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

BACKGROUND: In August 2000, the Minnesota Department of Health was notified of and investigated an outbreak of febrile respiratory illness among workers at a sugar-beet processing plant. METHODS: A case was defined as fever and respiratory symptoms occurring in a worker at the sugar-beet plant on or after 31 July 2000. Case patients were interviewed, medical and work records were reviewed, and clinical samples were obtained. The plant was inspected, and environmental samples were collected. RESULTS: Fourteen of 15 case patients performed high-pressure water cleaning in the confined space of an evaporator vessel. Symptoms included fever and chills (100%), chest tightness (93%), cough (80%), and shortness of breath (73%). In case patients, median temperature was 39.4 degrees C, median oxygen saturation was 93%, and median white blood cell count was 12x10(3) cells/ mu L. Four (29%) of 14 case patients showed evidence of Legionella pneumophila exposure, according to serologic testing. Water sources contained up to 10(5) cfu/mL of L. pneumophila and 22,200 endotoxin units/mL. CONCLUSIONS: Outbreak features were consistent with Pontiac fever. Respiratory symptoms, which are atypical for Pontiac fever, could be attributed to a high exposure dose of L. pneumophila from confined-space aerosolization or to endotoxin exposure. This outbreak demonstrates the potential occupational hazards for those performing high-pressure cleaning in confined spaces. Copyright © 2006 Infectious Diseases Society of America [ABSTRACT FROM AUTHOR]

OBJECTIVES: We estimated adult binge drinking prevalence in US metropolitan areas. METHODS: We analyzed 1997 and 1999 Behavioral Risk Factor Surveillance System data for 120 metropolitan areas in 48 states and the District of Columbia. RESULTS: The prevalence of binge drinking varied substantially across metropolitan areas, from 4.1% in Chattanooga, Tenn, to 23.9% in San Antonio, Tex, (median = 14.5%). Seventeen of the 20 metropolitan areas with the highest estimates were located in the upper Midwest, Texas, and Nevada. In 13 of these areas, at least one third of persons aged 18 to 34 years were binge drinkers. There were significant intrastate differences for binge drinking among metropolitan areas in New York, Tennessee, and Utah. CONCLUSIONS: Metropolitan-area estimates can be used to guide local efforts to reduce binge drinking. [ABSTRACT FROM AUTHOR]

Context: Methicillin-resistant Staphylococcus aureus (MRSA) has traditionally been considered a health care-associated pathogen in patients with established risk factors. However, MRSA has emerged in patients without established risk factors (community-associated MRSA).Objective: To characterize epidemiological and microbiological characteristics of community-associated MRSA cases compared with health care-associated MRSA cases.Design, Setting, and Patients: Prospective cohort study of patients with MRSA infection identified at 12 Minnesota laboratory facilities from January 1 through December 31, 2000, comparing community-associated (median age, 23 years) with health care-associated (median age, 68 years) MRSA cases.Main Outcome Measures: Clinical infections associated with either community-associated or health care-associated MRSA, microbiological characteristics of the MRSA isolates including susceptibility testing, pulsed-field gel electrophoresis, and staphylococcal exotoxin gene testing.Results: Of 1100 MRSA infections, 131 (12%) were community-associated and 937 (85%) were health care-associated; 32 (3%) could not be classified due to lack of information. Skin and soft tissue infections were more common among community-associated cases (75%) than among health care-associated cases (37%) (odds ratio [OR], 4.25; 95% confidence interval [CI], 2.97-5.90). Although community-associated MRSA isolates were more likely to be susceptible to 4 antimicrobial classes (adjusted OR, 2.44; 95% CI, 1.35-3.86), most community-associated infections were initially treated with antimicrobials to which the isolate was nonsusceptible. Community-associated isolates were also more likely to belong to 1 of 2 pulsed-field gel electrophoresis clonal groups in both univariate and multivariate analysis. Community-associated isolates typically possessed different exotoxin gene profiles (eg, Panton Valentine leukocidin genes) compared with health care-associated isolates.Conclusions: Community-associated and health care-associated MRSA cases differ demographically and clinically, and their respective isolates are microbiologically distinct. This suggests that most community-associated MRSA strains did not originate in health care settings, and that their microbiological features may have contributed to their emergence in the community. Clinicians should be aware that therapy with beta-lactam antimicrobials can no longer be relied on as the sole empiric therapy for severely ill outpatients whose infections may be staphylococcal in origin. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To assess the relationship between unintended pregnancy resulting in a live birth and binge drinking (having 5 or more alcoholic beverages on 1 occasion) in the 3 months before pregnancy (the preconception period) and to characterize women who are of childbearing age and binge drink. METHODS: A case-control study was conducted of women with pregnancies that resulted in a live birth, comparing those with unintended pregnancies with those with intended pregnancies. Data analyzed were from the 15 states that participated in the Pregnancy Risk Assessment Monitoring System from 1996-1999. RESULTS: Of 72 907 respondents, 45% of pregnancies were unintended. Compared with women with intended pregnancy, women with unintended pregnancy were more likely to be young and black and to report preconception binge drinking (16.3% vs 11.9%; odds ratio [OR]: 1.43; 95% confidence interval [CI]: 1.13-1.54). After adjusting for potential confounders, preconception binge drinking was associated with unintended pregnancy for white women (adjusted OR: 1.63; 95% CI: 1.47-1.80) but not for black women (adjusted OR: 0.96, 95% CI: 0.77-1.20). Overall, 14% of women reported preconception binge drinking. Women who binge drank in the preconception period were more likely to be white and unmarried; to smoke and be exposed to violence in the preconception period; and to consume alcohol, binge drink, and smoke during pregnancy. CONCLUSIONS: Binge drinking in the preconception period was associated with unintended pregnancies resulting in a live birth among white women but not among black women. Preconception binge drinkers were more likely to engage in other risky behaviors, including drinking during pregnancy. Comprehensive interventions to reduce binge drinking may reduce unintended pregnancies, as well as other adverse maternal and pediatric health outcomes. [ABSTRACT FROM AUTHOR]

Background: College is a critical life stage for alcohol-related harms to others (AHTOs), gender, and sexual identity. We tested associations between inclusively-defined gender and sexual identities (separately) and AHTOs among college students., Methods: The Healthy Minds Study (n = 8,308) provided data about three AHTOs: (1) babysitting a drunk student, (2) alcohol-related unwanted sexual advance, and (3) alcohol-related sexual assault. Independent variables included gender and sexual identity., Results: One in four students (25.5%) reported babysitting, 6.2% reported unwanted advances, and 1.2% reported sexual assaults. Compared to cisgender males, cisgender females had higher odds of reporting babysitting ( aOR  = 1.36, p  < 0.001) and unwanted advances ( aOR  = 2.59, p  < 0.001); trans masculine students had higher odds of reporting sexual assaults ( aOR  = 4.49, p  = 0.04)., Conclusions: AHTOs are prevalent on college campuses, and cisgender female and trans masculine students have higher odds of experiencing them. Alcohol interventions may protect cisgender female and gender minority students from the drinkers around them.

