youth for possession of alcohol increased in 1 year with a corresponding decrease of 35% in underage drunk driving crashes (Little & Bishop, 1998; Radecki, 1993).
Harm Reduction Policies—Drinking and Driving
Public policies concerning alcohol as described earlier are typically concerned with reducing retail and social access to alcohol in order to reduce drinking by youth and thus reduce alcohol problems. There are some policies that focus specifically on the reduction of alcohol-involved harm. A major policy approach to reducing alcohol-involved harm is drinking and driving enforcement.
Policies that discourage drinking before or while driving can reduce alcohol-related crashes and the injuries and deaths that result from them. Strategies for reducing alcohol-related traffic crashes include increased and highly visible law enforcement (e.g., sobriety checkpoints and random breath testing) and the level of legal BAC at which a driver is considered legally drunk or impaired.
Random Breath Testing
Random breath testing (RBT) involves extensive and continuous random stops of drivers who are required to take a breath test to establish their BAC. Tests of RBT in Australia, Canada, and Great Britain show that RBT can reduce traffic crashes. Shults et al. (2001) reviewed 23 studies of RBT and intensive enforcement and found a median decline of 22% (range 13%–36%) in fatal crashes, with slightly lower decreases for noninjury and other crashes for such strategies. A limited version of RBT, called sobriety checkpoints, is often implemented in individual US states. There is strong evidence that they reduce drinking and driving and related traffic crashes (Shults et al., 2001). In both Australia and the United States, the preventive effect of enforcement is enhanced if accompanied by publicity and news attention (see Shults et al., 2009). No studies have evaluated the specific effects of these strategies on adolescent drinking and driving, but there is little reason to believe that youthful drivers would not be affected by such policies.
Lowering Blood Alcohol Concentration Limits
BAC limits are public laws that legally define drunk driving using a BAC at or above a prescribed level for the whole population (e.g., from 0.08 to as low as 0.02). A review of both US and Australian studies (Shults et al., 2001) found reductions between 9% and 24% in fatal crashes associated with the implementation of zero-tolerance laws. Similarly, a review of Canadian studies concluded that lower BAC levels for young drivers were related to a 25% reduction in reported drinking and driving among young males in Ontario and an 8.9% reduction in single-vehicle nighttime crashes in Quebec (Chamberlain & Solomon, 2008). Some countries have set specific BAC limits for young drivers and commonly invoke penalties such as automatic license revocation. A study of all 50 US states and the District of Columbia found a net decrease of 24% in the number of young drivers with (p. 796) positive BACs as a result of the implementation of lower BAC limits for these ages (Voas, Tippetts, & Fell, 2003), and Wagenaar, O’Malley, and LaFond (2001) found similar results in 30 US states.
Graduated Licensing Places Special Limits on New or Young Drivers
Graduated licenses establish unique driving restrictions for young or novice drivers (e.g., restricts nighttime driving and/or prohibits driving with other adolescents). The policy effects appear to also be related to adolescent drinking and driving. A graduated licensing program in Connecticut led to a 14% net reduction in crash involvement among the youngest drivers; similarly, in New Zealand, a 23% reduction in car crash injuries among novice drivers was found after implementation of a graduated licensing system (Langley, Wagenaar, & Begg, 1996). Similar findings were reported by Goodwin et al. (2005).
Driver’s education was challenged in the 1970s for its qualifying and placing of younger drivers at risk behind the wheel; it was then replaced with graduated licensing in the 1980s. Eventually, the combination of policy restraints and driver’s education demonstrated significant improvements in teen auto injury and death rates. This illustrates a principle that many of the innovations in alcohol-related policy described earlier have established. The lesson has been that educational or mass media strategies alone, or policies alone, do not work as well as the combination of the two. Sobriety checkpoints, as noted earlier, depend for their best effect on strong media coverage and public information. Driver’s education by itself, with its qualifying of younger drivers to get licensed to drive, only produced more young, inexperienced drivers. But when combined with graduated licensing, the combination had dramatic effects (Green & Gielen, 2015).
