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Philip J. Cook is professor of public policy and economics at Duke University and former director of the university's Sanford Institute of Public Policy. His books include "Gun Violence, The Winner-Take-All Society", and "Selling Hope".

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"There is a vast literature on the illicit drugs, a large literature on nicotine, and nothing up-to-date and authoritative on the second most deadly, and arguably the most damaging, alcohol. Phil Cook, with a modesty and understatement that inspire trust, explores the options for reducing the harms, allowing the benefits, and respecting personal liberty. This is a masterly combination of analysis and evidence. It is also beautifully written."--Thomas C. Schelling, Nobel Prize-winning economist

"The war on tobacco was won: the harms were recognized and measures taken to reduce them. In this compelling book, Philip Cook shows that the war on alcohol, too, can be won if policymakers act on the overwhelming and converging evidence that simple measures can reduce the short-term and long-term harms caused by drinking. He brings order to a highly complicated set of causal issues by telling us what may be true, what is probably true, and what is indisputably true; and he shows how large gains can be made simply by taking account of the last set of facts."--Jon Elster, Columbia University

"This book contains the most thorough and penetrating analysis of alcohol-control policy to date. It is certain to become a landmark in the fields of health, economic, and public policy. It is a tour de force of virtually every aspect required to formulate sound policy in this crucial area. Bravo!"--Michael Grossman, City University of New York Graduate Center

"No previous book has brought alcohol policy issues together as comprehensively and set them in context as effectively as this one does. Perhaps most impressive is its author's ability to incorporate research from many fields and to translate this evidence and the evidence from his original analyses into a book that is both highly readable and accessible to a wide audience--an audience ranging from policy researchers and policymakers to public health professionals, historians, economists, and general readers."--Frank J. Chaloupka, University of Illinois, Chicago, and director of ImpacTeen

"Paying the Tab is unequivocally a major contribution to the field. Fully covering issues on both the supply and demand side of the market, with a wealth of new data, it provides the most comprehensive discussion of alcohol control that I am aware of. Economists will benefit tremendously from its presentation of the context for our current approach to the issue, and noneconomists will welcome the clear yet complete exposition of the methods used by economists to evaluate public policy."--Sara Markowitz, Rutgers University

Aus dem Klappentext

"There is a vast literature on the illicit drugs, a large literature on nicotine, and nothing up-to-date and authoritative on the second most deadly, and arguably the most damaging, alcohol. Phil Cook, with a modesty and understatement that inspire trust, explores the options for reducing the harms, allowing the benefits, and respecting personal liberty. This is a masterly combination of analysis and evidence. It is also beautifully written."--Thomas C. Schelling, Nobel Prize-winning economist

"The war on tobacco was won: the harms were recognized and measures taken to reduce them. In this compelling book, Philip Cook shows that the war on alcohol, too, can be won if policymakers act on the overwhelming and converging evidence that simple measures can reduce the short-term and long-term harms caused by drinking. He brings order to a highly complicated set of causal issues by telling us what may be true, what is probably true, and what is indisputably true; and he shows how large gains can be made simply by taking account of the last set of facts."--Jon Elster, Columbia University

"This book contains the most thorough and penetrating analysis of alcohol-control policy to date. It is certain to become a landmark in the fields of health, economic, and public policy. It is a tour de force of virtually every aspect required to formulate sound policy in this crucial area. Bravo!"--Michael Grossman, City University of New York Graduate Center

"No previous book has brought alcohol policy issues together as comprehensively and set them in context as effectively as this one does. Perhaps most impressive is its author's ability to incorporate research from many fields and to translate this evidence and the evidence from his original analyses into a book that is both highly readable and accessible to a wide audience--an audience ranging from policy researchers and policymakers to public health professionals, historians, economists, and general readers."--Frank J. Chaloupka, University of Illinois, Chicago, and director of ImpacTeen

"Paying the Tab is unequivocally a major contribution to the field. Fully covering issues on both the supply and demand side of the market, with a wealth of new data, it provides the most comprehensive discussion of alcohol control that I am aware of. Economists will benefit tremendously from its presentation of the context for our current approach to the issue, and noneconomists will welcome the clear yet complete exposition of the methods used by economists to evaluate public policy."--Sara Markowitz, Rutgers University

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Paying the Tab

Princeton University Press

Chapter One

We all pay the tab for cheap drinks.