Introduction: Alcohol use is involved in a large proportion of homicides and suicides each year in the U.S., but there is limited evidence on how policies targeting alcohol influence violence in the U.S., Context: Extant studies generally focus on individual policies in isolation of each other. This study examines the impacts of changes in states' alcohol policy restrictions on overall homicide and suicide rates and firearm-related homicide and suicide rates using a holistic measure of states' alcohol policy environments., Methods: Using a composite measure of state-level alcohol policies (Alcohol Policy Scale) and data from the National Vital Statistics System from 2002 to 2018, this study applied a Bayesian time series model to estimate the impacts of alcohol policy changes on overall and firearm-involved homicide and suicide rates. The analysis was performed in 2023 and 2024., Results: A 1 SD change in the Alcohol Policy Scale was associated with a 6% decline in homicide rates both overall (incident rate ratio=0.94; 95% credible interval = 0.89, 1.00) and for firearm homicides specifically (incident rate ratio=0.94, 95% CI=0.88, 1.01). There was no clear association of alcohol policy with suicides. The model predicts that a nationwide increase in alcohol restrictions equivalent to a shift from the 25 th to 75 th percentile of the scale's distribution would result in almost 1,200 fewer homicides annually., Conclusions: Increases in the restrictiveness of state-level alcohol policies are associated with reductions in homicides. More restrictive alcohol policy environments may offer an opportunity to reduce homicides., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To systematically assess the Canadian federal government's current alcohol policies in relation to public health best practices., Methods: The 2022 Canadian Alcohol Policy Evaluation (CAPE) Project assessed federal alcohol policies across 10 domains. Policy domains were weighted according to evidence for their relative impact, including effectiveness and scope. A detailed scoring rubric of best practices was developed and externally reviewed by international experts. Policy data were collected between June and December 2022, using official legislation, government websites, and data sources identified from previous iterations of CAPE as sources. Contacts within relevant government departments provided any additional data sources, reviewed the accuracy and completeness of the data, and provided amendments as needed. Data were scored independently by members of the research team. Final policy scores were tabulated and presented as a weighted overall average score and as unweighted domain-specific scores., Results: Compared to public health best practices, the federal government of Canada scored 37% overall. The three most impactful domains-(1) pricing and taxation, (2) marketing and advertising controls, and (3) impaired driving countermeasures-received some of the lowest scores (39%, 10%, and 40%, respectively). Domain-specific scores varied considerably from 0% for minimum legal age policies to 100% for controls on physical availability of alcohol., Conclusion: Many evidence-informed alcohol policies have not been adopted, or been adopted only partially, by the Canadian federal government. Urgent adoption of the recommended policies is needed to prevent and reduce the enormous health, social, and economic costs of alcohol use in Canada., (© 2024. The Author(s).)

Alcohol is a favorite psychoactive substance of Canadians. It is also a leading risk factor for death and disability, playing a causal role in a broad spectrum of health and social issues. Alcohol: No Ordinary Commodity is a collaborative, integrative review of the scientific literature. This paper describes the epidemiology of alcohol use and current state of alcohol policy in Canada, best practices in policy identified by the third edition of Alcohol: No Ordinary Commodity , and the implications for the development of effective alcohol policy in Canada. Best practices - strongly supported by the evidence, highly effective in reducing harm, and relatively low-cost to implement - have been identified. Measures that control affordability, limit availability, and restrict marketing would reduce population levels of alcohol consumption and the burden of disease attributable to it., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Crépault, Naimi, Rehm, Shield, Wells, Wettlaufer and Babor.)

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

Objective: A crucial question regarding the public health impacts of cannabis legalization is its impact on alcohol consumption and alcohol-related harm. However, little is known about whether these changing cannabis policies are occurring in liberal or in restrictive alcohol policy environments, either of which likely affect public health outcomes. We constructed comprehensive state-level alcohol and cannabis policy indices and explored relationships between them., Method: We assessed relationships between the Alcohol Policy Scale (APS) and the Cannabis Policy Scale (CPS) from 1999 to 2019. The APS and CPS were based on 29 and 17 state-level policies, respectively, and each policy was weighted for its relative efficacy and degree of state-year implementation., Results: From 1999 to 2019, average state APS scores increased modestly (became more restrictive) by 4.11 points (2019 M = 43.23, range: 24.44-66.31) and average CPS scores decreased (became less restrictive) by 15.33 points (2019 M = 76.40, range: 29.40-95.74) on a 100-point scale. In 2019, average APS scores were similar among states that prohibited (criminalized) possession of cannabis (42.00), decriminalized possession (41.33), legalized medical cannabis (44.36), and legalized recreational cannabis (43.32). Across states, there was no correlation between the restrictiveness of state-level alcohol and cannabis policies ( r = .03, p = .37) in unadjusted models, although there was some variation by time, geographic region, and political party, with a weak negative correlation in state fixed-effects models., Conclusions: Although cannabis policies liberalized rapidly from 1999 to 2019, alcohol policies stayed relatively stable and did not differ by degree of cannabis policy liberalization. In general, there were weak associations between cannabis and alcohol policies among states; however, there was some temporal, regional, and political variation.

Deaths from causes fully attributable to alcohol use have increased during the past 2 decades in the United States, particularly from 2019 to 2020, concurrent with the onset of the COVID-19 pandemic. However, previous studies of trends have not assessed underlying causes of deaths that are partially attributable to alcohol use, such as injuries or certain types of cancer. CDC's Alcohol-Related Disease Impact application was used to estimate the average annual number and age-standardized rate of deaths from excessive alcohol use in the United States based on 58 alcohol-related causes of death during three periods (2016-2017, 2018-2019, and 2020-2021). Average annual number of deaths from excessive alcohol use increased 29.3%, from 137,927 during 2016-2017 to 178,307 during 2020-2021; age-standardized alcohol-related death rates increased from 38.1 to 47.6 per 100,000 population. During this time, deaths from excessive alcohol use among males increased 26.8%, from 94,362 per year to 119,606, and among females increased 34.7%, from 43,565 per year to 58,701. Implementation of evidence-based policies that reduce the availability and accessibility of alcohol and increase its price (e.g., policies that reduce the number and concentration of places selling alcohol and increase alcohol taxes) could reduce excessive alcohol use and alcohol-related deaths., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Adam Sherk reports institutional support from the Canadian Cancer Society and Canadian Institutes for Health Research. No other potential conflicts of interest were disclosed.