Recommendations About Policies and Alcohol
Policies for which there is the greatest experience and evidence include (a) retail price of alcohol; (b) minimum age for drinking or purchase of alcohol; (c) drinking/driving deterrence, especially via regular and highly visible enforcement such as random breath testing and sobriety checkpoints; (d) hours and days of alcohol sales; (e) responsible beverage service—alcohol serving and sales policies, training, and enforcement; (f) lower BAC limits for driving; (g) density and concentration of alcohol outlets; and (h) public retail monopolies. All of these are either targeted at the retail availability of alcohol or at drink driving. Most of the evidence concerning effects on adolescents is concentrated in minimum purchase/drinking age and retail price, though there is no reason that adolescents are impacted by the policies which target all drinkers as well. Much less policy evidence is available for potential effects on social availability of alcohol and on restrictions on promotion and advertising of alcohol to youth.
Tobacco accounted for an increasing number of cancer, cardiovascular, and respiratory illnesses and deaths in Western countries through the first two thirds of the 20th century. Efforts to control tobacco advertising and consumption that began most earnestly in the mid-1960s in English-speaking countries of North America, Europe, and Australia have resulted in dramatic reductions in most tobacco-related diseases in those countries and other jurisdictions with the most aggressive and effective policies and programs. Their cancer deaths continued to rise even after successfully reduced smoking because the incidence and mortality from cancer has a 20- to 30-year lag time between smoking and cancer. Despite the 50% reductions in smoking among adults, some one in five continue to smoke in the United States. Most promising for the future health of Americans, the current smoking rate of US high school students declined from 39% to 22% between 1976 and 2006. We will examine particularly the US experience in bringing this dramatic decline about, with lessons drawn also from studies of specific policy interventions in other countries.
More detailed accounts of European trends in policies related to tobacco control are contained in a document commissioned by the European Union’s Directorate-General for Health and Consumer Protection (Tiessen et al., 2010).
European tobacco control policies encompass a wide range of policy measures, including restrictions on cross-border advertising, harmonization of tobacco excise duties, initiatives to reduce exposure to secondhand smoke, recommendations for comprehensive tobacco control policies across EU Member States, and tobacco product regulation. One of the key instruments is the Tobacco Products Directive (2001/37/EC), which (p. 797) establishes maximum tar, nicotine, and carbon monoxide (TNCO) yields for cigarettes, specifies the labeling provisions, bans the use of misleading descriptors—such as “mild,” “light,” and so on—and bans the marketing of oral tobacco in the European Union (except in Sweden).
The status of policies and programs in other countries around the world is documented in annual reports of the World Health Organization’s MPOWER program of guidance and technical assistance to countries seeking to implement the Framework Convention on Tobacco Control (WHO, 2004, 2008; Yach & Wipfli, 2006).
Policy Directed at Adolescent and Young Adult Smoking
Most adult tobacco users initiated their use during adolescence. Some 80% of adult smokers began smoking before 18 years of age. Adolescent smokeless tobacco users also tend to be more likely than nonusers to become adult cigarette smokers (Centers for Disease Control and Prevention, 2003, 2007; Johnson, O’Malley, Bachman, & Schulenberg, 2011). Youth cigarette use in the United States declined sharply during 1997–2003; rates have remained relatively stable in more recent years (Centers for Disease Control and Prevention, 2010b). Smokeless tobacco use by youth also declined in the late 1990s and early 2000s, but an increasing number of US high school students have reported using smokeless tobacco products in recent years through 2010 (Centers for Disease Control and Prevention, 2010a). The late 1990s declines in adolescent tobacco use nationally, and sharp declines at other times in some states and cities hold important lessons about policy influences, advocacy, and enforcement strategies.
Factors Associated With Adolescent Tobacco Use
Like most other substance abuse by youth, adolescent tobacco use has been found widely associated with socioeconomic status; use and approval of tobacco use by peers or siblings; limited skills to resist influences to use tobacco; smoking by parents or guardians; lack of parental support or involvement; availability, accessibility, and price of tobacco products (Task Force on Community Preventive Services, 2014); perceptions that tobacco use is the norm among peers and the general population; low levels of academic achievement; low self-image or self-esteem; and aggressive behavior (e.g., fighting, carrying weapons).
Price: Higher Costs for Tobacco Products Through Increased Excise Taxes
Price proved to be the most powerful and independent predictor of tobacco consumption rates, especially among youth, because of their more limited disposable income and the lower price elasticity for them. Taxation on tobacco was the main policy lever for increasing prices, because government could not dictate the industry’s pricing. Increased taxes on tobacco were partially offset by industry lowering their prices. Taxation also produced revenue that supported, in part, state-wide comprehensive tobacco control programs.
The Community Preventive Services Task Force (2014) has established from its systematic reviews that the effects of price increases are multiple and substantial.