EXCESS DRINKING IS A problem for millions of Americans and their families. It is also a problem for the communities in which they live, degrading public health and safety and ultimately lowering our standard of living. The public response to this problem has varied over time, but always with some mix of two general approaches. On the one hand are efforts, both public and private, to reduce excess drinking directly-education, persuasion, counseling, treatment, sanctions of various sorts. On the other hand are measures to reduce excess drinking by restricting availability or raising the price-licensing, product and sales regulation, liability rules, taxes, partial or complete bans. Both approaches can be effective. Yet during the last half century the public policy "mix" has largely neglected the second approach.

In fact, the post-World War II history has seen a long downward drift in prices (adjusted for inflation) together with a general weakening of other restrictions on availability, all without much discussion of what is being lost. To the extent that alcohol has had any prominence on the policy agenda, it has been primarily in connection with drunk driving. A grassroots movement led by Mothers Against Drunk Driving (MADD) and other such groups has succeeded in promoting tougher laws and stronger enforcement. As one consequence of this movement, Congress adopted a national minimum drinking age of twenty-one in 1984 primarily in the hope of reducing the fatal accident rate for teen drivers. These efforts have been quite successful in reducing drunk driving for both teens and adults. However, the "alcohol problem" is by no means limited to the highways. Our policy portfolio should respond to the full array of harms. The regulation of price and availability-alcohol-control measures-has great albeit neglected potential in that role.

Fortunately there has been enough interest in alcohol-control measures to support a research program by economists, epidemiologists, and other scientists. We now have a quarter century of research results on the causal effects of alcohol-control measures on drinking, abuse, and a wide array of consequences. This research has helped develop the case that the price and availability (both commercial and social) of alcohol affect the amount of alcohol-related harm to society. Although researchers in this area are often labeled "neo-prohibitionists" by industry spokespersons, in fact our work is more closely aligned with the alcohol-beverage-control movement of the 1930s that was the successor to Prohibition. The evidence suggests that higher excise taxes and some additional restrictions on marketing would save lives and pass the cost-benefit test. The goal is not prohibition, but moderation.

A BRIEF HISTORY

What is the problem to which alcohol policy is responding? The predominant answer has changed over the course of American history, and policy choices have followed. The first Congress met at a time (the 1790s) when heavy drinking was the norm. Alexander Hamilton, our first Secretary of the Treasury, advocated a domestic whiskey tax to raise revenue, noting that if it also promoted moderation in drinking, that would be all to the good. During the nineteenth century, alcohol became the matter for a broad moral crusade, which waxed and waned and waxed again. By the 1880s, the Women's Christian Temperance Union was denouncing alcohol itself (rather than the abuse of alcohol) as the problem, and actually persuaded most of the state legislatures to mandate WCTU-approved textbooks that labeled alcohol a poison and described at length its various deleterious effects on the body. Advocacy groups of that day also denounced the industry that supplied alcohol, saying that it lured working men into spending money on drinking and other vices, depriving their families of desperately needed necessities. The Anti-Saloon League eventually led the way to adoption of the prohibition amendment, implemented in 1920. But this Great Experiment proved a considerable disappointment. After a dozen years of ambivalent enforcement by federal and state governments, coupled with corruption and gang violence, most of the public and particularly the business community became disillusioned. The new voice of reason, led by business tycoon John D. Rockefeller Jr. and other plutocrats, favored repeal of national prohibition, to be replaced by state alcoholic-beverage-control systems and taxes that would, they believed, create an orderly legal market that was conducive to moderate drinking.