Introduction: Binge drinking and sexual assault are serious inter-related public health problems faced by college students. State-level alcohol policy restrictiveness has been found to decrease binge drinking among college students and, therefore, may also reduce occurrences of alcohol-related criminal offenses. It was hypothesized that more restrictive state alcohol policy environments would be associated with fewer liquor law violations and sexual assault offenses on U.S. college campuses., Methods: Data were aggregated across 3 academic years (2016-2017, 2017-2018, and 2018-2019) and represented n=1,290 institutions. Zero-inflated negative binomial regression modeling was performed in 2022-2023 to evaluate associations of state-level young adult binge drinking and the Alcohol Policy Scale (APS) with the numbers of campus-level alcohol-related arrests, alcohol-related disciplinary actions, rape offenses, and fondling offenses reported in national Campus Safety and Security data., Results: Higher APS scores had direct associations with fewer alcohol-related arrests (1.79% decrease per one-unit increase in APS, p=0.05), alcohol-related disciplinary actions (2.27% decrease per one-unit increase in APS, p=0.027), and rape offenses (0.85% decrease per one-unit increase in APS, p=0.021). The associations APS scores had with disciplinary actions and rape offenses were partially and fully mediated, respectively, by state-level young adult binge drinking. No associations were found between APS and fondling offenses., Conclusions: This cross-sectional study presents evidence that more restrictive state alcohol policies are associated with fewer alcohol-related arrests and disciplinary actions, and rape offenses on college campuses. Future research should identify the alcohol policy domains that are most protective against these outcomes., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Injuries often involve alcohol, but determining the proportion caused by alcohol is difficult. Several approaches have been used to determine the causal role of alcohol, but these methods have not been compared directly with one another. Such a comparison would be useful for understanding the strengths and comparability of different approaches. This study compared estimates of average annual alcohol-attributable deaths in the United States from injuries during 2015-19 using a blood alcohol concentration (BAC) method compared with a population attributable fraction (PAF) approach., Methods: For the BAC method, we used a direct method involving the proportion of decedents with a high blood alcohol concentration (BAC; e.g. ≥ 0.10%). For the PAF approach, we compared the use of unadjusted survey data with average consumption data adjusted using alcohol sales data to account for underreporting and also accounting for the underreporting of binge drinking. Survey data were from the Behavioral Risk Factor Surveillance System and mortality data were from the National Vital Statistics System., Results: The number of alcohol-attributable injury deaths using the direct method (48 516 deaths annually) was similar to that using PAF methods (47 879 deaths annually), but only when alcohol use measures were adjusted using alcohol sales data. Furthermore, estimates were similar for cause-specific categories of deaths, including non-motor vehicle unintentional injuries and motor vehicle crashes. Among PAF methods, excessive drinking accounted for 38.3% of injury deaths using unadjusted survey data, but 64.8% of injury deaths using adjusted data., Conclusions: Estimates of alcohol-attributable injury deaths from a direct method and from a population attributable fraction method that adjusts for alcohol use based on alcohol sales data appear to be comparable., (© 2023 Society for the Study of Addiction.)

Background and Aims: While heavy alcohol use consistently associates with liver disease, the effects of nonheavy alcohol consumption are less understood. We aimed to investigate the relationship between nonheavy alcohol use and chronic liver disease., Methods: This cross-sectional study included 2629 current drinkers in the Framingham Heart Study who completed alcohol use questionnaires and transient elastography. We defined fibrosis as liver stiffness measurement (LSM) ≥8.2 kPa. We defined at-risk nonalcoholic steatohepatitis (NASH) as FibroScan-aspartate aminotransferase (FAST) score >0.35 (90% sensitivity) or ≥0.67 (90% specificity). We performed logistic regression to investigate associations of alcohol use measures with fibrosis and NASH, adjusting for sociodemographic and metabolic factors. Subgroup analysis excluded heavy drinkers (>14 drinks per week for women or >21 for men)., Results: In this sample (mean age 54.4 ± 8.9 years, 53.3% women), mean LSM was 5.6 ± 3.4 kPa, 8.2% had fibrosis, 1.9% had NASH by FAST ≥0.67, and 12.4% had NASH by FAST >0.35. Participants drank 6.2 ± 7.4 drinks per week. Total drinks per week and frequency of drinking associated with increased odds of fibrosis (adjusted odds ratio [aOR], 1.18; 95% confidence interval [CI], 1.04-1.33; and aOR, 1.08; 95% CI, 1.01-1.16, respectively). Risky weekly drinking, present in 17.4%, also associated with fibrosis (aOR, 1.49; 95% CI, 1.03-2.14). After excluding 158 heavy drinkers, total drinks per week remained associated with fibrosis (aOR, 1.16; 95% CI, 1.001-1.35). Multiple alcohol use measures positively associated with FAST >0.35., Conclusions: In this community cohort, we demonstrate that nonheavy alcohol use associates with fibrosis and NASH, after adjustment for metabolic factors. Longitudinal studies are needed to determine the benefits of moderating alcohol use to reduce liver-related morbidity and mortality., (Copyright © 2023 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Organising alcohol retail systems with more or less public ownership has implications for health and the economy. The aim of the present study was to estimate the economic, health, and social impacts of alcohol use in Finland in 2018 (baseline), and in two alternative scenarios in which current partial public ownership of alcohol retail sales is either increased or fully privatised. Methods: Baseline alcohol-attributable harms and costs were estimated across five categories of death, disability, and criminal justice. Two alternate alcohol retail systems were defined as privately owned stores selling: (1) only low strength alcoholic beverages (public ownership scenario, similar to Sweden); or (2) all beverages (private ownership scenario). Policy analyses were conducted to estimate changes in alcohol use per capita. Health and economic impacts were modelled using administrative data and epidemiological modelling. Results: In Finland in 2018, alcohol use was estimated to be responsible for €1.51 billion (95% Uncertainty Estimates: €1.43 billion, €1.58 billion) in social cost, 3,846 deaths, and 270,652 criminal justice events. In the public ownership scenario, it was estimated that alcohol use would decline by 15.8% (11.8%, 19.7%) and social cost by €384.3 million (€189.5 million, €559.2 million). Full privatisation was associated with an increase in alcohol use of 9.0% (6.2%, 11.8%) and an increase in social cost of €289.7 million (€140.8 million, €439.5 million). Conclusion: The outcome from applying a novel analytical approach suggests that more public ownership of the alcohol retail system may lead to significant decreases in alcohol-caused death, disability, crime, and social costs. Conversely, full privatisation of the ownership model would lead to increased harm and costs., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This study was funded by the Finnish public partial alcohol retail monopoly, Alko. We received consent from the funding body to prepare this manuscript for publication in a completely independent manner., (© The Author(s) 2023.)

