Evidence Briefs: Public Health Topics
Drugs, Alcohol and Tobacco
The Problem:
Illicit drug use is a well-recognized public health problem. Overdose and other less acute harms are associated with the non-medical use of controlled substances. The policy response to illicit drug use in the United States has historically focused on a punitive model. Resulting high rates of incarceration have placed large numbers of non-violent offenders into correctional facilities. Life in prison exposes inmates to numerous health risks. High incarceration rates also strain families and communities particularly in areas already suffering from harms associated with low socioeconomic status. As a result, both illicit drug use and the prevailing policy response aimed at reducing it are sources of harm to population health. Reducing incarceration for non-violent crime – the majority of which involves use and trafficking of small amounts of illicit drugs – is widely recognized as an important policy objective. Congressional Research Service, GAO: Drug Courts.
The Law:
In response to growing evidence of the public health burden of over-criminalization and the failure of the traditional punitive approach to stem illicit drug activity, in the late 1980s, states and localities started experimenting with models aimed more at rehabilitation than retribution. Representing one form of what is often referred to as therapeutic justice, drugs courts emerged as a new model for dealing with minor drug-related crimes. These specialized courts aim to divert convicted drug-offenders into treatment rather than incarceration. Between 1989 and 2009, well over 2000 drugs courts were created in the United States. U.S. Department of Justice. Many drug courts are created though judicial rulemaking. Examples of laws creating drug courts can be found in Mississippi (M.S. Code § 9-23 et seq) and Illinois (730 ILCS 166.1 et seq).
The Evidence:
Wilson, et al., systematically reviewed studies assessing the effect of drug courts on recidivism. David B. Wilson, Ojmarrh Mitchell, And Doris L. Mackenzie, A systematic review of drug court effects on recidivism, Journal of Experimental Criminology (2006) 2:459Y487. The reviewers identified fifty studies that fit their inclusion criteria. Using meta-analytic techniques, the reviewers combined odds-ratios across the studies in a random effects model. The overall summary odds ratio – which was statistically significant – was 1.62. The reviewers’ interpretation of the results from the summary statistic and other correlates in the regression was that recidivism decreased by 26% for offenders in drug courts versus comparison groups. However, methodological weaknesses in the majority of the included studies were noted as a source of caution against this figure. A more conservative estimate of the effect was found when they limited their review to more methodologically sophisticated studies. Overall, however, the authors view the evidence as sufficient to support the effectiveness of drug courts in reducing recidivism.
The Bottom Line:
According to the authors of a peer-reviewed systematic review, there is sufficient evidence to support the effectiveness drug courts in reducing recidivism among individuals convicted of drug-related offenses.
The Problem:
Tobacco use is a source of chronic and fatal illnesses for users and persons with secondary exposure. In the United States, cigarette smoking contributes to one in five deaths and costs more than $193 billion in annual lost productivity and healthcare expenditures. CDC: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. Initiation of smoking and other tobacco use generally starts in adolescence; more than 80% of adult smokers started smoking as young children or teenagers. CDC: Youth Tobacco Use Fact Sheet.
The Law:
Pursuant to the 1997 federal “Synar law” states must prohibit the sale of tobacco products to children and take steps to ensure effective enforcement. 42U.S.C. 300x-26, 45 C.F.R. 96.130. States and localities have adopted numerous legal interventions to increase compliance with this prohibition. For example, some states prohibit the handling of tobacco products by minors working in retail and require posting of signs explicitly prohibiting sale of tobacco products to minors (Oklahoma, 37 O.S. §600.1-§600.12). Under age purchasers of tobacco face fines and community service (Washington, RCW 70.155.080). To increase compliance with youth access laws, localities and states also conduct compliance investigations (Missouri: Restricting Youth Access to Tobacco).