Along with repeal, the 1930s also saw the beginnings of an entirely different conception of the alcohol problem (Moore 1990). The founding and great success of Alcoholics Anonymous, coupled with well-publicized research by Yale scientist Edward Jellinek and the efforts of the National Council of Alcoholism, engendered a new "scientific" understanding. The locus of the problem was shifted from alcohol itself to that small fraction of the population who were vulnerable to alcoholism. Most people, it was thought, could drink safely and moderately-for them alcohol was not a problem-but for those relative few who were vulnerable, drinking posed a great risk. Given this new definition of the alcohol problem, the logical policy solution was not to control supply of the substance, but rather to help the unlucky ones who couldn't handle it. Alcoholism was the problem, alcoholism was a disease, and the right response was to encourage abstinence by those so afflicted. The liquor industry gladly bought into this perspective, since it exonerated their product from blame. Alcoholism research and treatment were established as national health priorities with the creation of the National Institute on Alcoholism and Alcohol Abuse (NIAAA) in 1970.

The alcoholism agenda is worthy but narrow. Programs to identify and treat individuals who have become dependent on alcohol inevitably miss a large portion of youthful abuse, drunk driving, alcohol-fueled domestic violence, and other problems, and bypass important opportunities for the prevention of alcohol dependence and abuse. Even Dr. Jellinek, the godfather of the alcoholism movement, recognized the importance of the social context; he suggested that whether someone with an innate propensity for alcoholism would actually develop the disease depends in part on whether he was living in a wet or dry environment. Thus, an effective prevention program must address the community's involvement in alcohol, not just the involvement of those members who have become dependent. In support of this perspective, an international group of researchers began writing about alcohol as a public health problem during the 1960s. The leaders included Milton Terris and Robin Room in the United States, Griffith Edwards in Britain, Wolfgang Schmidt and Robert Popham in Ontario, Kettil Bruun and Ole-Jrgen Skog in Scandinavia, and others. A number of these pioneers published a brief, elegant book in 1975 with sponsorship from the World Health Organization, making the case for a population-based, evidence-driven, multifaceted, pragmatic approach (Bruun et al. 1975). In the United States, a similar case was made in the report Alcohol and Public Policy by an expert panel assembled by the National Academy of Sciences under the leadership of Harvard public policy professor Mark H. Moore. The report was subtitled Beyond the Shadow of Prohibition (Moore and Gerstein 1981), but it could just as well have been subtitled Beyond the Shadow of Alcoholism.

A comprehensive community-oriented approach continues to be touted by the public health community, but perhaps with more success in Ontario and northern Europe than in the United States. Here public attention came to focus more narrowly on the particular concern of drunk driving. During the 1980s, MADD emerged as a force to be reckoned with by judges and legislatures, advocating effectively for the sensible position that DUI (driving under the influence) was a crime that should be taken more seriously by law enforcement and the courts. One important sidebar to this effort was a law establishing a national minimum drinking age of twenty-one, which Congress, moved by evidence on drunk driving fatalities caused by teenagers, accomplished in 1984. Since then the alcohol "problem" has been equated in most public discourse with drunk driving and underage drinking; whatever political energy exists behind alcohol control has focused on these issues. The fate of alcohol control contrasts markedly with the recent success of advocates promoting tobacco control and taxation.

TOBACCO CONTROL

In an era where the public is generally hostile to tax increases, the tobacco tax has become fair game for legislatures around the country. In 2002, for instance, New York State raised its tax to $1.50 per pack, and New York City added another $1.50, up from just 8 cents. Since then, the New York street vendors who import their packs (illegally) from lower-tax areas are known as the "$5 men," in reference to the price they charge; remarkably, it is a multiple of the legal price just a few years earlier. Other jurisdictions have joined in the tax-raising jamboree. Between 2000 and 2005, forty-two states and the District of Columbia enacted sixty-three cigarette-tax increases, with nineteen states exceeding $1 per pack. Besides the obvious attraction of bringing in revenue, these taxes are touted as improving the public health by encouraging confirmed smokers to quit or cut back, and by discouraging youths from developing the habit in the first place. These claims do encounter some skepticism. Indeed, it wasn't so long ago that most savvy commentators insisted that smokers' addiction would survive any sort of price increase, and adolescents would always find a way to experiment. But the evidence that price matters when it comes to smoking, accumulated over many years of careful study, is compelling. Death and taxes are both inevitable, but in this case there is a trade-off (Phelps 1988).