Complementary foods and beverages (CFBs) are key components of an infant's diet in the second 6 months of life. This article summarizes nutrition and feeding practices examined by the 2020 Dietary Guidelines Advisory Committees during the CFB life stage. Breastfeeding initiation is high (84%), but exclusive breastfeeding at 6 months (26%) is below the Healthy People 2030 goal (42%). Most infants (51%) are introduced to CFBs sometime before 6 months. The primary mode of feeding (ie, human milk fed [HMF]; infant formula or mixed formula and human milk fed [FMF]) at the initiation of CFBs is associated with the timing of introduction and types of CFBs reported. FMF infants (42%) are more likely to be introduced to CFBs before 4 months compared with HMF infants (19%). Different dietary patterns, such as higher prevalence of consumption and mean amounts, were observed, including fruit, grains, dairy, proteins, and solid fats. Compared with HMF infants of the same age, FMF infants consume more total energy (845 vs 631 kcal) and protein (22 vs 12 g) from all sources, and more energy (345 vs 204 kcal) and protein (11 vs 6 g) from CFBs alone. HMF infants have a higher prevalence of risk of inadequate intakes of iron (77% vs 7%), zinc (54% vs <3%), and protein (27% vs <3%). FMF infants are more likely to have an early introduction (<12 months) to fruit juice (45% vs 20%) and cow's milk (36% vs 24%). Registered dietitian nutritionists and nutritional professionals should consider tailoring their advice to caregivers on dietary and complementary feeding practices, taking into account the primary mode of milk feeding during this life stage to support infants' nutrient adequacy. National studies that address the limitations of this analysis, including small sample sizes and imputed breast milk volume, could refine findings from this analysis., (Copyright © 2022 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

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

Objective: Rapid shifts toward cannabis liberalization in the United States have created immense policy variability that is challenging to measure. We developed composite measures to characterize the restrictiveness of U.S. state cannabis policy environments., Method: Nine panelists, consisting of four research team members and five expert policy consultants, nominated distinct cannabis policies pertaining to cannabis prohibition, medicalization, and legalization for recreational use. For each of the 17 nominated policies, panelists developed implementation ratings and rated each policy's relative efficacy for reducing excessive cannabis use by adults, youth use, and impaired driving. Cannabis Policy Scale scores were then calculated for each state-year for all 50 states from 1999 to 2019 by weighting policies by their efficacy and implementation ratings, and then summing over policies., Results: Median Cannabis Policy Scale scores remained stable until 2008, when they started declining (representing policy liberalization), with steeper declines after 2012. In 2019, state Cannabis Policy Scale scores targeting excessive use among the general population ranged from 29.6 to 66.7 for recreational cannabis legalization states, and from 72.4 to 93.4 for medical cannabis legalization states. Cannabis Policy Scale scores using youth-specific and driving-specific efficacy ratings showed similar trends., Conclusions: The Cannabis Policy Scale reflects trends toward liberalization of cannabis policy in many U.S. states. Even within crude policy phenotypes (e.g., medical cannabis programs), Cannabis Policy Scale scores varied considerably between states and over time. The Cannabis Policy Scale is a new measure that can add nuance to cannabis policy research and help assess cannabis policy-outcome relationships., Competing Interests: The authors have no conflicts of interest to declare.

Background: Cannabis policy is developing faster than empirical evidence about policy effects. With a panel of experts in substance use policy development and research, we identified key cannabis policies and their provisions enacted by U.S. states; rated their theoretical efficacy in a restrictive form for reducing problematic use and impaired driving in the context of a recreational cannabis market as judged by experts; and rated the strength of evidence for each policy., Methods: Using a modified Delphi approach, 9 panelists rated the comparative efficacy of 18 state cannabis policies for reducing youth use of cannabis, excessive cannabis use among the general population, and cannabis-impaired driving. Each outcome was rated separately using a Likert scale, and panelists also rated the strength of evidence supporting each efficacy rating. Investigators provided descriptions of each policy so that the nine panelists had similar conceptions of each policy., Results: State monopoly (state owns all production, manufacturing, wholesale, and retail operations) was rated as the most effective policy for all three outcome areas. Restrictions on retail physical availability, taxes, retail price restrictions, and retail operations restrictions were also highly rated for all three outcomes. Policies regulating cannabis businesses and products were judged more effective than policies targeting consumer use and behavior. Panelists reported there was little or no direct evidence from the cannabis policy literature for most of the included policies., Conclusion: These ratings can facilitate research as well as policy-making decisions. A relatively small number of policies were judged to be highly effective across all three domains, indicating that for the most part adult excessive use, youth use, and impaired driving can all be reduced with the same set of policies; these policies tended to target the behaviors of businesses rather than consumers. The low levels of direct evidence available to inform policy ratings, as reported by the policy panelists, makes clear the need for ongoing and sustained cannabis policy research., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Introduction: Alcohol is a leading contributor to liver disease, however, estimating the proportion of liver disease deaths attributable to alcohol use can be methodologically challenging., Methods: We compared three approaches for estimating alcohol-attributable liver disease deaths (AALDD), using the USA as an example. One involved summing deaths from alcoholic liver disease and a proportion from unspecified cirrhosis (direct method); two used population attributable fraction (PAF) methodology, including one that adjusted for per capita alcohol sales. For PAFs, the 2011-2015 Behavioral Risk Factor Surveillance System and per capita sales from the Alcohol Epidemiologic Data System were used to derive alcohol consumption prevalence estimates at various levels (excessive alcohol use was defined by medium and high consumption levels). Prevalence estimates were used with relative risks from two meta-analyses, and PAFs were applied to the 2011-2015 average annual number of deaths from alcoholic cirrhosis and unspecified cirrhosis (using National Vital Statistics System data) to estimate AALDD., Results: The number of AALDD was higher using the direct method (28 345 annually) than the PAF methods, but similar when alcohol prevalence was adjusted using per capita sales and all alcohol consumption levels were considered (e.g. 25 145 AALDD). Using the PAF method, disaggregating non-drinkers into lifetime abstainers and former drinkers to incorporate relative risks for former drinkers yielded higher AALDD estimates (e.g. 27 686) than methods with all non-drinkers combined., Discussion and Conclusions: Using PAF methods that adjust for per capita sales and model risks for former drinkers yield more complete and possibly more valid AALDD estimates., (© 2022 Australasian Professional Society on Alcohol and other Drugs.)

