State Costs of Excessive Alcohol Consumption, 2006

      Background

      Excessive alcohol consumption is responsible for an average of 80,000 deaths in the U.S. each year and cost $223.5 billion ($1.90/drink) in 2006. Comparable state estimates of this cost are needed to help inform prevention strategies.

      Purpose

      The goal of the study was to estimate the economic cost of excessive drinking by state for 2006.

      Methods

      From December 2011 to November 2012, an expert panel developed methods to allocate component costs from the 2006 national estimate to states for (1) total; (2) government; (3) binge drinking; and (4) underage drinking costs. Differences in average state wages were used to adjust productivity losses.

      Results

      In 2006, the median state cost of excessive drinking was $2.9 billion (range: $31.9 billion [California] to $419.6 million [North Dakota]); the median cost per drink, $1.91 (range: $2.74 [Utah] to $0.88 [New Hampshire]); and the median per capita cost, $703 (range: $1662 [District of Columbia] to $578 [Utah]). A median of 42% of state costs were paid by government (range: 45.0% [Utah] to 37.0% [Mississippi]). Binge drinking was responsible for a median of 76.6% of state costs (range: 83.1% [Louisiana] to 71.6% [Massachusetts]); underage drinking, a median of 11.2% of state costs (range: 20.0% [Wyoming] to 5.5% [District of Columbia]).

      Conclusions

      Excessive drinking cost states a median of $2.9 billion in 2006. Most of the costs were due to binge drinking and about $2 of every $5 were paid by government. The Guide to Community Preventive Services has recommended several evidence-based strategies—including increasing alcohol excise taxes, limiting alcohol outlet density, and commercial host liability—that can help reduce excessive alcohol use and the associated economic costs.

      Introduction

      Excessive alcohol consumption is responsible for an average of 80,000 deaths and 2.3 million years of potential life lost (YPLL) each year in the U.S.

      Alcohol and Public Health. Online tools. Alcohol-Related Disease Impact (ARDI) software. www.cdc.gov/alcohol/ardi.htm.

      Excessive alcohol consumption has many adverse health and social consequences—it causes increased healthcare costs as a result of injuries and chronic health conditions; property damage from fire and motor vehicle crashes; increased crime and criminal justice system costs; and lost worker productivity due to absenteeism, diminished output while at work, and reduced earnings potential.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      A comprehensive analysis based on U.S. Public Health Service Guidelines
      • Hodgson T.A.
      • Meiners M.R.
      Guidelines for cost-of-illness studies in the Public Health Service.
      estimated that the economic cost of excessive drinking in the U.S. was $223.5 billion (about $1.90 per drink) in 2006 (the study noted that the $223.5 billion figure was likely to be a substantial underestimate of the true cost for a variety of reasons).
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      Excessive drinkers and their families bore less than half of the costs associated with excessive alcohol consumption (41.5%), whereas federal, state, and local government bore 42.1% of these costs. Binge drinking accounted for 76.1% of the total cost, and lost productivity accounted for 72.2% of total cost.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      National cost estimates are useful for assessing the public health impact of excessive alcohol use, but most of the strategies for preventing excessive drinking that are recommended by the Guide to Community Preventive Services (hereafter referred to as the Community Guide)

      Guide to Community Preventive Services. Preventing excessive alcohol consumption. www.thecommunityguide.org/alcohol/index.html.

      are implemented at the state and local levels. These recommended strategies include increasing alcohol excise taxes, limiting alcohol outlet density, and commercial host (dram shop) liability (refers to laws that hold alcohol retailers responsible for harms caused by patrons who were underage or intoxicated).
      State-level estimates of the economic costs of excessive drinking are therefore needed to inform the planning and implementation of these and other evidence-based prevention strategies. Such estimates can also help policy makers assess the cost of prevention strategies for excessive drinking relative to the cost of alcohol-attributable harms. In addition, comparing the economic costs of excessive drinking across states may provide valuable insights into factors that may influence excessive alcohol consumption and its adverse effects, and thus underlie these cost differences. Accordingly, the purpose of the current study was to generate estimates of the economic costs of excessive alcohol use in states to help assess the extent of the problem and inform the design and implementation of evidence-based prevention strategies, such as those recommended by the Community Guide.

      Methods

      From December 2011 to November 2012, an expert panel developed methods to estimate the costs of excessive alcohol consumption for the 50 states and the District of Columbia (hereafter referred to as states). After reviewing cost estimates already made by some states,
      • Liu L.Y.
      Economic cost of alcohol and drug abuse in Texas—2000.
      • Barkey P.M.
      The economic cost of alcohol abuse in Montana.
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      • Bohs R.
      • Sayed B.
      The annual economic impact of drug and alcohol abuse in Florida.

      Roeber J. The human and economic cost of alcohol abuse in New Mexico, 2006. New Mexico Epidemiology 2009. Number 10. November 27, 2009.

      Whelan R, Josephson A, Holcombe J. The economic cost of alcohol and drug abuse in Oregon in 2006. ECONorthwest. Portland OR. January 14, 2008.

      Economic costs of alcohol and other drug abuse in Alaska, 2005 update. The McDowell Group, Inc. Anchorage, Alaska. December 2005.