The Evidence:
Stead and Lancaster systematically reviewed studies assessing the effect of laws restricting youth access to tobacco and interventions aimed at increasing compliance with youth access laws. Lindsay F Stead and Tim Lancaster. A systematic review of interventions for preventing tobacco sales to minors. Tob Control 2000 9: 169-176. The reviewers identified 27 studies that fit their criteria of employing either experimental or observational designs with data both before and after the adoption of a law or compliance intervention. The studied laws included requirements for compliance checks; the evaluated interventions included experiments with compliance checks and education campaigns with retailers about fines and enforcement of youth access laws. Most of the included studies found reductions in prevalence of smoking among youths or decreases in reported ease of purchasing tobacco for minors. Although the reviewers were cautious because of methodological limitations in the studies such as the inability to control for potentially confounding effects from other youth smoking prevention programs and the possibility that effects wane over time, they view the collective body of studies as sufficient evidence to conclude that laws restricting youth access and interventions aimed at increasing compliance do indeed reduce access to tobacco for minors. The reviewers observed that greater levels of compliance activity – such as personal visits to retailers – were more likely to result in greater reductions in smoking or access.
The Bottom Line:
According to the authors of a peer-reviewed systematic review, there is sufficient evidence to support the effectiveness of youth access laws and interventions aimed at increasing compliance as a means of decreasing access to tobacco for minors.
The Problem:
Tobacco use is a source of chronic and fatal illnesses for users and persons with secondary exposure. In the United States, cigarette smoking contributes to one in five deaths and costs more than $193 billion annually in lost productivity and healthcare expenditures. CDC: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. It has been suggested that workplace smoking bans aid in smoking cessation efforts by changing how individuals view tobacco use. CDC: Smoke-Free Workplaces Reduce Smoking.
The Law:
Smoking bans and restrictions prohibit smoking in specified areas. These restrictions aim to eliminate or reduce exposure to secondhand smoke. Smoking bans and restrictions are found in state and local laws as well as regulations governing workplace safety. For examples of state smoking bans, see ARS 36-601.01 (Arizona), Utah Health Code § 26.83.3 (Utah), VT Health Code § 1742 (Vermont), and RI Health & Safety Code § 23-20.10-3 (Rhode Island).
The Evidence:
Fichtenberg and Glantz systematically reviewed and conducted a meta-analysis of 26 studies that assessed the impact of workplace smoking bans on tobacco consumption using a fixed effects meta-analysis. Fichtenberg & Glantz, Effect of smokefree workplaces on smoking behaviour: systematic review. BMJ 2002; 325: 188. The authors limited their analysis to primary studies that assessed the effect of total smoking bans, and excluded studies examining the effects of laws limiting smoking to specific areas. The 26 studies were conducted in Australia, Canada, the United States and Germany. Each of the included studies employed a cross-sectional design and measured both prevalence of cigarette smoking and quantity of cigarettes smoked before and after the introduction of a workplace smoking ban. Meta-analysis of the studies revealed a 3.8 percent reduction in prevalence of cigarette smokers and a reduction of 3.1 cigarettes a day per continuing smoker. The meta-analysis also found that the bans were associated with the consumption of 1.3 fewer cigarettes a day per employee.
The Bottom Line:
According to the authors of a peer-reviewed meta-analysis, there is substantial evidence that workplace smoking bans effectively reduce the prevalence of smoking, the quantity of cigarettes smoked, and exposure to second hand smoke.
Publication Date: 02/15/2011
The Problem:
Alcohol consumption is a risk factor for various public health harms. Impaired driving is one of the largest contributors to motor vehicle crashes. Each year in the United States roughly 13,400 people die and an additional 255,500 are injured in motor vehicle crashes involving an alcohol-impaired driver. In 2006, these crashes accounted for almost a third of all U.S. traffic-related deaths. CDC: Impaired Driving Factsheet. Alcohol consumption is also a risk factor for cancer and other chronic conditions such as cirrhosis.
The Law:
Tax law is a mechanism for reducing consumption of unhealthy products. Both the federal government and the states have used taxes as a means of increasing the cost of products associated with health risks. Taxes can be levied upon the production and or sale of alcohol. The former are often described as excise taxes. According to the Federation of Tax Administrators, almost every state taxes the sale or production of beer, liquor and wine. For examples of state laws taxing alcohol, see Ca Revenue & Taxation Code §§ 32201-32203 (California) and Pa Code §§ 74.1-74.21 (Pennsylvania).
