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Assessing the Costs of Excessive Alcohol Consumption in Minnesota

Open AccessPublished:August 10, 2022DOI:https://doi.org/10.1016/j.amepre.2022.04.031

      Introduction

      Alcohol consumption, particularly excessive drinking, incurs a high societal cost. This study aimed to apply current state-specific data from 1 state, Minnesota, to established national methods for estimating the societal cost of excessive alcohol consumption for 2 purposes: first, to update the cost estimate for the state and, second, to understand the potential benefits of using state-specific data versus a national apportionment strategy for economic burden estimates.

      Methods

      In 2021, established methods were used to apply alcohol-attributable fractions for health care, lost productivity, crime, and other effects (e.g., motor vehicle crashes) to 2019 Minnesota data. The main outcome measure was the annual prevalence cost (incurred and paid each year) of excessive alcohol use in Minnesota from the societal perspective. Secondary outcome measures were the cost of specific outcomes (e.g., crime), different types of consumption (e.g., drinking during pregnancy), the cost to government payers, and the cost per drink.

      Results

      The societal cost of alcohol use in Minnesota in 2019 was nearly $8 billion dollars (2019 USD) or $1,383 per resident. This estimate is substantially higher than a previous estimate on the basis of apportionment of a national estimate.

      Conclusions

      The cost of alcohol use in Minnesota is considerable. Geographically specific and current cost estimates can inform decision making about the public health impact of excessive alcohol use and the cost effectiveness of prevention strategies. Evidence-based prevention strategies to reduce alcohol use include increased alcohol taxes, enhanced enforcement of laws prohibiting sales to minors, and electronic screening and brief intervention.

      INTRODUCTION

      Excessive alcohol use is one of the leading causes of preventable death in the U.S., contributing to >95,000 deaths each year.
      • Mokdad AH
      • Ballestros K
      • et al.
      U.S. Burden of Disease Collaborators
      The State of U.S. Health, 1990-2016: burden of diseases, injuries, and risk factors among U.S. states.
      ,

      Alcohol related disease impact (ARDI) application. Centers for Disease Control and Prevention. https://www.cdc.gov/ARDI. Updated April 2022. Accessed November 9, 2020.

      It is associated with acute causes of death such as alcohol poisoning and traffic crashes as well as chronic causes such as alcoholic liver disease and 7 types of cancer.

      Alcohol related disease impact (ARDI) application. Centers for Disease Control and Prevention. https://www.cdc.gov/ARDI. Updated April 2022. Accessed November 9, 2020.

      Although any amount of alcohol can cause harm, excessive drinking is the most harmful, incurring substantial costs owing to premature death, injury and violence, crime, property damage, disease, and lost productivity. Binge drinking, the costliest form of alcohol consumption, continues at high rates. A recent study estimated that over 17% of U.S. adults self-reported binge drinking weekly and consumed an average of 7 drinks per binge drinking episode.
      • Kanny D
      • Naimi TS
      • Liu Y
      • Brewer RD.
      Trends in total binge drinks per adult who reported binge drinking–United States, 2011-2017.
      Timely cost estimates can inform decision making about the public health impact of excessive alcohol use and the cost effectiveness of prevention strategies.

      Excessive alcohol consumption. Community Preventive Services Task Force. https://www.thecommunityguide.org/topic/excessive-alcohol-consumption. Accessed March 23, 2018.

      National estimates of the economic burden of excessive alcohol use in the U.S. are comprehensive but outdated. Such estimates were published first in 1992 and most recently updated in 2010,

      Harwood HJ, Fountain D, Livermore G. The economic costs of alcohol and drug abuse in the U.S., 1992. Report prepared for the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism,Rockville, MD: NIH, DHHS. https://pubs.niaaa.nih.gov/publications/10report/chap06c.pdf. Published 1998. Accessed April 19, 2022.