      • Boeke M.
      • Clarke J.
      • Griffin T.
      • Lewis R.
      • Louricus M.
      The human and economic cost of alcohol use in Minnesota, 2007.
      the panel decided to calculate each state’s cost estimate as a share of the recent 2006 national estimate. This approach was similar to the analyses that had been done in some states, ensured that state costs were calculated based on U.S. Public Health Service recommendations,
      • Hodgson T.A.
      • Meiners M.R.
      Guidelines for cost-of-illness studies in the Public Health Service.
      and used current scientific information. This approach also ensured that state and national estimates of the economic cost of excessive drinking were comparable (e.g., that state sums add to the national total); allowed for the estimation of some costs (e.g., impaired productivity at work) that required data that were only available at the national level; and ensured that all state costs were calculated for the same year, thus facilitating state comparisons of the cost of excessive alcohol consumption per drink and per capita.

      Definition of Excessive Alcohol Consumption

      Consistent with the national definition and previous cost study,
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      excessive alcohol consumption was defined as binge drinking (≥4 drinks per occasion for a woman, and ≥5 drinks per occasion for a man); heavy drinking (>1 drink per day on average for a woman, and >2 drinks per day on average for a man); any alcohol consumption by youth aged <21 years; and any alcohol consumption by pregnant women. Alcohol dependence and alcohol abuse were considered outcomes of excessive drinking and not the primary basis for assessing economic costs, as most excessive drinkers are not alcohol-dependent. However, a history of alcohol dependence was used as a specific indicator of excessive drinking in some analyses (e.g., productivity losses based on lost earnings at work).

      National Study

      The methodology used in the national cost study followed U.S. Public Health Service Guidelines
      • Hodgson T.A.
      • Meiners M.R.
      Guidelines for cost-of-illness studies in the Public Health Service.
      and therefore focused on the direct and indirect costs of excessive alcohol consumption. Intangible costs, such as pain and suffering, were excluded. Healthcare costs, productivity losses, and costs due to other alcohol-related effects in 2006 were obtained from national databases. Alcohol-attributable fractions were obtained from multiple sources and used to assess the proportion of costs that should be attributed to excessive alcohol consumption.
      Healthcare costs included the treatment costs for 54 health conditions (whether fatal or nonfatal) that were fully or partially attributable to alcohol

      Alcohol and Public Health. Online tools. Alcohol-Related Disease Impact (ARDI) software. www.cdc.gov/alcohol/ardi.htm.

      , including alcohol dependence or abuse and fetal alcohol syndrome (FAS); research and prevention costs; health insurance administration costs; and the costs of training substance abuse and mental health professionals. Productivity losses included those associated with premature mortality; impaired productivity (at work, at home, and while institutionalized); work-related absenteeism; crime (lost work days among victims and lost productivity from incarcerations); and reduced productivity related to FAS. Other effects included costs associated with property damage due to crimes; criminal justice system costs, including for police protection, the court system, correctional institutions, private legal costs, and alcohol-related crimes (e.g., driving under the influence, liquor law violations, and public drunkenness); motor vehicle crashes; fire damage; and FAS-related special education. Full details on the methods used in the national study
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      are available at www.ajpmonline.org/article/S0749-3797%2811%2900538-1/addOns and www.lewin.com/~/media/Lewin/Site_Sections/Publications/Economic%20Cost%20of%20Excessive%20Alcohol%20Consumption.pdf.

      Calculation of State Total Cost Estimates

      The same 26 cost components that were used to estimate national costs were also used to calculate state costs. For each of these 26 components, an allocator (Appendix A, available online at www.ajpmonline.org) was selected to apportion the national cost to the states (Appendix B, available online at www.ajpmonline.org). The selection of allocators was made by the expert panel. In general, allocators were selected based on their data availability; consistency with the national estimate; relationship to a particular cost; representativeness of the population affected (e.g., state share of total binge episodes among women of child-bearing age was used to allocate national costs for FAS); and scientific evidence linking an allocator to a specific cost item. Some allocators were directly related to a cost category (e.g., state budgets for fire protection services); others were based on risk measures (e.g., binge drinking episodes) or health outcomes (e.g., alcohol-attributable deaths [AADs]).

      Healthcare-related allocators

      Various allocators were used to derive state healthcare costs for treatment of alcohol-attributable conditions (Appendix A, available online at www.ajpmonline.org). The 2006 National Survey of Substance Abuse, Treatment Services (N-SSATS),

      National Survey of Substance Abuse, Treatment Services (N-SSATS): 2006, Data on Substance Abuse Treatment Facilities. Table 6.28. wwwdasis.samhsa.gov/06nssats/nssats2k6web.pdf.

      provided a March 31, 2006, census of the number of patients in substance abuse treatment facilities for alcohol-related problems in each state; the state’s proportion of all such patients was used to allocate costs related to such treatment. Average annual state-specific AADs for 2001–2005, available on the CDC’s alcohol-related disease impact (ARDI) application,

      Alcohol and Public Health. Online tools. Alcohol-Related Disease Impact (ARDI) software. www.cdc.gov/alcohol/ardi.htm.

      were used to allocate national healthcare treatment costs related to excessive drinking (e.g., ambulatory care visits, hospitalizations). State-specific binge drinking episodes among women aged 18–44 years from the 2006 Behavioral Risk Factor Surveillance System (BRFSS; special analyses run from data at www.cdc.gov/brfss/ on August 13, 2012)

      CDC. Behavioral Risk Factor Surveillance System. www.cdc.gov/brfss/ (August 13, 2012).

      were used to allocate costs due to FAS. No adjustment was made for state-level differences in healthcare treatment costs, because a state-level index for relative service costs was not available.

      Productivity-related allocators

      Because the national estimates for impaired work and household productivity losses were based on alcohol dependence, the number of people aged ≥12 years with alcohol dependence by state as reported in the 2005–2006 National Surveys on Drug Use and Health was used to allocate these costs to states.