The Evidence:
Wagenaar et al. systematically reviewed studies that assessed the relationship between alcohol prices, alcohol taxes, consumption, and sales. Wagenaar et al. Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction 2009; 104(2): 179-190. The reviewers identified 112 studies that met their inclusion criteria. These studies contained 1003 estimates of the relationship – or elasticity – between price or tax amount and consumption of a specific type of alcohol. Wagenaar et al. calculated mean elasticities for specific kinds of alcohol and conducted a random effects meta-analysis on an entire collection of estimates. The mean elasticities for beer, wine and spirits were all negative and statistically significant, meaning that increases in price are associated with substantial decreases in consumption. The meta-analysis of all 1003 estimates revealed large inverse relationships between consumption and increases in taxes or prices for all types of alcohol.
The Bottom Line:
According to the authors of a peer-reviewed meta-analysis, taxes that increase the price of alcohol effectively reduce overall alcohol consumption.
Publication Date: 02/02/2011
The Problem:
Tobacco use is a source of chronic and fatal illnesses for users and persons with secondary exposure. In the United States, cigarette smoking contributes to one in five deaths and costs more than $193 billion annually in lost productivity and healthcare expenditures. CDC: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. Nearly 25 percent of annual deaths related to cardiovascular disease in the United States can be attributed to smoking and cigarette smokers are 2 to 3 times more likely to die from cardiovascular disease than non-smokers. CDC: The Health Consequences of Smoking. Complete Report. 2004
The Law:
Smoking bans and restrictions prohibit smoking in specified areas. These restrictions aim to eliminate or reduce exposure to secondhand smoke. Smoking bans and restrictions are found in state and local laws as well as regulations governing workplace safety. For examples of state smoking bans, see ARS 36-601.01 (Arizona), Utah Health Code § 26.83.3 (Utah), VT Health Code § 1742 (Vermont), and RI Health & Safety Code § 23-20.10-3 (Rhode Island).
The Evidence:
Meyers et al. performed a systematic review and meta-analysis of 11 studies that assessed the impact of public smoking bans (including workplaces) on the incidence of acute myocardial infarction (AMI) on the general population. Meyers et al. Cardiovascular effect of bans on smoking in public places: A systematic review and meta-analysis. J Am Coll Cardiol, 2009; 54:1249-1255. Studies were drawn from the United States, Canada, Italy, and Scotland. The authors used a random effects meta-analysis to control for differences in study population size and duration of observations. The meta-analysis found that public smoking bans reduce the risk of AMI by 17 percent, and this risk continues to decrease each year after ban implementation. Meyers et al. suggest that the duration of the post-ban effect may be explained by greater compliance to bans, decreased prevalence of smoking, improved air quality, and reduced environmental exposure to tobacco.
The Bottom Line:
According to a peer-reviewed systematic review and meta-analysis, substantial evidence suggests that public smoking bans effectively reduce the risk of acute myocardial infarction.
Origin: Alcoholism: Clinical and Experimental Research, July 23, 2010
Alex C. Wagenaar, associate director at PHLR, and Mildred M. Maldonado-Molina recently published an article in Alcoholism: Clinical and Experimental Research.
They write that more than "a hundred studies have established the effects of beverage alcohol taxes and prices on sales and drinking behaviors. Yet, relatively few studies have examined effects of alcohol taxes on alcohol-related mortality. We evaluated effects of multiple changes in alcohol tax rates in the state of Florida from 1969 to 2004 on disease (not injury) mortality."
They " found significant reductions in mortality related to chronic heavy alcohol consumption following legislatively induced increases in alcohol taxes in Florida." and concluded that "increased alcohol taxes are associated with significant and sizable reductions in alcohol-attributable mortality in Florida. Results indicate that 600 to 800 lives per year could be saved if real tax rates were returned to 1983 levels (when the last tax increase occurred). Findings highlight the role of tax policy as an effective means for reducing deaths associated with chronic heavy alcohol use."