      Harwood HJ, Updating estimates of the economic costs of alcohol abuse in the U.S.: estimates, update methods and data. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism, NIH Publication No. 98–4327, 1998, Rockville MD: NIH https://pubs.niaaa.nih.gov/publications/economic-2000/. Published 1998. Accessed April 19 2022.

      • Bouchery EE
      • Harwood HJ
      • Sacks JJ
      • Simon CJ
      • Brewer RD.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      • Sacks JJ
      • Gonzales KR
      • Bouchery EE
      • Tomedi LE
      • Brewer RD.
      2010 national and state costs of excessive alcohol consumption.
      estimating the national cost of excessive alcohol use at $249 billion. In that study, cost was estimated for each state by assigning a share of the national cost by type (e.g., crimes) using associated administrative or survey data sources. Cost at the state level was apportioned out on the basis of 26-line items, such as binge drinking rates, the proportion of arrests, and differences in state wages. However, there are many state-specific variables that could affect the cost that was not considered. This study aimed to apply current state-specific data from Minnesota to established national methods for estimating the societal cost of excessive alcohol consumption for 2 purposes: first, to update the cost estimate for the state and, second, to understand the benefits of using state-specific data versus a national apportionment strategy for economic burden estimates.

      METHODS

      This study follows the approach described in the final report from the Lewin Group detailing the methodology for the 2006 national cost study.

      Lewin Group. Economic costs of excessive alcohol consumption in the United States, 2006. Falls Church, VA: Lewin Group. www.lewin.com/content/dam/Lewin/Resources/Site_Sections/Publications/CDC_Report_Rev.pdf. Published February 2013. Accessed April 19, 2022.

      This approach estimates the proportion of costs for health care, crime, productivity losses associated with mortality and morbidity, and other expenses that can be attributed to excessive alcohol use. Similar methods were used by several previous studies assessing the economic cost of alcohol misuse.

      Harwood HJ, Fountain D, Livermore G. The economic costs of alcohol and drug abuse in the U.S., 1992. Report prepared for the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism,Rockville, MD: NIH, DHHS. https://pubs.niaaa.nih.gov/publications/10report/chap06c.pdf. Published 1998. Accessed April 19, 2022.

      Harwood HJ, Updating estimates of the economic costs of alcohol abuse in the U.S.: estimates, update methods and data. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism, NIH Publication No. 98–4327, 1998, Rockville MD: NIH https://pubs.niaaa.nih.gov/publications/economic-2000/. Published 1998. Accessed April 19 2022.

      • Bouchery EE
      • Harwood HJ
      • Sacks JJ
      • Simon CJ
      • Brewer RD.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      • Sacks JJ
      • Gonzales KR
      • Bouchery EE
      • Tomedi LE
      • Brewer RD.
      2010 national and state costs of excessive alcohol consumption.
      This approach is more conservative because it does not calculate intangible costs such as pain and suffering, rather it focuses on the direct and indirect costs associated with excessive alcohol consumption. Estimates for this study were developed for 2019, the most recent year cost and outcome data were available (Appendix 1, available online).

      Alcohol-Attributable Fractions

      Alcohol-attributable fractions (AAFs) were used to quantify the proportion of costs that were attributable to alcohol consumption. For the analysis of health-related costs, including deaths and healthcare expenditures, the conditions included were based on the Centers for Disease Control and Prevention's Alcohol-Related Disease Impact (ARDI) system,

      Alcohol related disease impact (ARDI) application. Centers for Disease Control and Prevention. https://www.cdc.gov/ARDI. Updated April 2022. Accessed November 9, 2020.

      which provides estimates of alcohol-related deaths and years of potential life lost. The selection of alcohol-attributable conditions included in ARDI and the methodology used to obtain the AAFs have been described in more detail elsewhere.
      • Bouchery EE
      • Harwood HJ
      • Sacks JJ
      • Simon CJ
      • Brewer RD.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      ,
      • Esser MB
      • Sherk A
      • Subbaraman MS
      • et al.
      Improving estimates of alcohol-attributable deaths in the United States: impact of adjusting for the underreporting of alcohol consumption.
      The ARDI AAFs were used for fatalities and for nonfatal chronic conditions.