Total Demand (Changes in Use and Consumption of Tobacco Products)
A 20% increase in tobacco unit price would be associated with a 7.4% median reduction in demand among adults (16 studies, median price elasticity estimate: –0.37; interquartile interval [IQI]: –0.47 to –0.29) and a 14.8% median reduction in demand among young people (13 studies, median elasticity of –0.74; IQI: –1.13 to –0.57).
Prevalence of Tobacco Use
A 20% increase in tobacco unit price would be associated with 3.6% median reduction in the proportion of adults who use tobacco (26 studies, median elasticity of –0.18; IQI: –0.31 to –0.11) and a 7.2% median reduction in the proportion of young adults who use tobacco (22 studies, median elasticity of –0.36; IQI: –0.73 to –0.24).
Cessation of Tobacco Use
A 20% increase in tobacco unit price would be associated with a 6.5% increase in cessation among adults (one study, elasticity = 0.375) and an 18.6% median increase in cessation among young people (five studies, median elasticity of 0.93; IQI: 0.37 to 1.00).
Initiation of Tobacco Use
A 20% increase in tobacco unit price would be associated with an 8.6% median reduction in initiation among young people (seven studies, median elasticity of –0.43; IQI: –0.90 to –0.0).
The specific health-risk behaviors associated with tobacco use include high-risk sexual behavior, use of alcohol, and use of other drugs. How much of these (p. 798) associations are attributable to causation in one direction or the other, with tobacco use as a gateway drug or as a consequence of exposure to the other risk behaviors, cannot be conclusively answered and varies with contexts. The most plausible explanation for the associations is the covariance of both tobacco consumption and the other risk behaviors with common social influences, including environmental conditions conducive to smoking or nonsmoking behavior. Many of these influences are susceptible to modification or control through policy.
Counteradvertising Mass-Media Campaigns
Television and radio commercials, posters, and other media messages targeted toward youth to counter pro-tobacco marketing have been a particularly notable feature of comprehensive programs credited with reductions in adolescent tobacco use (Mukherjea & Green, 2015). One way such efforts have been found to achieve these successes is to raise broad awareness of the tactics used by the tobacco industry to “dupe” teenagers and other demographic groups into smoking (Campaign for Tobacco Free Kids, 2012a, b, c; Tobacco Education and Research Oversight Committee, 2014). The “Truth” campaign of Florida, later taken to scale nationally by the Legacy Foundation, presented youth with messages showing how deceptive and duplicitous tactics of the tobacco industry were seducing young people into desires to use tobacco. These counteradvertising tactics were shown to be effective in reducing teen smoking and engaging adolescents actively in supporting antitobacco campaigns and advocacy (Legacy Foundation, 2014).
In 2002, New York City launched a multipronged, phased initiative to reduce adult and youth smoking rates that included increasing the state’s tobacco excise tax, making workplaces smoke-free, expanding cessation services, providing tobacco education, and implementing an extensive television-based media campaign based in part on the “Truth” campaign model from Florida. Counteradvertising messages were broadcast at varying levels for 10 months. The state conducted a simultaneous antitobacco campaign for 12 months. From 2002 to 2006, adult smoking rates in the city declined 19% overall (see Figure 35.1). Among young adults aged 18 to 24 years, smoking declined 17% in the year after the implementation of the media campaign and 35% from the start of the broader initiative in 2002 (Centers for Disease Control and Prevention, 2007). Statistics on the New York City high school students show a 52% decrease in smoking in between 1997 and 2005 (CDC, 2007, 2010b, 2014a; http://www.nyc.gov/html/doh/downloads/pdf/survey/survey-2006teensmoking.pdf).
Strategies recommended for countermarketing and related mass communication campaigns are compiled in various federal government publications, including the Centers for Disease Control and Prevention (2003); Green et al. (2000); Schar et al. (2006) and National Cancer Institute (2002, 2005); and Sparks and Green (2000).
(p. 799) Comprehensive School-Based Tobacco-Use Prevention Policies and Programs (e.g., Tobacco-Free Campuses)
Systematic reviews have been inconclusive to negative on the singular effectiveness of school-based curricula or classroom interventions by themselves to prevent tobacco experimentation or uptake among youth. When adopted or tested without the support of school-wide smoke-free policies, classroom curricular interventions have been disappointing, but they appear to have been vindicated as a component of comprehensive school health and comprehensive school-based tobacco control (Centers for Disease Control and Prevention, 2014b; Green et al., 1985). Smoke-free schools have been the vanguard of local smoke-free legislation protecting youth, often in concert with smoke-free workplaces, restaurants, and public buildings to protect adults from secondhand smoke (Green & Gielen, 2015). These, together with mass media campaigns, have contributed to the “denormalization” of smoking, which has been a conscious strategy of some state programs, including the pioneer program of California (Rogers, 2010).