      State estimates of substance use and mental health from the 2005-2006 national surveys on drug use and health. Table B17. oas.samhsa.gov/2k6state/ageTabs.htm.

      In the national estimate, premature mortality was valued as the net present value (discounted at 3%) of a lost future wage stream related to age at death. Accordingly, a state’s proportion of national YPLL from deaths caused by any of the 54 alcohol-attributable conditions as reported in ARDI

      Alcohol and Public Health. Online tools. Alcohol-Related Disease Impact (ARDI) software. www.cdc.gov/alcohol/ardi.htm.

      was used as the allocator for premature mortality. The national cost of absenteeism was only assessed for binge drinking, so state-specific binge drinking episodes, as reported in the 2006 BRFSS,

      CDC. Behavioral Risk Factor Surveillance System. www.cdc.gov/brfss/ (August 13, 2012).

      were used to apportion this cost to states. For productivity losses related to incarceration, the number of inmates in jails or prisons by state, as reported in the Bureau of Justice 2006 midyear census,

      Sabol WJ, Minton TD, Harrison PM. Prison and jail inmates at midyear 2006. Bureau of Justice Statistics Bulletin, June 2007, NCJ 217675 U.S. Department of Justice. June 2007. Appendix Table 2 and Appendix Table 8. bjs.ojp.usdoj.gov/content/pub/pdf/pjim06.pdf.

      was used to allocate costs to states.
      For all productivity-related losses, a cost adjustment was also used to account for differences in average wages among states. Depending on the type of loss, one of three state wage adjustors was used: 2006 mean hourly wage for all occupations,

      Bureau of Labor Statistics. Occupational employment statistics. Download occupational employment and wage estimates. May 2006 estimates for all occupations and for child care workers. www.bls.gov/oes/oes_dl.htm.

      2006 mean hourly wage for child care workers

      Bureau of Labor Statistics. Occupational employment statistics. Download occupational employment and wage estimates. May 2006 estimates for all occupations and for child care workers. www.bls.gov/oes/oes_dl.htm.

      ; and 2006 mean hourly minimum wage.

      U.S. Department of Labor, Office of State Standards Programs Wage and Hour Division web site. Changes in basic minimum wages in non-farm employment under state law: selected years 1968 to 2012. www.dol.gov/whd/state/stateMinWageHis.htm.

      An allocated state estimate was multiplied by the ratio of the relevant state wage adjustor to the national wage. These products were summed for all states and then the state’s proportion of the wage-adjusted national total was used to reallocate the original national cost, effectively increasing relative productivity losses for states with a higher wage structure, and lowering it for those with a lower wage structure.

      Allocators for other costs

      Motor vehicle crash costs were allocated based on a state’s share of the total alcohol-impaired (blood alcohol content ≥0.08) motor vehicle crash deaths as reported in the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System (FARS) for 2006.

      National Highway Traffic System Administration. Fatality analysis reporting system. www-fars.nhtsa.dot.gov/Main/index.aspx (States Tab; alcohol tab; year=2006 and BAC=0.08+).

      Criminal justice system costs were allocated by a state’s share of national corrections costs,

      U.S. Department of Justice, Bureau of Justice Statistics. Direct expenditures for state and local justice system activities by type of activity and level of government, fiscal year 2006. Sourcebook of Criminal Justice Statistics Online. www.albany.edu/sourcebook/csv/t162006.csv.

      arrests for violent and property crime,

      U.S. Department of Justice, Federal Bureau of Investigation. Uniform crime reporting statistics. bjs.ojp.usdoj.gov/ucrdata/Search/Crime/State/StatebyState.cfm.

      or arrests for alcohol-related crimes.

      Sourcebook of Criminal Justice Statistics Online. www.albany.edu/sourcebook/csv/t4282006.csv.

      Government expenditures for fire protection services

      U.S. Census Bureau. State and local government finance. Historical data: 2006. www.census.gov/govs/estimate/historical_data_2006.html. Found under Expenditures for public safety.

      were used to allocate fire costs, as fire protection constituted 74% of alcohol-attributable fire costs in the national study.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.

      Cost to Government

      The national study
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      estimated that government paid $94.2 billion (42.1%) of the total cost of excessive alcohol consumption in the U.S. in 2006. These costs were allocated to states in the same manner as total costs (see above) and should be viewed as an approximation. Federal funds are often combined with state funds to pay for alcohol-attributable expenditures (e.g., treatment costs for alcohol dependence). Therefore, no attempt was made to disaggregate federal and state governmental contributions to the cost of excessive drinking for each state. Moreover, given differences across states in policies and the share of costs paid in each category by federal versus state funds and the lack of data to accurately distinguish these relative shares, such an effort would be technically difficult, if not impossible.

      Cost Per Alcoholic Drink and Cost Per Capita

      The number of standard drinks per state was estimated by multiplying the number of gallons of ethanol sold

      Volume beverage and ethanol consumption for States, census regions, and the U.S., 1970–2007. www.niaaa.nih.gov/Resources/DatabaseResources/QuickFacts/AlcoholSales/consum02.htm.

      by the specific gravity of ethanol (0.79) by the weight of 1 gallon of water (8.33 pounds) and the number of grams in 1 pound (453.59) and dividing that product by the number of grams of ethanol in a standard drink (14.0).

      National Institute on Alcohol Abuse and Alcoholism. NIH publications. What is a standard drink? pubs.niaaa.nih.gov/publications/practitioner/pocketguide/pocket_guide2.htm.

      The estimated state cost was divided by the number of standard drinks per state to arrive at the state cost per drink. The cost was also divided by the state population

      Annual estimates of the population for the U.S., regions, and states, and for Puerto Rico: April 1, 2000, to July 1, 2006. www.census.gov/popest/states/tables/NST-EST2006-01.xls.

      to estimate per capita cost.