Additional URL(s):
Alcoholism: Clinical and Experimental Research
Substance Abuse Policy Research Program
Publication Date: 12/07/2009
The Problem:
The operation of motor vehicles while intoxicated is a major public health problem. Each year in the United States roughly 13,400 people die and an additional 255,500 are injured in motor vehicle crashes involving an alcohol-impaired driver. In 2006, these crashes accounted for almost a third of all U.S. traffic-related deaths. CDC: Impaired Driving Factsheet
The Law:
At selective breath testing (SBT) checkpoints, law enforcement officials may require a driver to submit to a breath test if the officer has a reasonable suspicion that the driver is intoxicated. As of September 2009, law enforcement agencies in 38 U.S. states and the District of Columbia may conduct sobriety checkpoints. Governors Highway Safety Association. Law enforcement agencies in 11 states are either not authorized by the state to conduct checkpoints or are prohibited from conducting checkpoints by interpretations of state constitutions or by statutes (e.g., Wisconsin, Wis. Stat. § 349.02(2)(a)). Law enforcement officers follow established procedures in conducting checkpoints, including using objective criteria to determine checkpoint locations and using a predetermined system for stopping cars (e.g., every fourth vehicle at a checkpoint is stopped). For examples of laws authorizing checkpoints, see Utah Code Ann. §§ 77-23-101 et seq (Utah) and Nev. Rev. Stat. § 484.359 (Nevada).
The Evidence:
In a systematic review, Shults et al. reviewed 13 studies on SBT checkpoints. Shults, et al. Reviews of Evidence Regarding Interventions to Reduce Alcohol-Impaired Driving. Am J Prev Med. 2001;21(4S):66-88. The reviewers found that the use of SBT checkpoints is effective in reducing fatal and nonfatal injuries involved in motor vehicle accidents and in the reduction of total alcohol related crashes. SBT checkpoints were found to reduce fatal and nonfatal injuries during crashes by a median 20 percent. An ancillary benefit noted in the underlying studies of SBT checkpoints is the increased policing of other illegal activity behavior such as driving with a suspended license.
The Bottom Line:
In the judgment of a Community Guide expert panel, there is strong evidence supporting the effectiveness of SBT sobriety checkpoints as a public health intervention aimed at reducing the harms associated with alcohol impaired driving.
Additional Information:
The Community Guide provides online access to a table summarizing the studies used in the review.
The Insurance Institute for Highway Safety provides online access to a table listing statutes and judicial interpretations authorizing or prohibiting sobriety checkpoints.
Publication Date: 12/07/2009
The Problem:
Tobacco use is a source of chronic and fatal illnesses for users and persons with secondary exposure. In the United States, cigarette smoking contributes to one in five deaths and costs more than $193 billion in annual lost productivity and healthcare expenditures. CDC: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004.
The Law:
Smoking bans and restrictions prohibit smoking in specified areas. These restrictions aim to eliminate or reduce exposure to second hand smoke. Smoking bans and restrictions are found in state and local laws as well as regulations governing workplace safety. For examples of state smoking regulations, see ARS 36-601.01 (Arizona), Utah Health Code § 26.83.3 (Utah), VT Health Code § 1742 (Vermont), and RI Health & Safety Code § 23-20.10-3 (Rhode Island).
The Evidence:
In a systematic review, a Community Guide expert panel reviewed 10 studies that assessed the effectiveness of smoking bans and restrictions as means of reducing exposure to secondhand smoke in workplaces. Hopkins DP et al. Reviews of Evidence Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke. Am J Prev Med 2001; 20(2S). Some of the underlying studies measured the impact of specific smoking restriction laws; others measured the impact of policies initiated and enforced by private entities. The reviewers identified reductions in self-reported exposure or actual nicotine vapor in 9 of the 10 studies. Reductions in vapor measures ranged from 44 percent to 97 percent.
The Bottom Line:
In the judgment of a Community Guide expert panel, there is strong evidence supporting smoking bans and restrictions as effective public health interventions aimed at decreasing exposure to secondhand smoke.
Additional Information:
An interactive map from the Robert Wood Johnson Foundation gives policy-makers and advocates a nationwide picture of continuing state efforts on key tobacco control policies.
Additional Resources: Smoke-free Laws by State
Publication Date: 12/07/2009
The Problem:
The operation of motor vehicles while intoxicated is a major public health problem. Each year in the United States roughly 13,400 people die and an additional 255,500 are injured in motor vehicle crashes involving an alcohol-impaired driver. These crashes account for 32 percent of all U.S. traffic-related deaths and cost roughly $51 billion a year. CDC: Impaired Driving Factsheet.