Purpose: The liberalization of cannabis policies has the potential to affect the use of other substances and the harms from using them, particularly alcohol. Although a previous review of this literature found conflicting results regarding the relationship between cannabis policy and alcohol-related outcomes, cannabis policies have continued to evolve rapidly in the years since that review., Search Methods: The authors conducted a narrative review of studies published between January 1, 2015, and December 31, 2020, that assessed the effects of cannabis policies on the use of alcohol in the United States or Canada., Search Results: The initial search identified 3,446 unique monographs. Of these, 23 met all inclusion criteria and were included in the review, and five captured simultaneous or concurrent use of alcohol and cannabis., Discussion and Conclusions: Associations between cannabis policy liberalization and alcohol use, alcohol-related outcomes, and the co-use of alcohol and cannabis were inconclusive, with studies finding positive associations, no associations, and negative associations. Although several studies found that cannabis policy liberalization was associated with decreases in alcohol use measures, these same studies showed no impact of the cannabis policy on cannabis use itself. The lack of a consistent association was robust to subject age, outcome measure (e.g., use, medical utilization, driving), and type of cannabis policy; however, this may be due to the small number of studies for each type of outcome. This paper discusses several notable limitations of the evidence base and offers suggestions for improving consistency and comparability of research going forward, including a stronger classification of cannabis policy, inclusion of measures of the alcohol policy environment, verification of the impact of cannabis policy on cannabis use, and consideration of mediation effects., Competing Interests: Disclosures The authors declare no competing financial or nonfinancial interests.

Alcoholic beverages are carcinogenic to humans. Globally, an estimated 4.1% of new cancer cases in 2020 were attributable to alcoholic beverages. However, the full cancer burden due to alcohol is uncertain because for many cancer (sub)types, associations remain inconclusive. Additionally, associations of consumption with therapeutic response, disease progression, and long-term cancer outcomes are not fully understood, public awareness of the alcohol-cancer link is low, and the interrelationships of alcohol control regulations and cancer risk are unclear. In December 2020, the U.S. NCI convened a workshop and public webinar that brought together a panel of scientific experts to review what is known about and identify knowledge gaps regarding alcohol and cancer. Examples of gaps identified include: (i) associations of alcohol consumption patterns across the life course with cancer risk; (ii) alcohol's systemic carcinogenic effects; (iii) alcohol's influence on treatment efficacy, patient-reported outcomes, and long-term prognosis; (iv) communication strategies to increase awareness of the alcohol-cancer link; and (v) the impact of alcohol control policies to reduce consumption on cancer incidence and mortality. Interdisciplinary research and implementation efforts are needed to increase relevant knowledge, and to develop effective interventions focused on improving awareness, and reducing harmful consumption to decrease the alcohol-related cancer burden., (©2021 American Association for Cancer Research.)

Objective: Self-reported alcohol consumption in U.S. public health surveys covers only 30%-60% of per capita alcohol sales, based on tax and shipment data. To estimate alcohol-attributable harms using alcohol-attributable fractions, accurate measures of total population consumption and the distribution of this drinking are needed. This study compared methodological approaches of adjusting self-reported survey data on alcohol consumption to better reflect sales and assessed the impact of these adjustments on the distribution of average daily consumption (ADC) levels and the number of alcohol-attributable deaths., Method: Prevalence estimates of ADC levels (i.e., low, medium, and high) among U.S. adults who responded to the 2011-2015 Behavioral Risk Factor Surveillance System (BRFSS; N = 2,198,089) were estimated using six methods. BRFSS ADC estimates were adjusted using the National Alcohol Survey, per capita alcohol sales data (from the Alcohol Epidemiologic Data System), or both. Prevalence estimates for the six methods were used to estimate average annual alcohol-attributable deaths, using a population-attributable fraction approach., Results: Self-reported ADC in the BRFSS accounted for 31.3% coverage of per capita alcohol sales without adjustments, 36.1% using indexed-BRFSS data, and 44.3% with National Alcohol Survey adjustments. Per capita sales adjustments decreased low ADC prevalence estimates and increased medium and high ADC prevalence estimates. Estimated alcohol-attributable deaths ranged from approximately 91,200 per year (BRFSS unadjusted; Method 1) to 125,200 per year (100% of per capita sales adjustment; Method 6)., Conclusions: Adjusting ADC to reflect total U.S. alcohol consumption (e.g., adjusting to 73% of per capita sales) has implications for assessing the impact of excessive drinking on health outcomes, including alcohol-attributable death estimates., Competing Interests: None of the authors have any conflicts of interest or financial disclosures.

Objectives. To assess cannabis and alcohol involvement among motor vehicle crash (MVC) fatalities in the United States. Methods. In this repeated cross-sectional analysis, we used data from the Fatality Analysis Reporting System from 2000 to 2018. Fatalities were cannabis-involved if an involved driver tested positive for a cannabinoid and alcohol-involved based on the highest blood alcohol concentration (BAC) of an involved driver. Multinomial mixed-effects logistic regression models assessed cannabis as a risk factor for alcohol by BAC level. Results. While trends in fatalities involving alcohol have remained stable, the percentage of fatalities involving cannabis and cannabis and alcohol increased from 9.0% in 2000 to 21.5% in 2018, and 4.8% in 2000 to 10.3% in 2018, respectively. In adjusted analyses, fatalities involving cannabis had 1.56 (95% confidence interval [CI] = 1.48, 1.65), 1.62 (95% CI = 1.52, 1.72), and 1.46 (95% CI = 1.42, 1.50) times the odds of involving BACs of 0.01% to 0.049%, 0.05% to 0.079%, and 0.08% or higher, respectively. Conclusions. The percentage of fatalities involving cannabis and coinvolving cannabis and alcohol doubled from 2000 to 2018, and cannabis was associated with alcohol coinvolvement. Further research is warranted to understand cannabis- and alcohol-involved MVC fatalities. ( Am J Public Health . 2021;111(11):1976-1985. https://doi.org/10.2105/AJPH.2021.306466).