      Cost of Binge Drinking

      The national study
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      estimated that binge drinking was responsible for $170.7 billion (76.4%) of the total cost of excessive alcohol consumption in the U.S. in 2006. National binge drinking costs were distributed to states in a similar manner to the total costs, with some exceptions (Appendix A, online at www.ajpmonline.org). For example, healthcare-related allocations involving AADs were restricted to AADs from acute causes plus 68.5% of AADs for alcohol abuse and alcohol dependence (based on the proportion of people with these conditions who reported binge drinking in the past month in the National Epidemiologic Survey on Alcohol and Related Conditions

      Alcohol use and alcohol use disorders in the U.S.: main findings from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), January 2006. U.S. alcohol epidemiologic data reference manual, volume 8, number 1. NIH. National Institute on Alcohol Abuse and Alcoholism, Bethesda MD. pubs.niaaa.nih.gov/publications/NESARC_DRM/NESARCDRM.htm.

      [NESARC]). Liquor law violations were also removed from arrest-related allocators because they may not have involved binge drinking. As in the national study, component costs that were associated with acute intoxication (e.g., motor vehicle crashes, crime costs, deaths from acute conditions, and healthcare costs from acute conditions) were 100% assigned to binge drinking.

      Cost of Underage Drinking

      The national study
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      estimated that underage drinking was responsible for $24.6 billion (11.0%) of the total cost of excessive alcohol consumption in the U.S. in 2006. These costs were allocated to states using the same general approach that was used to allocate total costs and the costs of binge drinking (Appendix A, available online at www.ajpmonline.org). To the extent possible, allocators were restricted to indicators and specific outcomes that affected youth aged <21 years (e.g., alcohol dependents aged 12–20 years and binge drinking in those aged 12–20 years).
      Underage AADs were restricted for all but two causes to those aged <21 years. The state-specific estimates of underage AADs due to homicide and motor vehicle crashes were instead based on state-specific estimates of the age of the responsible person (e.g., the age of the driver in an alcohol-attributable fatal motor vehicle crash or the age of a murderer) rather than the age of the decedent, to better reflect the number of underage AADs from underage drinking. For those allocators where data were unavailable for all underage youth, an allocator was selected that was thought to be reflective of this population (e.g., the state share of juveniles in residential placement or live births to girls aged 15–19 years; Appendix A, available online at www.ajpmonline.org).