Policies and Programs to Increase Smoking Cessation
Another policy effort within comprehensive tobacco control programs has been to reduce barriers to access to and use of smoking cessation programs and supports. These have notably targeted the reduction of out-of-pocket costs of smoking cessation programs, including the costs of nicotine replacement drugs. The Community Preventive Task Force Services (2012b) has recently updated its previous review (Hopkins et al., 2001) of studies testing the effectiveness of policy or program changes that reduce tobacco users’ out-of-pocket costs and that make evidence-based treatments, including medication, counseling, or both, more affordable for people interested in quitting (Community Preventive Task Force Services, 2012b); also see similar reviews by Fiore et al. (2008) and the Cochrane Collaboration (Reda, Kotz, Evers, & van Schayck, 2009). Policies sought to achieve this either by providing new benefits or by changing the level of benefits offered to reduce costs or co-payments. These policies or interventions may also include promoting to tobacco users and health care providers the benefit of increased awareness and interest in quitting and use of evidence-based treatments. Of the 18 new studies reviewed (1999–2011), three were from Europe, including the United Kingdom (Dey et al., 1999), the Netherlands (Kaper et al., 2005, 2006), and Germany (Twardella & Brenner, 2007), nine had controlled trial designs, and nine had other evaluation designs. The studies showed a median increase of 2.8% in quit attempts. This outcome is considered important despite its limited assurance of effective quitting on the particular attempt because successful quitting is known to increase with the number of quit attempts. Twelve studies with 20 arms showed a median effective quitting rate of a 4.3 percentage point increase. Though modest, these improvements are particularly significant in relation to a major barrier to access and quitting among low-income and underserved populations.
Community, State, and National Interventions That Reduce Commercial Promotion and Availability of Tobacco Products
Besides the federal and state laws seeking to constrain advertising of tobacco products to youth, and commercial access to such products, communities have taken additional policy and program steps in these directions. These have included more aggressive enforcement of penalties for sales to minors younger than the state minimum age, laws removing cigarettes from vending machines, laws locking tobacco products behind counters, and laws restricting the proximity to schools of retail tobacco sales. The enforcement of sales-to-minors laws have included state and community “sting” operations in which younger-appearing adults are hired to request cigarettes in retail stores to determine whether they ask to see identification before making the sale.
The most sweeping US national policies on tobacco promotion following the Surgeon General’s Report (US Department of Health and Human Services, 1994) declaring the health hazards of smoking were the fair broadcasting doctrine of the late 1960s, which required equal time for counteradvertising of tobacco, and the Surgeon General’s warning statement on each package of tobacco. Nothing in tobacco control has approached the pervasive influence of these federal communication mandates (with the exception of increased taxes on tobacco) until the 2010 Congressional Act giving the Food and Drug Administration the authority to label all tobacco products with graphically explicit messages about the horrors of harm done by tobacco consumption. As the FDA moved toward field testing of graphic images and messages to implement this law, US District Court Judge Richard Leon ruled twice (after appeal of the first ruling) (p. 800) for tobacco companies and issued a permanent injunction blocking implementation of FDA’s new graphic health warnings.
The Campaign for Tobacco Free Kids has issued a statement saying:
It is incomprehensible that Judge Leon would conclude that the warnings are “neither factual nor accurate” when they unequivocally tell the truth about cigarette smoking—that it is addictive, harms children, causes fatal lung disease, cancer, strokes and heart disease, and can kill you. What isn’t factual or accurate about these warnings? Not even the tobacco industry disputes these facts.
To read more about this court decision, see, among news reports in February 2012: http://abcnews.go.com/US/wireStory/judge-blocks-graphic-images-cigarette-packages-15821958. See also on the general subject of warning labels and their impact in tobacco, Freeman et al. (2010) and Tiessen et al. (2010).