Background: Identification of nutrients of public health concern has been a hallmark of the Dietary Guidelines for Americans (DGA); however, a formal systematic process for identifying them has not been published., Objectives: We aimed to propose a framework for identifying "nutrients or food components" (NFCs) of public health relevance to inform the DGA., Methods: The proposed framework consists of 1) defining terminology; 2) establishing quantitative thresholds to identify NFCs; and 3) examining national data. The proposed framework utilizes available data from 3 key data sources or "prongs": 1) dietary intakes; 2) biological endpoints; and 3) clinical health consequences such as prevalence of health conditions, directly or indirectly through validated surrogate markers., Results: In identifying potential NFCs of public health concern, the 2020 DGA Committee developed a decision-tree framework with suggestions for combining the 3 prongs. The identified NFCs of public health concern for Americans ≥1 y old included fiber, calcium (≥2 y old), vitamin D, and potassium for low intakes and sodium, added sugars, and saturated fats (≥2 y old) for high intakes that were associated with adverse health consequences. Iron was identified among infants ages 6-12 mo fed human milk. For reproductive-aged and pregnant females, iron (all trimesters) and folate (first trimester) were identified for low intake, based on dietary and biomarker data (iron) or the severity of the consequence (folic acid and neural tube defects). Among pregnant women, low iodine was of potential public health concern based on biomarker data. Other NFCs that were underconsumed, overconsumed, and pose special challenges were identified across the life course., Conclusions: The proposed decision-tree framework was intended to streamline and add transparency to the work of this and future Dietary Guidelines Advisory Committees to identify NFCs that need to be encouraged or discouraged in order to help reduce risk of chronic disease and promote health and energy balance in the population., (Published by Oxford University Press on behalf of the American Society for Nutrition 2021.)

Introduction: Legal limits on the amount of cannabis sold per transaction in states with recreational cannabis may promote moderate use and limit diversion. However, state sales limits are heterogeneous and difficult to interpret in terms of tetrahydrocannabinol dose equivalents., Methods: This cross-sectional study examined how transaction sales limits on recreational cannabis translate to tetrahydrocannabinol doses among U.S. states allowing commercial cannabis sales as of January 1, 2020. Weight-based quantity limits by cannabis type (flower/bud, concentrates, and edibles) were converted into grams of tetrahydrocannabinol content per transaction using known potency values in 2020., Results: Weight-based sales limits for flower and concentrate vary considerably across states (range=1.0-2.5 oz for flower and 3.5-15.0 g for concentrate), whereas limits for edible cannabis are heterogeneous. A total of 4 states have independent limits for each product category, and 6 states place limits across all products sold in the transaction. Because no states impose limits on the potency of flower or concentrates, the small differences in the weight-based limits translate into large differences in grams of tetrahydrocannabinol allowed to be sold. Assuming a typical dose of 10 mg of tetrahydrocannabinol, current laws allow for sales of up to 560 (Alaska) to 2,283 (Michigan) doses per transaction on the basis of median product potencies., Conclusions: All states allow a large number of tetrahydrocannabinol doses per transaction, larger than what is typically consumed by daily users over a month. States concerned about public health and diversion should consider reducing sales limits and basing them on total tetrahydrocannabinol content across all purchased products., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Alcohol and firearms are commonly involved in suicide in the United States. State alcohol and firearm policies may impact alcohol and firearm related suicide, yet little is known about these relationships. This study examines relationships between state alcohol and firearm policies and suicides involving alcohol, guns, or both, and explores interactive policy associations., Methods: Alcohol policies were assessed with the Alcohol Policy Scale. Firearm policies were assessed using the Gun Law Scorecard from Giffords Law Center. Suicide data from the National Violent Death Reporting System in 2015 covered 22 states. State- and individual-level GEE Poisson and logistic regression models assessed relationships between policies and firearm- and/or alcohol-involved suicides with a 1-year lag., Results: In 2015, there were 8996 suicide deaths with blood alcohol concentration test results in the 22 included states. Of those deaths, alcohol and/or firearms were involved in 5749 or 63.9%. Higher alcohol and gun law scores were associated with reduced incidence rates and odds of suicides involving either alcohol or firearms (adjusted incidence rate ratios [IRR] 0.72 (95% CI 0.63, 0.83) for alcohol policies, 0.86 (95% CI 0.82, 0.90) for firearm policies). Relationships were similar for suicides involving both alcohol and firearms, and there was an interactive effect, such that states with restrictive policies for both had the lowest rates of suicides involving alcohol or guns., Conclusions: More restrictive alcohol and firearm policies are associated with lower rates and odds of suicides involving alcohol or firearms, and alcohol and firearms, and may be a promising means by which to reduce suicide.

Excessive alcohol use is a leading cause of preventable death in the United States (1) and costs associated with it, such as those from losses in workplace productivity, health care expenditures, and criminal justice, were $249 billion in 2010 (2). CDC used the Alcohol-Related Disease Impact (ARDI) application* to estimate national and state average annual alcohol-attributable deaths and years of potential life lost (YPLL) during 2011-2015, including deaths from one's own excessive drinking (e.g., liver disease) and from others' drinking (e.g., passengers killed in alcohol-related motor vehicle crashes). This study found an average of 95,158 alcohol-attributable deaths (261 deaths per day) and 2.8 million YPLL (29 years of life lost per death, on average) in the United States each year. Of all alcohol-attributable deaths, 51,078 (53.7%) were caused by chronic conditions, and 52,921 (55.6%) involved adults aged 35-64 years. Age-adjusted alcohol-attributable deaths per 100,000 population ranged from 20.8 in New York to 53.1 in New Mexico. YPLL per 100,000 population ranged from 631.9 in New York to 1,683.5 in New Mexico. Implementation of effective strategies for preventing excessive drinking, including those recommended by the Community Preventive Services Task Force (e.g., increasing alcohol taxes and regulating the number and concentration of alcohol outlets), could reduce alcohol-attributable deaths and YPLL. † ., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Timothy Stockwell reports grants and personal fees from Alko, Finland, outside the submitted work. Richard Saitz reports nonfinancial support from Alkermes; personal fees from UpToDate and Massachusetts Medical Society; support and consulting fees from the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the Patient-Centered Outcomes Research Institute; travel support and consulting fees from the American Medical Association, the American Society of Addiction Medicine, Wolters Kluwer, National Council on Behavioral Healthcare, the International Network on Brief Intervention for Alcohol and other drugs, Systembolaget, Kaiser Permanente, RAND, the Institute for Research and Training in the Addictions, the National Council on Behavioral Healthcare, Charles University (Czech Republic), National Committee on Quality Assurance, and the University of Oregon; and salary support from Burroughs Wellcome Fund. No other potential conflicts of interest were disclosed.