      Results

      Across all states, the median cost of excessive drinking was $2.9 billion with the highest cost being observed in California ($31.9 billion) and the lowest in North Dakota ($419.6 million). To allow for comparison across states, costs were normalized for each state by population and by number of drinks consumed. When costs were normalized by population, the median cost was $703 per person annually. The District of Columbia’s per capita cost ($1662) was the highest and was more than double the median. Alaska had the second-highest per capita cost ($1096). Utah, at $578, had the lowest per capita cost and was the only state to have costs below $600 per capita. Thirty-nine states had per capita costs between $600 and $800, and 25 states were clustered around the median with costs between $650 and $750 per capita (Table 1; Figure 1).
      Table 1Estimated total and governmental costs of excessive alcohol consumption, by state, 2006
      Total cost ($)Governmental cost ($)
      StateCost (millions)Cost per drinkPer capita costCost (millions)Cost per drinkPer capita cost% of total cost
      Alabama3,216.62.056991,252.60.8027238.9
      Alaska734.52.341096315.21.0047042.9
      Arizona5,325.62.078642,244.20.8736442.1
      Arkansas1,871.22.12666750.40.8526740.1
      California31,856.42.2587413,675.20.9737542.9
      Colorado4,306.31.959061,882.80.8539643.7
      Connecticut2,712.61.917741,136.60.8032441.9
      Delaware686.81.40805299.00.6135043.5
      District of Columbia966.72.351662403.30.9869441.7
      Florida13,341.71.537385,635.80.6531242.2
      Georgia6,345.31.946782,647.60.8128341.7
      Hawaii821.51.42639334.50.5826040.7
      Idaho977.41.57667401.00.6427341.0
      Illinois9,335.41.827283,797.70.7429640.7
      Indiana4,206.71.946661,792.20.8228442.6
      Iowa1,853.51.64622762.30.6725641.1
      Kansas1,921.52.09695799.10.8728941.6
      Kentucky2,764.82.066571,151.70.8627441.7
      Louisiana3,403.91.757941,367.60.7031940.2
      Maine879.91.51666372.60.6428242.3
      Maryland4,172.41.967431,857.70.8733144.5
      Massachusetts5,112.61.767942,173.80.7533842.5
      Michigan8,218.82.168143,511.80.9234842.7
      Minnesota3,547.41.656871,456.20.6828241.0
      Mississippi2,138.01.93735790.40.7127237.0
      Missouri4,464.61.867641,797.30.7530840.3
      Montana791.21.73838300.40.6631838.0
      Nebraska1,118.41.57632476.00.6726942.6
      Nevada1,940.91.23778814.20.5232642.0
      New Hampshire852.30.88648348.30.3626540.9
      New Jersey5,937.11.696802,530.20.7229042.6
      New Mexico1,876.12.36960793.51.0040642.3
      New York14,225.92.117376,262.50.9332444.0
      North Carolina6,042.72.006822,536.70.8428642.0
      North Dakota419.61.36660169.70.5526740.4
      Ohio7,654.21.926673,259.10.8228442.6
      Oklahoma2,491.22.676961,047.21.1229342.0
      Oregon2,864.81.757741,280.00.7834644.7
      Pennsylvania8,398.11.816753,604.70.7829042.9
      Rhode Island827.41.74775354.90.7533242.9
      South Carolina3,274.71.777581,269.50.6829438.8
      South Dakota542.21.60693213.50.6327339.4
      Tennessee4,165.62.096901,683.70.8427940.4
      Texas16,524.81.897036,718.00.7728640.7
      Utah1,473.82.74578664.01.2326045.0
      Vermont423.71.45679181.20.6229042.8
      Virginia5,354.91.927012,261.20.8129642.2
      Washington5,319.12.138322,374.40.9537144.6
      West Virginia1,129.82.01621452.70.8124940.1
      Wisconsin4,180.21.457521,796.00.6232343.0
      Wyoming468.01.91909195.50.8038041.8
      State median2,864.81.917031,252.60.7829342.0
      Figure thumbnail gr1
      Figure 1Ordered per capita cost of excessive alcohol consumption, by state, U.S., 2006
      When costs were normalized by the number of drinks consumed, the median cost per drink was $1.91. Utah ($2.74) and Oklahoma ($2.67 per drink) were the only two states with a cost per drink that was >25% above the median. In contrast, five states (Delaware, Hawaii, Nevada, New Hampshire, and North Dakota) had a cost per drink that was >25% less than the median. The cost per drink in New Hampshire ($0.88) was less than half the median (Table 1).
      Across all states, the median cost to government was $1.3 billion (range: $13.7 billion [California] to $169.7 million [North Dakota]). A median of 42% of the total state cost was paid by government with a range of 45% in Utah to 37% in Mississippi. For the median state, excessive drinking cost the government $0.78 per drink (Table 1).
      Productivity losses represented the largest share (median 70.5%) of total state costs of excessive drinking. Healthcare costs represented 11.6%, and other costs such as alcohol-related criminal justice system costs, motor vehicle crash, and crime-related property damage represented 17.0%. The share of costs represented by each cost category varied substantially across the states. The share represented by productivity losses ranged from 60.9% in Wyoming to 82.1% in DC. The median proportion of costs for health care ranged from 15.9% in Vermont to 7.8% in Texas (Table 2).
      Table 2Estimated healthcare, productivity, and other costs of excessive alcohol consumption, by state, 2006
      HealthcareProductivityOther
      Other includes costs associated with property damage due to crimes; criminal justice system costs, including costs for police protection, the court system, correctional institutions, private legal costs, and alcohol crimes (e.g., driving under the influence, liquor law violations, and public drunkenness); motor vehicle crashes; property damage from fire; and special education related to fetal alcohol syndrome.
      StateCost (millions $)% of total costCost (millions $)% of total costCost (millions $)% of total cost
      Alabama330.710.32,206.268.6679.721.1
      Alaska75.810.3566.277.192.512.6
      Arizona617.011.63,709.169.6999.518.8
      Arkansas171.19.11,279.268.4420.922.5
      California3,012.19.523,876.575.04,967.715.6
      Colorado650.415.13,075.771.4580.313.5
      Connecticut307.211.32,053.575.7351.913.0
      Delaware86.412.6477.969.6122.517.8
      District of Columbia83.18.6794.082.189.69.3
      Florida1,472.611.09,352.970.12,516.118.9
      Georgia573.69.04,557.971.81,213.819.1
      Hawaii73.38.9600.773.1147.618.0
      Idaho114.111.7676.369.2187.019.1
      Illinois960.910.37,149.876.61,224.813.1
      Indiana571.513.62,965.770.5669.515.9
      Iowa214.011.51,342.172.4297.416.0
      Kansas236.412.31,374.471.5310.716.2
      Kentucky406.914.71,904.568.9453.416.4
      Louisiana316.09.32,323.568.3764.422.5
      Maine133.615.2614.969.9131.414.9
      Maryland532.312.82,935.070.3705.216.9
      Massachusetts631.212.33,902.776.3578.711.3
      Michigan946.511.56,107.274.31,165.114.2
      Minnesota312.88.82,753.377.6481.313.6
      Mississippi224.910.51,396.665.3516.524.2
      Missouri501.411.23,157.970.7805.218.0
      Montana92.911.7529.967.0168.321.3
      Nebraska126.011.3789.370.6203.118.2
      Nevada203.210.51,362.270.2375.419.3
      New Hampshire89.010.4640.875.2122.414.4
      New Jersey570.99.64,517.176.1849.014.3
      New Mexico278.814.91,283.968.4313.416.7
      New York1,729.412.210,502.673.81,993.914.0