      Alcohol related disease impact (ARDI) application. Centers for Disease Control and Prevention. https://www.cdc.gov/ARDI. Updated April 2022. Accessed November 9, 2020.

      A 2015 meta-analysis
      • Cherpitel CJ
      • Ye Y
      • Bond J
      • et al.
      Alcohol attributable fraction for injury morbidity from the dose-response relationship of acute alcohol consumption: Emergency Department data from 18 countries.
      provided AAFs for nonfatal motor vehicle crashes (11.1%), assault-related injuries (40.1%), fall injuries (14.3%), and other injuries (9.8%).
      For crime, the AAF from ARDI was used for homicide because it considers only the alcohol use of the perpetrator and not that of the victim. Alcohol-related crimes such as driving under the influence of alcohol and liquor law violations were considered 100% attributable to alcohol. For the remaining offenses, estimates created by Bouchery et al. (2011) using self-reports of the proportion of inmates who reported that they were intoxicated at the time of their offense were used.
      • Bouchery EE
      • Harwood HJ
      • Sacks JJ
      • Simon CJ
      • Brewer RD.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      The AAFs for jail inmates were used both to attribute jail costs and for arrests and victim costs by offense.

      Cost Calculations

      Alcohol-related costs were estimated for health care, productivity losses, and other effects such as crime and the criminal justice system (Appendix 1, available online). First, the best available data source was identified to estimate the number of individuals affected or the number of alcohol-related events. Next, a valid source of costs for each consequence was identified or else the mean cost per individual or event. If needed, the mean cost was adjusted to 2019 dollars. Finally, the proportion attributable to alcohol consumption was identified (Figure 1). For example, for breast cancer among females, (1) hospital discharge data were used to identify the number of hospital discharges where ICD-10-CM code C50 was the primary diagnosis code; (2) the mean expenditure for these discharges was estimated, adjusting for the cost-to-charge ratio; (3) the AAF for breast cancer was identified (0.053, Appendix 2, available online); and (4) finally, the number of alcohol-attributable hospital discharges for breast cancer, the estimated mean cost per discharge, and the AAF were multiplied to get the final estimate of hospitalization costs for that condition.
      Figure 1
      Figure 1Cost-estimation process.
      AAF, alcohol-attributable fraction.
      Healthcare costs included treatment for alcohol use disorder (AUD) and 58 health conditions that are either fully or partially attributable to alcohol (Appendix 2, available online). Costs associated with healthcare treatment for individuals with fetal alcohol syndrome (FAS), crime victim medical treatment, health research and prevention, health insurance administration, and costs related to training substance abuse and mental health professionals were also included. For hospital and ambulatory care, only cases where the first-listed diagnosis was alcohol attributable were counted. Hospital treatment for FAS, prematurity, low birth weight, intrauterine growth retardation, child maltreatment, and motor vehicle crashes were included for individuals of all ages. For partially alcohol-attributable conditions (i.e., those where alcohol imparts increased risk of the condition), costs were calculated for individuals aged ≥15 years for acute conditions and aged ≥20 years for chronic conditions. Costs related to emergency medical services (i.e., ambulance services) were calculated using the same alcohol-attributable conditions and AAFs as for hospital and ambulatory care. The alcohol-attributable share of alcohol and other drug research and prevention programs was based on the share of substance abuse treatment spending that was for alcohol (38.5%).
      Minnesota Department of Human Services
      Drug and Alcohol Abuse Normative Evaluation System (DAANES).
      Alcohol-related illness, disability, death, and incarceration prevent individuals from being as productive as they may have been without excessive drinking. Productivity losses included those associated with premature mortality, impaired productivity (at home, at work, and while hospitalized), absenteeism from work, crime (lost days of work for victims, lost productivity owing to incarceration), and FAS. Estimates for lost work and household productivity were used from the Lewin Group,