Global Tobacco Policy Initiatives
In the international context, the United States has had some important innovations and successes that have been emulated elsewhere, but it lags in other respects (Green et al., 2000; Tiessen et al., 2010). The World Health Organization (WHO) Report on the Global Tobacco Epidemic (2011) documents that in the previous 2 years, more than 1 billion people around the world had been newly protected by tobacco control interventions, including mass media campaigns, graphic health warnings, and various policies, including smoke-free public spaces. In addition, there has been significant progress toward protecting children and adults from tobacco in countries throughout the world, with policies controlling industry advertising and other marketing practices, and controls on smuggling, pricing, and sales.
Gruesomely graphic warning labels and hard-hitting mass media campaigns have proven effective in reducing tobacco use and encouraging people to quit. According to the report, more than 1 billion people now live in countries with legislation requiring large graphic health warnings on every cigarette pack sold in their countries, and 1.9 billion people live in the 23 countries that have aired high-quality national antitobacco mass media campaigns within the past 2 years. During this time in the United States, Congress authorized the Food and Drug Administration to issue requirements for more prominent, graphic cigarette health warnings on all cigarette packaging and advertisements in the United States.
According to the WHO report, 16 countries with a total of 385 million people have newly enacted national-level, smoke-free laws covering all public places and workplaces. Comprehensive smoke-free laws at the subnational level newly protect an additional 100 million people. In the United States over the past decade, 25 states and the District of Columbia enacted laws for smoke-free workplaces, bars, and restaurants. However, despite increased adoption of state and local smoke-free laws, approximately 88 million nonsmoking Americans aged 3 years and older are still exposed to secondhand smoke each year. More than half of children over age 3 years are exposed to secondhand smoke.
Unfortunately, the report also noted that though global governments collect nearly $133 billion in tobacco excise tax revenue, less that $1 billion is actually spent on tobacco control. In the United States, between 2000 and 2009, states collected $203.5 billion from tobacco settlement funds and tobacco taxes. Yet only 2% of annual tobacco-generated revenues ($25.3 billion) are being dedicated to state tobacco prevention and cessation programs; 14.6% would be needed to fund state tobacco control programs fully at CDC-recommended levels (Centers for Disease Control and Prevention, 2014a).
Tobacco use is the leading preventable cause of premature disease and death in the world. About half of all current smokers will die prematurely from smoking-related causes. In the 20th century, the tobacco epidemic killed 100 million people worldwide; during the 21st century, it will kill more than 1 billion unless urgent action is taken. Containing this epidemic is one of the most important public health priorities of our time.
Other highlights of this report include the following:
• The greatest progress in tobacco control in terms of population coverage has been in countries adopting health warnings on tobacco packaging; three more countries with a total population of 458 million have enacted recent pack labeling laws.
• An additional 115 million people are living in countries with the recommended minimum tobacco taxes, and 26 countries and one territory now have taxes constituting the recommended minimum of 75% of retail price.
(p. 801) • Low- and middle-income countries have been in the forefront of developing anti-tobacco mass media campaigns, showing that countries can successfully implement this intervention regardless of income classification.
To combat the tobacco epidemic, the Centers for Disease Control and Prevention and the World Health Organization recommend MPOWER, a set of six proven strategies: monitoring tobacco use and prevention policies; protecting people from tobacco smoke; offering help to quit tobacco use; warning about the dangers of tobacco; enforcing bans on tobacco advertising, promotion and sponsorship; and raising taxes on tobacco.
The Centers for Disease Control and Prevention oversees the Global Adult Tobacco Survey, which produces national and subnational estimates on tobacco use and key tobacco control indicators among adults aged 15 years and older, and the Global Youth Tobacco Survey, a school-based survey designed to monitor tobacco use and key tobacco control indicators among youth aged 13–15 years (Warren et al., 2000). Data from both surveys were used in compiling the Global Tobacco Epidemic 2011 report (Frieden, 2011).
Successful Reductions in Adolescent Tobacco Use
Some efforts have been made to rate the components of tobacco control efforts (e.g., Lipperman-Kreda, Friend, & Grube, 2014), but the conventional wisdom is that policies and programs must be interdependent and synergistic. If they fail to support and reinforce each other, they undermine or even cancel each other out. If they have the slightest inconsistency or contradictions, teenagers are quick to see hypocrisy in them and to dismiss them as adult propaganda and an excuse to act out their objection to adult control. Other reasons that the CDC’s Office on Smoking and Health (Centers for Disease Control and Prevention, 2014a) and others have concluded from the experience of statewide and community programs that “comprehensive” tobacco control must coordinate policies and programs is that they depend on each other for success, they must emanate from different levels of organizations and government, and each component of comprehensive programs differentially reaches different segments of the population (see Eriksen et al., 2010).