      North Carolina667.711.04,278.570.81,096.618.1
      North Dakota59.314.1280.966.979.418.9
      Ohio894.411.75,536.572.31,223.316.0
      Oklahoma305.512.31,707.468.5478.319.2
      Oregon430.015.01,946.467.9488.417.0
      Pennsylvania1,005.712.05,934.070.71,458.417.4
      Rhode Island110.613.4606.173.3110.713.4
      South Carolina345.910.62,191.766.9737.222.5
      South Dakota69.312.8355.065.5117.921.7
      Tennessee432.410.42,865.268.8868.020.8
      Texas1,295.27.811,901.872.03,327.820.1
      Utah187.412.71,048.771.2237.816.1
      Vermont67.315.9291.968.964.415.2
      Virginia528.99.93,938.473.5887.516.6
      Washington809.315.23,715.569.9794.314.9
      West Virginia134.011.9787.069.7208.818.5
      Wisconsin507.912.22,836.367.9836.020.0
      Wyoming59.012.6285.160.9123.926.5
      State median316.011.62,053.570.5488.417.0
      a Other includes costs associated with property damage due to crimes; criminal justice system costs, including costs for police protection, the court system, correctional institutions, private legal costs, and alcohol crimes (e.g., driving under the influence, liquor law violations, and public drunkenness); motor vehicle crashes; property damage from fire; and special education related to fetal alcohol syndrome.
      Across all states, the median cost of binge drinking was $2.2 billion (range: $23.5 billion [California] to $305.3 million [North Dakota]). Binge drinking was responsible for a median of 76.6% of state costs (range: 83.1% [Louisiana] to 71.6% [Massachusetts]; Table 3). Across all states, underage drinking was responsible for a median of $361.4 million in economic costs (range: $3.5 billion [California] to $53.6 million [District of Columbia]). The median proportion of total state costs due to underage drinking was 11.2% but varied widely (range: 20.0% [Wyoming] to 5.5% [District of Columbia]; Table 3).
      Table 3Estimated costs for binge drinking and underage drinking, by state, 2006
      Binge drinking (all ages)Underage drinking
      StateCost (millions $)% of total costCost (millions $)% of total cost
      Alabama2,595.480.7408.512.7
      Alaska545.074.2108.114.7
      Arizona4,118.677.3533.210.0
      Arkansas1,520.981.3205.811.0
      California23,540.573.93470.810.9
      Colorado3,225.274.9531.512.3
      Connecticut2,030.674.9219.78.1
      Delaware525.076.471.610.4
      District of Columbia745.877.153.65.5
      Florida10,261.376.91618.312.1
      Georgia5,063.879.8653.910.3
      Hawaii632.977.095.311.6
      Idaho748.976.6135.913.9
      Illinois7,130.376.4936.810.0
      Indiana3,228.776.8556.413.2
      Iowa1,386.074.8255.513.8
      Kansas1,492.177.7256.413.3
      Kentucky2,208.679.9316.411.4
      Louisiana2,827.383.1361.410.6
      Maine653.274.2120.613.7
      Maryland3,223.877.3470.411.3
      Massachusetts3,658.971.6406.47.9
      Michigan6,096.074.2830.210.1
      Minnesota2,644.474.5446.412.6
      Mississippi1,773.983.0207.99.7
      Missouri3,522.978.9505.611.3
      Montana609.277.087.811.1
      Nebraska844.775.5207.218.5
      Nevada1,481.576.3203.410.5
      New Hampshire625.773.493.110.9
      New Jersey4,420.974.5543.89.2
      New Mexico1,423.275.9158.68.5
      New York10,596.374.51183.68.3
      North Carolina4,774.779.0566.19.4
      North Dakota305.372.769.416.5
      Ohio5,777.875.5880.311.5
      Oklahoma1,966.778.9279.411.2
      Oregon2,097.673.2386.113.5
      Pennsylvania6,443.176.7968.711.5
      Rhode Island594.471.873.78.9
      South Carolina2,587.679.0367.211.2
      South Dakota412.876.1107.319.8
      Tennessee3,336.880.1489.811.8
      Texas12,989.278.61846.911.2
      Utah1,141.177.4260.217.7
      Vermont315.674.554.712.9
      Virginia4,161.577.7572.810.7
      Washington3,960.274.5575.810.8
      West Virginia883.878.2122.710.9
      Wisconsin3,178.676.0601.114.4
      Wyoming371.579.493.520.0
      State median2,208.676.6361.411.2
      In order to assess the relative magnitude of the total state costs for excessive drinking, these costs were compared to the total state costs for smoking and the total state cost of Medicaid (including federal and state contributions). Although derived using different methods, the total state costs for excessive drinking were generally of the same order of magnitude as the total cost of smoking to states in 2004, and in many states, the total state cost of Medicaid in 2006 as well (Table 4). The total state costs of smoking ranged from $17.7 billion in California to $291 million in Wyoming, and the total state cost of Medicaid ranged from $44.7 billion in New York to $421 million in Wyoming.
      Table 4Costs of excessive drinking, smoking, and Medicaid, by state (millions $)
      StateExcessive drinking 2006Smoking 2004
      From www.cdc.gov/tobacco/data_statistics/state_data/data_highlights/2006/pdfs/dataHighlights06rev.pdf. These costs are not directly comparable to the costs of excessive drinking because of a different base year, methods used to estimate the cost, and components included in the analyses.
      Medicaid 2006
      From Table 1 at www.kff.org/medicaid/upload/7334-03.pdf; includes federal contribution to state for Medicaid
      Alabama3,2173,5503,886
      Alaska735326960
      Arizona5,3262,7796,196
      Arkansas1,8712,1182,895
      California31,85617,72734,247
      Colorado4,3062,3062,873
      Connecticut2,7132,6484,213
      Delaware687588947
      District of Columbia9674761,302
      Florida13,34212,79912,763
      Georgia6,3455,3346,841
      Hawaii8226441,101
      Idaho9776521,044
      Illinois9,3358,39810,119
      Indiana4,2074,5795,674
      Iowa1,8541,9802,615
      Kansas1,9221,7902,078
      Kentucky2,7653,6384,378
      Louisiana3,4043,3934,861
      Maine8801,0961,954
      Maryland4,1723,7475,000
      Massachusetts5,1135,4669,697
      Michigan8,2197,2038,288
      Minnesota3,5473,2685,666
      Mississippi2,1382,1323,270
      Missouri4,4654,5546,477
      Montana791572726
      Nebraska1,1181,0361,537
      Nevada1,9411,3971,178
      New Hampshire8529691,107
      New Jersey5,9375,8029,084
      New Mexico1,8769282,490
      New York14,22614,18944,712
      North Carolina6,0435,7709,140
      North Dakota420437504
      Ohio7,6549,03312,251
      Oklahoma2,4912,7182,973
      Oregon2,8652,1932,941
      Pennsylvania8,3989,83015,512
      Rhode Island8278701,697
      South Carolina3,2752,9304,069
      South Dakota542502607
      Tennessee4,1664,9066,066
      Texas16,52512,27618,116
      Utah1,4746181,473
      Vermont424430948
      Virginia5,3554,5144,654
      Washington5,3193,7005,579
      West Virginia1,1301,6832,099
      Wisconsin4,1803,6664,653
      Wyoming468291421
      State median2,8652,7183,886
      U.S.-Total223,479194,451303,882
      a From www.cdc.gov/tobacco/data_statistics/state_data/data_highlights/2006/pdfs/dataHighlights06rev.pdf. These costs are not directly comparable to the costs of excessive drinking because of a different base year, methods used to estimate the cost, and components included in the analyses.
      b From Table 1 at www.kff.org/medicaid/upload/7334-03.pdf; includes federal contribution to state for Medicaid