Background & Aims: Many individuals presumed to have nonalcoholic fatty liver disease (NAFLD) consume moderate amounts of alcohol. Little is known about patterns of alcohol use in patients with NAFLD or how drinking behaviors affect liver fat., Methods: We conducted a cross-sectional study of 2475 participants of the Framingham Heart Study with hepatic steatosis, as determined by computed tomography. We performed multivariable-adjusted logistic regression models to evaluate the association between alcohol drinking patterns and hepatic steatosis. Models were adjusted for sociodemographic factors, diet, and the components of the metabolic syndrome. We excluded heavy alcohol users, defined as women who consume more than 14 alcohol drinks per week and men who consume more than 21 alcohol drinks per week., Results: In our sample (mean age, 49.8 ± 10.2 y; 50.3% women), the prevalence of hepatic steatosis was 17.5%. The total number of alcohol drinks per week and the maximum drinks consumed per drinking day each were associated with hepatic steatosis (adjusted odds ratio [aOR], 1.15; 95% CI, 1.02-1.29 and aOR 1.15; 95% CI, 1.02-1.30). Binge drinking occurred in 25.4% of individuals with presumed NAFLD and was associated with an increased odds of hepatic steatosis (aOR, 1.45; 95% CI, 1.06-1.98) among alcohol users. In a beverage-specific analysis, alcohol use patterns were associated with hepatic steatosis among beer drinkers, but not among wine drinkers., Conclusions: In a cross-sectional study of participants of the Framingham Heart Study with hepatic steatosis, we observed an association between alcohol use and liver fat, even after excluding heavy alcohol users from our analysis. Alcohol use therefore appears to be a risk factor for NAFLD. Prospective studies are needed to validate these findings and determine if alcohol use should be a focus for research, prevention, and treatment of presumed NAFLD., (Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Introduction: Motor vehicle crashes are a leading cause of injury death in the U.S. Restrictive alcohol policies protect against crashes involving alcohol above the legal blood alcohol concentration of 0.08%. Characteristics of motor vehicle crash fatalities involving blood alcohol concentrations below the limit and their relationships to alcohol control policies have not been well characterized., Methods: Motor vehicle crash fatality data and crash and decedent characteristics from 2000 to 2015 came from the Fatality Analysis Reporting System and were analyzed in 2018-2019. Alcohol Policy Scale scores characterized alcohol policy environments by state-year. Generalized estimating equation alternating logistic regression models assessed these scores and the odds that a fatality involved alcohol below the legal threshold., Results: Of 612,030 motor vehicle crash fatalities, 223,471 (37%) died in alcohol-involved crashes, of which 33,965 (15% of alcohol-involved fatalities or 6% of all fatalities) had a blood alcohol concentration <0.08%. A 10 percentage point increase in Alcohol Policy Scale score, approximating the interquartile range among states, was associated with reduced odds of fatalities involving alcohol <0.08% vs 0.00% (AOR=0.91, 95% CI=0.89, 0.93). These findings held across multiple subgroup analyses by decedent and crash characteristics. Similar results were found for odds of alcohol involvement <0.05% vs 0.00% (AOR=0.90, 95% CI=0.88, 0.93), and ≥0.05% but <0.08% vs <0.05% (AOR=0.93, 95% CI=0.89, 0.96)., Conclusions: The number of lower blood alcohol concentration fatalities is substantial. States with more restrictive alcohol policies tend to have reduced odds of lower blood alcohol concentration motor vehicle crashes than states with weaker policies., (Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Higher alcohol taxation is protective against alcohol-related morbidity and mortality. All states have specific (volume-based) excise taxes for alcohol that decrease if not adjusted for inflation. These taxes have diminished substantially in real terms since their inception after National Prohibition in the United States. The purpose of this study was to examine trends in the magnitude and frequency of changes in state specific excise taxes to document their erosion., Method: Alcohol excise tax data were examined for all 50 states from 1933 to 2018. Tax data were obtained from the Alcohol Policy Information System, Pacific Institute for Research and Evaluation, Wine Institute, and HeinOnline. Linear and logistic regression analyses were conducted for beer, wine, and distilled spirits taxes to examine trends in the frequency and inflation-adjusted magnitude of changes in taxes from the year of alcohol tax inception., Results: From 1933 until 1970, beer, wine, and distilled spirits tax rates increased in value compared with inception rates, but by 2018 alcohol taxes had declined 66%, 71%, and 70%, respectively, compared with their inception values. The erosion of taxes after 1970 was driven primarily by declines in the magnitude of tax increases through the 1970s and 1980s, followed by declines in the frequency of tax increases in subsequent decades., Conclusions: The value of alcohol excise taxes has declined since 1970 from both insufficient tax increases and later infrequent tax increases. Laws that index rates to inflation could sustain the public health benefit of reduced morbidity and mortality resulting from higher alcohol tax rates.

Importance: The use of benzodiazepines or alcohol together with opioids increases overdose risk, but characterization of co-involvement by predominant opioid subtype is incomplete to date. Understanding the use of respiratory depressants in opioid overdose deaths (OODs) is important for prevention efforts and policy making., Objective: To assess the prevalence and number of alcohol- or benzodiazepine-involved OODs by opioid subtypes in the United States from 1999 to 2017., Design and Setting: This repeated cross-sectional analysis used data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) database of all opioid-involved poisoning deaths from January 1, 1999, to December 31, 2017, for the United States. State-level binge drinking prevalence rates for 2015 to 2017 were obtained from the Behavior Risk Factor Surveillance System of the Centers for Disease Control and Prevention, and benzodiazepine prescribing rates for 2012 (most recent available data) were obtained from IMS Health, a commercial database. Data were analyzed from July 10, 2018, to May 16, 2019., Main Outcomes and Measures: Prevalence of alcohol or benzodiazepine co-involvement for all OODs and by opioid subtype, nationally and by state., Results: From 1999 to 2017, 399 230 poisoning deaths involved opioids, of which 263 601 (66.0%) were male, and 204 560 (51.2%) were aged 35 to 54 years. Alcohol co-involvement for all opioid overdose deaths increased nonlinearly from 12.4% in 1999 to 14.7% in 2017. By opioid subtype, deaths involving heroin and synthetic opioids (eg, fentanyl; excluding methadone) had the highest alcohol co-involvement at 15.5% and 14.9%, respectively, in 2017. Benzodiazepine co-involvement in all OODs increased nonlinearly from 8.7% in 1999 to 21.0% in 2017. Benzodiazepines were present in 33.1% of prescription OODs and 17.1% of synthetic OODs in 2017. State-level rates of binge drinking were significantly correlated with alcohol co-involvement in all OODs (r = 0.34; P = .02). State benzodiazepine prescribing rates were significantly correlated with benzodiazepine co-involvement in all OODs (r = 0.57; P < .001)., Conclusions and Relevance: This study found that alcohol and benzodiazepine co-involvement in opioid-involved overdose deaths was common, varied by opioid subtype, and was associated with state-level binge drinking and benzodiazepine prescribing rates. These results may inform state policy initiatives in harm reduction and overdose prevention efforts.