Meanwhile, alcohol taxes have received much less attention from state legislatures. State legislatures raised alcohol excise taxes just eight times during the period 2002 to 2005, and all of these increases were modest in magnitude. Why the difference with tobacco? True, fewer people die from drinking than smoking each year, but the alcohol-related death count is still considerable, on the order of 75,000 to 100,000, as compared with 435,000 deaths due to tobacco (Mokdad, et al. 2004; Midanik et al. 2004). Most of these drinking deaths are the result of injury, taking a heavy toll on children and young adults. And unlike most smoking deaths, a sizable share of the drinking deaths involve innocent bystanders-victims of drunk drivers, victims of arguments transformed into deadly assaults due to intoxication, victims who are children abused or neglected by alcoholic parents.

Furthermore, the evidence supporting the public health benefits of increased alcohol taxes is every bit as strong as for cigarette taxes. An increase in the average prices of beer or liquor induced by a tax increase would reduce per capita alcohol consumption, the incidence of alcohol abuse by youths and adults, and the rate of accidents and crimes resulting from abuse. Over the long run, higher alcohol prices would reduce the prevalence of alcoholism and organ damage associated with chronic excess consumption. As in the case of tobacco, a small increase in tax would have a small effect on the public health, a large increase in tax a larger effect. These conclusions are solidly grounded in the evidence compiled by economists and public health researchers.

The divergence between alcohol and tobacco policy is not just for excise taxes, but for other regulations as well. In the late 1990s, at the insistence of the state attorneys general, the tobacco industry agreed to eliminate vending machines and restrict marketing practices in a number of ways. The National Association for Stock Car Auto Racing (NASCAR) Winston Cup series has changed its name and tobacco companies no longer are allowed to sponsor cars and drivers; meanwhile, NASCAR allowed liquor companies to serve as sponsors for the first time in 2004.

Why, then, have legislators pushed up tobacco taxes and tightened controls while neglecting alcohol policy? It is no doubt relevant politically that over twice as many Americans drink as smoke, and the drinkers are as a group more influential politically-they tend to be better educated, richer, and less ambivalent. (Most smokers say that they want to quit. Most drinkers express no such aspiration.) Beyond that political reality, the public health argument for seeking a reduction in drinking has been confused in recent years by evidence that drinking is not all bad. Alcohol appears to be a potent anticholesterol drug that, "taken" in moderation in middle age, may actually extend life. On the other hand, smoking in any amount at any age is harmful. And finally, the public and the legislators they elect are not necessarily reading the latest research on alcohol price effects. Ordinary people (not including economists) may remember that we tried national Prohibition a while back and it proved disastrous. Does it make sense that an increase in taxes and tighter regulations would succeed where a total ban failed?

THE EVIDENCE

In what follows, I make an effort to explain the nature of this research evidence in some detail, and in a number of instances provide new results. Because it is not possible to run experiments with alcohol-control measures, making reliable causal inferences is a challenge. Much of the evidence that is most persuasive comes from analyzing the "quasi-experiment" generated by states' changing their policies. For example, the effect of the minimum drinking age law on highway fatality rates can be estimated by comparing changes in youthful highway fatalities in states that changed their minimum with states that didn't; between 1970 and 1988 there were scores of such changes, which together provide the basis for reliable inferences about what difference minimum age laws can make.

The goal here is to get beyond intuition. There is a powerful tendency to assess social-science research findings on the basis of prior beliefs, since in a sense everyone's an expert. If we are already inclined to believe a new research result, then we welcome it as support for our views. If it contradicts our prior beliefs, then we feel free to ignore it; after all, it may be based on faulty methods or poor data, and in any event it will probably be contradicted by another social scientist in the near future. In my experience most people's intuition tells them that prices and regulations simply don't matter, or don't matter much, when it comes to drinking-that drinkers decide whether and how much and in what circumstances to drink for reasons that are scarcely affected by prices and availability. A summary of research results is not going to persuade most people to abandon this intuition, since that would require that they do the hard work of reinterpreting their personal observations. For that reason I aspire to provide enough detail about data and research methods that it cannot be dismissed too easily.

(Continues...)

Excerpted from Paying the Tabby Philip J. Cook Copyright © 2007 by Princeton University Press . Excerpted by permission.
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