      Discussion

      In 2006, excessive alcohol use cost states a median of $2.9 billion ($703 per person or about $1.91 per drink). More than 70% of these costs were due to binge drinking, and about $2 of every $5 of these costs were paid by government. Several states have independently estimated the economic cost of excessive alcohol consumption.
      • Liu L.Y.
      Economic cost of alcohol and drug abuse in Texas—2000.
      • Barkey P.M.
      The economic cost of alcohol abuse in Montana.
      • Rosen S.M.
      • Miller T.R.
      • Simon M.
      The cost of alcohol in California.
      • Bohs R.
      • Sayed B.
      The annual economic impact of drug and alcohol abuse in Florida.

      Roeber J. The human and economic cost of alcohol abuse in New Mexico, 2006. New Mexico Epidemiology 2009. Number 10. November 27, 2009.

      Whelan R, Josephson A, Holcombe J. The economic cost of alcohol and drug abuse in Oregon in 2006. ECONorthwest. Portland OR. January 14, 2008.

      Economic costs of alcohol and other drug abuse in Alaska, 2005 update. The McDowell Group, Inc. Anchorage, Alaska. December 2005.

      • Boeke M.
      • Clarke J.
      • Griffin T.
      • Lewis R.
      • Louricus M.
      The human and economic cost of alcohol use in Minnesota, 2007.
      It is difficult to compare the state cost estimates in this report to those estimates because of differences in the overall analytic framework used, inconsistencies in the definition of excessive alcohol use, different sources of cost information, and the time periods assessed. However, estimates in the current study were quite similar to two individual state cost estimates that were for the same year—New Mexico estimated the 2006 economic cost of excessive drinking at $2.5 billion

      Roeber J. The human and economic cost of alcohol abuse in New Mexico, 2006. New Mexico Epidemiology 2009. Number 10. November 27, 2009.

      (vs $1.9 billion in the current study); and Oregon estimated the cost at $3.2 billion

      Whelan R, Josephson A, Holcombe J. The economic cost of alcohol and drug abuse in Oregon in 2006. ECONorthwest. Portland OR. January 14, 2008.

      (vs $2.9 billion in the current study).
      The state estimates calculated here are most likely substantial underestimates, as they were based on apportioning a national estimate that was also underestimated.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      For example, no matter how divided up among the states, the national estimate for reductions in workplace or household productivity did not include women, for technical reasons.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      Moreover, they were based on only the impact of alcohol dependence on productivity, and with the exception of a portion of absenteeism, omitted the likely impact of excessive alcohol consumption by nondependent drinkers (binge and heavy drinking) on other forms of lost workplace productivity (e.g., presenteeism, such as attending work while “hung over”).
      The mortality, morbidity, and associated lost productivity estimates were based on only the primary cause of death or illness and did not include contributing causes that were related to alcohol. Neither the national study nor these state estimates included intangible costs like pain, suffering, and bereavement. A study of the costs of underage drinking estimated that 67% of the total economic impact was due to intangible costs.
      • Miller T.R.
      • Levy D.T.
      • Spicer R.S.
      • Taylor D.M.
      Societal costs of underage drinking.
      Should a similar relationship apply here, the costs of excessive alcohol consumption for states would have been at least two times higher. Multiple additional sources of underestimation for the national costs that were apportioned to states are described in Table 3 of the national report.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      Observed interstate differences in the costs of excessive alcohol consumption were influenced by a number of factors, some of which were likely independent of differences in alcohol consumption (e.g., road design and access to emergency medical services). However, differences in cost per drink and cost per capita do reflect differences in individual alcohol consumption (a proxy for excessive alcohol use), which is influenced by social and cultural factors such as varying demographics,
      • Kanny D.
      • Liu Y.
      • Brewer R.D.
      CDC. Binge drinking—U.S., 2009.
      religiosity,
      • Haber J.R.
      • Grant J.D.
      • Jacob T.
      • Koenig L.B.
      • Heath A.
      Alcohol milestones, risk factors, and religion/spirituality in young adult women.
      urbanicity,
      • CDC
      Vital signs: binge drinking prevalence, frequency, and intensity among adults—U.S., 2010.
      accepted drinking norms,
      • Greenfield T.K.
      • Room R.
      Situational norms for drinking and drunkenness: trends in the U.S. adult population, 1979-1990.
      and other issues.
      • Ahern J.
      • Galea S.
      • Hubbard A.
      • Midanik L.
      • Syme S.L.
      "Culture of drinking" and individual problems with alcohol use.
      Excessive alcohol consumption is also influenced by alcohol control policies related to the availability and accessibility of alcohol (and their enforcement); alcohol advertising; alcohol excise taxes; and drinking and driving.
      • Cook P.J.
      • Moore M.J.
      The economics of alcohol abuse and alcohol-control policies.
      • Campbell C.A.
      • Hahn R.A.
      • Elder R.
      • et al.
      Task Force on Community Preventive Services. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms.