Each year, excessive drinking accounts for one in 10 deaths among U.S. adults aged 20-64 years (1), and approximately 90% of adults who report excessive drinking* binge drink (i.e., consume five or more drinks for men or four or more drinks for women on a single occasion) (2). In 2015, 17.1% of U.S. adults aged ≥18 years reported binge drinking approximately once a week and consumed an average of seven drinks per binge drinking episode, resulting in 17.5 billion total binge drinks, or 467 total binge drinks per adult who reported binge drinking (3). CDC analyzed 2011-2017 Behavioral Risk Factor Surveillance System (BRFSS) data to assess trends in total annual binge drinks per adult who reported binge drinking in the United States overall and in the individual states. The age-adjusted † total annual number of binge drinks per adult who reported binge drinking increased significantly from 472 in 2011 to 529 in 2017. Total annual binge drinks per adult who reported binge drinking also increased significantly from 2011 to 2017 among those aged 35-44 years (26.7%, from 468 to 593) and 45-64 years (23.1%, from 428 to 527). The largest percentage increases in total binge drinks per adult who reported binge drinking during this period were observed among those without a high school diploma (45.8%) and those with household incomes <$25,000 (23.9%). Strategies recommended by the Community Preventive Services Task Force § for reducing excessive drinking (e.g., regulating alcohol outlet density) might reduce binge drinking and related health risks., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Background: Although more restrictive alcohol control policies (e.g., higher alcohol taxes) are related to lower levels of alcohol consumption, little is known about the relationship between alcohol policies and rates of alcohol-attributable cancer., Methods: State alcohol policy restrictiveness, as measured by a validated policy scale, were related to state rates of six alcohol attributable cancers in the U.S. from 2006 to 2010 in a lagged, cross-sectional linear regression that controlled for a variety of state-level factors. Cancer mortality rates were from the Center for Disease Control and Prevention's Alcohol-Related Disease Impact application, which uses population-attributable fraction methodology to calculate mortality from cancers of the esophagus, larynx, liver, oropharynx, prostate (male only) and breast (female only)., Results: More restrictive state alcohol policies were associated with lower cancer mortality rates for the six cancer types overall (beta [β] -0.33; 95% confidence interval [CI] -0.59, -0.07), and among men (β -0.45; 95% CI -0.81, -0.10) and women (β -0.21; 95% CI -0.40, -0.02). A 10% increase in the restrictiveness of alcohol policies (based on the mean APS among states) was associated with an 8.5% decrease in rates of combined alcohol-attributable cancers. In all analyses stratified by cancer subtype and sex, the associations were in the hypothesized direction (i.e., more restrictive state policy environments were associated with lower rates of alcohol-attributable cancers), with the exception of laryngeal cancer among women., Conclusion: Strengthening alcohol policies is a promising prevention strategy for alcohol-related cancer., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: U.S. policymakers and public health practitioners lack composite indicators (indices) to assess and compare the restrictiveness of state-level alcohol policy environments, conceptualized as the presence of multiple policies in effect in a particular place and time. The purposes of this study were to characterize the alcohol policy environment in each U.S. state and Washington, DC, in 2018, and to examine changes during the past 20 years., Method: State-specific Alcohol Policy Scale (APS) scores from 1999 to 2018 were based on 29 policies, after weighting each present policy by its efficacy and degree of implementation. Modified APS scores were also calculated on the basis of two sets of mutually exclusive policy subgroups., Results: APS scores in 2018 varied considerably between states, ranging from 25.6 to 67.9 on a theoretical scale of 0 to 100; the median score was 43.5 (based on a 0-100 range), and 43 states had scores less than 50. The median change in state APS scores from 1999 to 2018 was positive (+4.9, range: -7.4 to +10.3), indicating increases in the restrictiveness of policy environments, with decreases in only five states. The increases in APS scores were primarily attributable to the implementation of stronger impaired-driving laws, whereas policies to reduce excessive drinking were unchanged. There was no correlation between states' excessive drinking policy scores and their impaired-driving scores (r = .05, p = .74)., Conclusions: Based on this policy scale, few states have restrictive policy environments. Although states adopted policies targeting impaired driving during the study period, there was no change in policies to reduce excessive drinking.

Introduction: Harnessing engagement in online searching and social media may provide complementary information for monitoring alcohol use, informing prevention and policy evaluation, and extending knowledge available from national surveys., Methods: Relative search volumes for 7 alcohol-related keywords were estimated from Google Trends (data, 2014-2017), and the proportion of alcohol use-related Twitter posts (data, 2014-2015) was estimated using natural language processing. Searching/posting measures were created for all 50 U.S. states plus Washington, D.C. Survey reports of alcohol use and summaries of state alcohol policies were obtained from the Behavioral Risk Factor Surveillance System (data, 2014-2016) and the Alcohol Policy Scale. In 2018-2019, associations among searching/posting measures and same state/year Behavioral Risk Factor Surveillance System reports of recent (past-30-day) alcohol use and maximum number of drinks consumed on an occasion were estimated using logistic and linear regression, adjusting for sociodemographics and Internet use, with moderation tested in regressions that included interactions of select searching/posting measures and the Alcohol Policy Scale., Results: Recent alcohol use was reported by 52.93% of 1,297,168 Behavioral Risk Factor Surveillance System respondents, which was associated with all state-level searching/posting measures in unadjusted and adjusted models (p<0.0001). Among drinkers, most searching/posting measures were associated with maximum number of drinks consumed (p<0.0001). Associations varied with exposure to high versus low levels of state policy controls on alcohol., Conclusions: Strong associations were found among individual alcohol use and state-level alcohol-related searching/posting measures, which were moderated by the strength of state alcohol policies. Findings support using novel personally generated data to monitor alcohol use and possibly evaluate effects of alcohol control policies., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

We estimated calorie intake from alcohol in Canada, overall and by gender, age, and province, and provide evidence to advocate for mandatory alcohol labelling requirements. Annual per capita (aged 15+) alcohol sales data in litres of pure ethanol by beverage type were taken from Statistics Canada's CANSIM database and converted into calories. The apportionment of consumption by gender, age, and province was based on data from the Canadian Tobacco, Alcohol and Drug Survey. Estimated energy requirements (EER) were from Canada's Food Guide. The average drinker consumed 250 calories, or 11.2% of their daily EER in the form of alcohol, with men (13.3%) consuming a higher proportion of their EER from alcohol than women (8.2%). Drinkers consumed more than one-tenth of their EER from alcohol in all but one province. By beverage type, beer contributes 52.7% of all calories derived from alcohol, while wine (20.8%); spirits (19.8%); and ciders, coolers, and other alcohol (6.7%) also contribute substantially. The substantial caloric impact of alcoholic drinks in the Canadian diet suggests that the addition of caloric labelling on these drinks is a necessary step.