As seen in the drug control policy and practice (Reuter, 2013), tobacco policies are made more politically possible with an informed electorate, and they are more expediently passed with an outraged, or at least very concerned, public. These are facilitated by informational, educational, and motivational messages through various media and channels. For youth there is a need for mass media to provide a backdrop of messages and images that are consistent with those they receive from family and teachers, rather than inconsistent. Hollywood film images of smokers who are protagonists and magazine advertisements with images of glamorous models smoking, for example, send an inconsistent message about smoking from those presented in school by teachers or at home by concerned parents. Adolescents sometimes defiantly mock rules for nonsmoking in schools and other public places when they see them as adult control on behavior they perceive to be fashionable, cool, or even normative in the adult world to which they aspire.
A particular challenge to coordinated policies and programs is that the tobacco industry outspends state tobacco control programs at least $10 to $1, and up to $20 to $1 on media and marketing during political campaigns to raise taxes on cigarettes (because that alone among policies has a known independent effect on tobacco consumption, especially on adolescents who have less disposable income). Most political efforts to ban smoking in public places were successfully beaten back by tobacco industry lobbying at state and federal levels in the 1970s, but they were passed during those periods in most of the city and county initiatives because the industry could not put out the multiplicity of “brush fires” at the local level. Coordinating local and state policy and program efforts has been key to the notable successes of California and other states and municipalities. Localities, for example, cannot afford the high costs of mass media placements, and states cannot tailor all aspects of programs and policies to every jurisdiction where wide diversity exists. When each level of government and voluntary agency action coordinates and divides the labor of comprehensive programs and policies, the synergy produces more successful outcomes.
Based upon the 2012 US National Survey on Drug Use and Health (NSDUH), an estimated 23.9 million Americans aged 12 years or older had used at least one illicit drug within the past 30 days of their interview. Among American youth (ages 12–17 years), approximately 10% had used an illicit (p. 802) drug within the past month (Substance Abuse and Mental Health Services Administration, 2014).
Public policies concerning illicit drugs and adolescence are typically concerned with drug use, possession, retail sale, and production. While some of the same policy strategies exist (at least in name), drug policies are largely based upon deterrence and most often involve extensive use of law enforcement in most countries.
Retail Price and Illegal Drug Use
Although illegal, retail price of illegal drugs also affects the demand. Pacula et al. (2001) estimated that the price elasticity for use of marijuana in the last 30 days ranged from –0.002 to –0.69 such that a 10% increase in the cost of marijuana could produce as much as a 6.9% decrease in the number of youth who used in the last month. Other studies have also found that an increase in price yields decreased use of marijuana (De Simone & Farrelly, 2001; Pacula et al., 2001), cocaine (Caulkins, 1995), and heroin (Saffer & Chaloupka, 1999). The underlying assumption for law enforcement is that it will reduce supplies and costs to suppliers and thus increase retail prices. However, massive increases in drug enforcement during the past two decades in the United States have not had the expected effect; that is, prices for cocaine and heroin have fallen substantially without an evident decrease in demand (Caulkins, Reuter, & Taylor, 2006). Rydell and Everingham (1994) concluded, employing a series of mathematical models, that supply costs increase as producers replace seized product and assets, compensate drug traffickers for the risk of arrest and imprisonment, and devote resources to avoiding seizures and arrests. However, as drug researchers have noted (Caulkins et al., 2006; Reuter, 2001), retail drug markets are influenced by factors such as addiction, product illegality, and the role of violence. They point out that prohibition plus some modest but nontrivial level of enforcement can drive up drug prices beyond what they would be if drugs were legal. In summary, efforts to increase the price of illicit drugs through interdiction would appear to affect their use, although it is not clear that this will affect drug abuse. In that adolescents have less disposable funds than other age groups, the potential price effects for illicit drugs could be more significant for youth.
Retail and Social Availability of Illicit Drugs
All illicit drugs are retail products that are affected by both supply and demand factors. Illegal sales are accomplished more through social networks, especially for methamphetamine rather than cocaine or heroin sales. Methamphetamine dealers are more likely than cocaine and heroin dealers to sell out of single-family homes and to sell out of areas with fewer security measures (Eck, 1995; Rodriguez, Katz, Webb, & Schaefer, 2005). Drugs change hands multiple times between import (or production in the case of domestically manufactured drugs) and final sale to the user (Caulkins, 1997a, 1997b). As one moves down through the distribution hierarchy, transaction size gets smaller and the price per unit increases.