The Law:
Blood alcohol per se laws set a blood alcohol limit at which an individual is considered legally impaired (i.e., impairment is “per se” because actual inability to function need not be established). Currently, all states set their BAC limit at 0.08 percent; some previously set the BAC levels at 0.10 percent. For examples of BAC per se laws, see Cal. Veh. Code §23152 (California), Fla. Stat. §316.193 (Florida), K.S.A. §8-1567 (Kansas), M.R.S. §2411 (Maine), N.M. Stat. Ann. §66-8-102 (New Hampshire), N.M. Stat. Ann. §66-8-102 (New Mexico), N.C. Gen. Stat. §20-138.1 (North Carolina), O.R.S. 813.010 (Oregon), Utah Code §41-6a-502 (Utah), 23 V.S.A. §1201 (Vermont), and Va. Code Ann. §18.2-266 (Virginia).
The Evidence:
In a Community Guide systematic review, Shults et al. reviewed eight studies that examined the impact of lowering the BAC limit to 0.08 percent on the rate of alcohol-related motor-vehicle deaths. Shults, et al. Reviews of Evidence Regarding Interventions to Reduce Alcohol-Impaired Driving. Am J Prev Med. 2001;21(4S):66-88.According to the reviewers, the underlying studies reveal a considerable association between the adoption of 0.08 percent BAC laws and a decline in alcohol-related motor-vehicle deaths; the median reduction in motor vehicle fatalities after the laws were adopted was 7 percent. Shults et al view these studies as strong evidence of the effectiveness of 0.08 BAC laws as a public health intervention. However, they caution that most of the BAC laws analyzed were enacted along with, or were supplemented by, other preventive drunk-driving laws, such as Administrative License Revocation (ALR) laws, making it difficult to isolate the exact magnitude of the impact of BAC laws.
The Bottom Line:
In the judgment of a Community Guide expert panel, there is strong evidence that laws adopting decreased BAC levels effectively reduce alcohol-related motor-vehicle deaths.
Additional Information:
The Community Guide provides online access to a table summarizing the results of each study it reviewed.
Additional Resources: The Community Guide
Publication Date: 12/07/2009
The Problem:
The operation of motor vehicles while intoxicated is a major public health problem. Each year in the United States roughly 13,400 people die and an additional 255,500 are injured in motor vehicle crashes involving an alcohol-impaired driver. In 2006, these crashes accounted for almost a third of all U.S. traffic-related deaths. CDC: Impaired Driving Factsheet.
The Law:
In an effort to reduce drunk-driving recidivism, municipalities and states have experimented with ignition interlock programs. Ignition interlock devices disable a car’s ignition until the driver provides a breath sample that confirms that the driver’s blood alcohol content (BAC) is under the requisite limit. Participation in ignition interlock programs is sometimes required as a condition of sentences for violating drunk- driving laws. Initially, participation in the US was generally on a voluntary basis (e.g., violators could participate to regain their driving privileges earlier than otherwise provided) or was left to the court’s discretion and implemented only for repeat offenders. For examples of ignition interlock laws, see 75 Pa.C.S. §§ 88.1-88.8 (Pennsylvania), 90 MGL 24(c)(2) (Massachusetts), and A.R.S. §28-1381(I)(6) (Arizona).
The Evidence:
In a systematic review, Willis et al. reviewed 14 studies in the U.S. and Canada evaluating the effects of ignition interlock programs on drunk-driving recidivism. Willis et al. Alcohol ignition interlock programmes for reducing drink driving recidivism. Cochrane Database of Systematic Reviews. 2004; Issue 3. The underlying studies measured three types of outcomes: (1) recidivism rates while the driver participated in the ignition interlock program, (2) recidivism rates after the ignition interlock device was removed from the vehicle, and (3) recidivism rates during the entire study period. The reviewers found that interlock program participants were less likely to repeat offend than the control group. The impact was even more pronounced for repeat offenders. However, in each instance, recidivism returned to pre-intervention rates after the devices were removed. Though effective as a short term intervention, continued research on the effects of ignition interlock programs on drunk-driving recidivism over longer time periods is needed.
The Bottom Line:
In the judgment of a Cochrane Collaboration expert panel, ignition interlock programs reduce drunk-driving recidivism, but only while the devices are attached.
Additional Information:
Mothers Against Drunk Driving (MADD) maintains an online table listing the states with ignition interlock laws.
Additional Resources: Mothers Against Drunk Driving
© RWJF 2012
Contact Us |
Sitemap
Public Health Law Research is a national program of the Robert Wood Johnson Foundation. It is housed at the Temple University Beasley School of Law.