      Strengths and Limitations

      There are a number of advantages to assessing the cost of excessive alcohol consumption in states based on national costs. First, this approach overcame a data limitation in that it supported estimation of alcohol-attributable costs for items where data were only available at the national level (e.g., productivity losses at work), but where the costs themselves were actually incurred at the state and local levels. Second, by using a standard approach to assess costs, this methodology allowed for cost comparisons between states and ensures that national and state totals align. Third, this methodology was more cost-efficient and timely than assessing costs in each state or local area, and provides a starting point for more-detailed cost assessments, which state or local health agencies may wish to conduct in the future.
      Assessing the economic cost of excessive alcohol consumption in states based on national costs has limitations. First, as previously noted, national cost estimates substantially underestimate the actual cost of excessive alcohol use for a variety of reasons.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      Second, although state cost allocators (e.g., alcohol-attributable health outcomes) were carefully selected to reflect the expected distribution of state costs for a particular cost component (e.g., alcohol-attributable hospitalizations), it is likely that some of these allocators did not fully capture factors that might have influenced the state distribution of some national costs.
      Third, some cost allocators (e.g., the state share of alcohol-attributable deaths) are likely to vary from year to year, affecting the stability of state cost estimates for various subgroups such as underage youth, particularly in smaller states. Fourth, some alcohol-attributable costs (e.g., criminal justice costs for police protection and legal adjudication) were affected by other factors, such as the availability of state resources to enforce laws against alcohol-attributable crimes (e.g., driving while impaired). As a result, differences in these costs across states may not accurately reflect true differences in the occurrence of alcohol-attributable outcomes. Fifth, costs for alcohol regulatory structures were not included. Sixth, although productivity-related losses were adjusted to account for differences in state wages, state adjustment factors were not available for many cost items (e.g., differences in the cost of repairing a motor vehicle that was damaged in an alcohol-attributable crash), resulting in some imprecision in the allocation of these costs to states. The wage adjustments used in this study also resulted in a lost life being valued differently in different states even after taking into account differences in the demographic characteristics of the decedent (i.e., age and gender). Seventh, state estimates of the per-drink cost of excessive alcohol consumption were based on the total gallons of ethanol sold in a state. As a result, it reflects both state sales of alcohol and state drinking levels. Although per capita alcohol sales in states generally correlate strongly with self-reported alcohol consumption in states,
      • Nelson D.E.
      • Naimi T.S.
      • Brewer R.D.
      • Roeber J.
      U.S. state alcohol sales compared to survey data, 1993—2006.
      a substantial proportion of the alcohol sales in some states, such as New Hampshire and Nevada, are to nonresidents, resulting in a substantial underestimate of the actual state cost for excessive alcohol consumption on a per-drink basis.
      Based on the ratio of self-reported consumption to alcohol sales in 2006,
      • Nelson D.E.
      • Naimi T.S.
      • Brewer R.D.
      • Roeber J.
      U.S. state alcohol sales compared to survey data, 1993—2006.
      had alcohol sales in New Hampshire and Nevada been restricted to state residents, the estimated cost per drink would likely have been 112% and 54% higher, respectively, than reported here (unpublished analysis, 2012). Finally, there are many differences across states, such as demographics, economic conditions, and governmental policy, that were not accounted for in the methods of this study. Accordingly, some states may wish to generate their own estimates of the costs of excessive alcohol consumption using state-specific data sources to increase the precision of these estimates. These cost estimates will be updated as more current data become available.

      Conclusion

      Excessive alcohol consumption has a substantial, but largely under-recognized, economic impact on all states in the U.S. The Community Guide

      Guide to Community Preventive Services. Preventing excessive alcohol consumption. www.thecommunityguide.org/alcohol/index.html.

      has recommended several evidence-based strategies—including increasing alcohol excise taxes, limiting alcohol outlet density, and commercial host (dram shop) liability—that can help reduce excessive alcohol use and the associated economic costs.

      Acknowledgements

      The authors acknowledge the assistance of Marissa Esser, MPH, Dafna Kanny, PhD, Yong Liu, MD, MS, and Jessica Mesnick, MPH, all from the Alcohol Program, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), CDC; and of Mandy Stahre, PhD, MPH, EIS Officer, CDC.
      This project was supported by Contracts 200-2012-M-51945 and 200-2011-M-41451 from the CDC to the CDC Foundation.
      The findings and conclusions in this report are those of the authors and do not necessarily represent the official views of the CDC.
      JJS conducted this work while an employee of Sue Binder Consulting, Inc., and received funding for this project from the CDC Foundation. Jim Roeber conducted this work while an employee of the New Mexico Department of Health. Ellen Bouchery conducted this work while an employee of Mathematica, Inc., and received funding for this project from the CDC Foundation. Katherine Gonzales conducted this work while an employee of the Michigan Department of Community Health. Frank Chaloupka conducted this work while an employee of University of Illinois at Chicago. Robert Brewer conducted this work while an employee of the CDC.
      No financial disclosures were reported by the authors of this paper.

      Appendix. Supplementary data

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