For example, methamphetamine sold in US drug markets is supplied by domestic labs and foreign producers, most notably the large “super labs” in Mexico that have become an increasingly important source in recent years. Analyses on the spatial relations between drug sales and use, however, suggest that associations may be more complex with drug sales occurring across neighborhoods (i.e., use is higher among residents of surrounding areas compared to those living in communities with drug markets; Freisthler, LaScala, Gruenewald, & Treno, 2005).
One implication of the substantial differential between the replacement cost of drugs and their retail value is that law enforcement efforts that remove drugs at the higher levels of the distribution system (where the replacement costs are relatively low) are less damaging to the drug trade than seizures made at the lower levels of the distribution hierarchy. Freisthler, Gruenewald, et al. (2005) examined the geographic relationships between availability and self-reported drug use. Use of illegal drugs was significantly positively related to sales of drugs in surrounding geographic areas for both youth (aged 12 to 18 years) and adults (those 19 years old and older). Interestingly, drug sales within any given area were unrelated to self-reported use among youth and negatively associated with use among adults. Thus, areas of greatest access—at least for adults—are not necessarily the areas of greatest use. Because drug markets are more likely to be located in places immediately adjacent to high drug use areas, prevention efforts may need to be located within different areas of communities to address the issues of sales, use, and related problems.
A unique version of cannabis retail distribution is the public policy to permit sale if a physician’s prescription is submitted. While often debated, there is concern that such availability increases adolescent use of cannabis. A recent study analyzed adolescent (p. 803) cannabis use from 2003 to 2011 comparing states which had a medical marijuana policy to those without such policies and found that there was no evidence of an increase in adolescent use associated with this policy (Lynne-Landsman, Livingston, & Wagenaar, 2013).
High-Level Law Enforcement to Disrupt Drug Importation and Distribution Operations
Efforts to interdict illicit drugs, including methamphetamine, are undertaken at various levels of government. The long-term effects of such interdiction efforts are tempered by several factors, including the relatively cheap replacement costs of drugs seized high in the distribution system and the adaptability of drug traffickers to modify their operations and find new supply routes and new sources of drugs.
Civil Remedies to Disrupt Local Drug Markets
While police crackdowns focus primarily on individuals (i.e., dealers and users), a number of civil remedies use actions targeted at drug selling locations to try to reduce the quantity of drugs sold by making it more difficult for buyers and sellers to engage in the drug trade. Eck and Wartell (1998) reported the results of a randomized study of abatement actions, with rental properties where drug sales had occurred being assigned to one of three conditions (letter sent to property owners informing them of drug sales and warning of fines or closure of the building if the problem continued; warning letter plus a request for a meeting between police and property owner; no abatement notice). Follow-up over the next 30 months indicated that significantly fewer crimes were reported in the two abatement conditions than in the control condition (see Eck, 2002). Another form of civil remedy, code enforcement, involves community groups using enforcement of local building codes, zoning laws, or health codes to pressure property owners to stop drug sales from being conducted inside or in front of residences. Little is known about the effectiveness of code enforcement in reducing drug activity. However, a study by Mazerolle et al. (2000) used a randomized experiment with 100 drug hotspots assigned to traditional police enforcement (surveillance, arrests, and field interrogation) or traditional police enforcement plus civil enforcement (abatement actions and code enforcement). The properties subject to the civil actions showed a decrease in drug sales and a decline in signs of disorder relative to the properties assigned to traditional police enforcement only.
Altering the Physical Environment to Hinder Drug Selling
Some community groups have used various strategies to alter the physical environment where drug sales are occurring (e.g., boarding up abandoned houses, cutting back shrubbery in parks, improving lighting) to deny drug dealers a safe haven for conducting business. Green (1996) found that not only did a program of code enforcement combined with police crackdowns not lead to displacement effects, but it resulted in diffused benefits to the surrounding area. Davis and Lurigio (1996) noted that while displacement is a serious possibility when local retail drug markets are disrupted, it often does not occur or the displaced activities are of a lesser magnitude such that benefits associated with a local intervention may accrue to the surrounding areas.
Summary of Drug Policies
Drug policies and public health approaches to prevention have not been evaluated as extensively as those concerning alcohol and tobacco. The Committee on Data and Research for Policy on Illegal Drugs of the United States (2001) points to the need for data and research information that policymakers lack in order to create effective national policy concerning illicit drugs. The Drugs and Public Policy Group (2010) summarized key points concerning international evidence on drug policy to include the following: (1) there is scientific evidence that can inform drug policy development, especially concerning health services for drug dependency but that policies with little evidence of effectiveness are most preferred in many countries, (2) no single policy can solve the drug problem in any country, (3) increasing law enforcement efforts against drug dealers has diminishing returns and does not result in large price increases beyond which might occur with routine enforcement, (4) opiate treatment has the ability to reduce drug problems related to that use, (5) there is limited scientific evidence to guide law enforcement policies of interdiction against drug supply and related incarnation of offenders, and (6) drug policies should be not evaluated only in terms of their intended effects but also in terms of the unintended effects (which might in some situations be worse than the status quo). An international review of drug policies conducted by Greenfield and Paoli (2012) found a number (p. 804) of contradictions and inefficiencies in supply-side policies and suggested a harm reduction policy approach, thus marking clearer distinction between the two policy approaches.
The most recent change in drug policy in the United States is the unprecedented legalization of the production and retail sale of cannabis to adults in 11 states by 2018, though still illegal by federal law. This follows a number of states that have established the policy for medical marijuana. In an editorial, Hawken et al. (2013) expressed concern about the unknown impacts and public health and safety consequences of these policies and the limited research knowledge about the associated risks. Such research concerning these drug policies will be needed over upcoming years for a complete evaluation.
Evidence About Public Policies—Practice Evidence and Research Evidence
Substances and products used by adolescents, including alcohol, tobacco, and illicit drugs, are produced, distributed, and sold by a substantial domestic and international collection of establishments, organizations, informal consortiums, and companies. The increased expansion of this multifaceted industry has been discussed for alcohol by Babor, Caulkins, et al. (2010), for tobacco by The World Health Organization (WHO) Report on the Global Tobacco Epidemic (2011), and for drugs by Babor, Caetano, et al. (2010). This expansion has unique effects on countries that have fewer historical traditions and experiences with commercially produced and distributed substances of abuse. While indigenous (often informal, family or small group) based alcohol and illicit drug production have typically existed in such countries, they are often displaced with more modern and cost-effective production and distribution technologies. Such countries as well as more industrially developed nations can take advantage of public policies that seek to reduce harm. In terms of the effects of public policies on alcohol, tobacco, and drug use and related problems, there is substantial evidence from scientific studies or evaluations from many countries, especially on tobacco control, from North America (Partos et al., 2013), Europe (Tiessen et al., 2010), Australia (Freeman, Gartner, Hall, & Chapman, 2010), and New Zealand (Salmond, Crampton, Atkinson, & Edwards, 2012). Thus, there is guarded confidence in the potential of many of the public policies described in this chapter to reduce adolescent use and associated alcohol problems. Examples of efforts to summarize international evidence on alcohol policy effects include Babor, Caetano, et al. (2010), which provides a summary of research as well as indications of evidence weakness or limitations, and Casswell et al. (2012). The book by Babor and colleagues is the fourth such book written by a collection of international alcohol researchers from many countries, which began with the first such publication (Bruun et al., 1975). Other such reports were Edwards et al. (1994, 1995) and Babor et al. (2003). A specific review of evidence concerning adolescents and public policy can be found in Grube and Nygaard (2005). An important international summary of policy research concerning illicit drugs is provided by Babor, Caulkins, et al. (2010).
Another effort to independently evaluate the overall weight of evidence concerning policies has been carried out by the US Centers for Disease Control via its program “Using Evidence for Public Health Decision Making: Preventing Excessive Alcohol Consumption and Related Harms,” which summarizes recommended strategies for reducing alcohol problems.
The cumulative international evidence is that public health policy approaches have demonstrated potential to reduce harm from and use of alcohol, tobacco, and illicit drugs, and in many instances such policies have specific effects for adolescents. This evidence can increase the confidence for policymakers that evidence-based policies have strong potential to reduce substance abuse problems in the 21st century.
Further research on the effects of public policies to reduce the harms associated with alcohol, tobacco, and drugs will always be useful and welcomed. However, an essential challenge for policies concerning substances in the future will be examining the barriers and opportunities for the implementation of policies to reduce the harm related these substances. Such challenges most certainly include political, cultural, and economic issues.
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