      Lewin Group. Economic costs of excessive alcohol consumption in the United States, 2006. Falls Church, VA: Lewin Group. www.lewin.com/content/dam/Lewin/Resources/Site_Sections/Publications/CDC_Report_Rev.pdf. Published February 2013. Accessed April 19, 2022.

      and the lost productive time was valued at estimated earnings levels (estimated average earnings plus fringe benefits in Minnesota). Consistent with the Lewin Group report, productivity losses were not estimated (for work and home) for women.
      Several additional effects were captured, including costs associated with property damage owing to crime, the criminal justice system, motor vehicle crashes, fire damage, and FAS-related special education. Criminal justice system costs include those related to police, the court system, correctional institutions, private legal costs, and alcohol crimes (driving under the influence, liquor law violations, and public drunkenness). Costs for FAS-related healthcare treatment, productivity losses, and special education were taken from a 2004 study by the Lewin Group reported by Bouchery et al. (2011).
      • Bouchery EE
      • Harwood HJ
      • Sacks JJ
      • Simon CJ
      • Brewer RD.
      Economic costs of excessive alcohol consumption in the U.S., 2006.

      Subgroup Analyses

      Once the cost estimates were finalized, costs were apportioned out by those owing to binge drinking, underage drinking, and drinking while pregnant. In addition, costs were broken out to those owing to alcohol-involved crime (Appendix 3, available online). These subgroups are not mutually exclusive and likely overlap.
      Binge drinking was defined as ≥4 drinks consumed by a woman or ≥5 drinks consumed by a man within a 2-hour period. This pattern of drinking typically results in a blood alcohol level of 0.08 g/dL or higher for an average adult. Because the AAFs for acute conditions were based on intoxication, the costs of treating acute conditions were fully attributed to binge drinking. Crime costs were also based on the offender being intoxicated, so all crime costs were fully attributed to binge drinking. Motor vehicle crash and fire costs were also fully attributed to binge drinking.
      To estimate the proportion of costs attributable to binge drinking for AUD treatment and for reduced productivity owing to lost earnings among people with a history of AUD, the percentage of individuals with a history of alcohol dependence who reported binge drinking in the past 30 days was calculated (68.5%).
      • Chen CM
      • Dufour MC
      • Yi HY
      Alcohol Consumption Among Young Adults Ages 18–24 in the United States: Results from the 2001–2002 NESARC Survey.
      For productivity losses because of premature mortality, all costs attributed to acute causes of death and 68.5% of the deaths because of chronic conditions were attributed to binge drinking.
      Where possible, costs were estimated separately for those aged <21 years. When it was not possible to estimate costs for those aged <21 years directly, the same share of the costs was attributed to underage drinking as the share of Minnesota's population aged <21 years. When calculating productivity losses, only individuals aged 18–20 years were considered.
      All costs associated with FAS, spontaneous abortion, and adverse birth outcomes (prematurity, low birth weight, and intrauterine grown retardation) were attributed to drinking during pregnancy. Costs for treatment, medical equipment, special education, and lost productivity were based on estimates from the national cost study.

      Harwood HJ, Updating estimates of the economic costs of alcohol abuse in the U.S.: estimates, update methods and data. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism, NIH Publication No. 98–4327, 1998, Rockville MD: NIH https://pubs.niaaa.nih.gov/publications/economic-2000/. Published 1998. Accessed April 19 2022.

      Crime-related costs included victim costs (medical, lost productivity, property damage, homicide), criminal justice system costs, and motor vehicle traffic crashes. Victim costs were estimated on the basis of the 2019 National Crime Victimization survey.

      National crime victimization survey. Bureau of Justice Statistics. https://ncvs.bjs.ojp.gov/Home. Updated November 19, 2021. Accessed April 19, 2022.

      Who Bears the Cost

      Costs were also estimated for 4 categories on the basis of who directly bore the costs: (1) government (federal, state, and where possible, local); (2) excessive drinkers and their families; (3) private health insurers; and (4) others, including employers, crime victims, and other members of society.

      RESULTS

      Excessive alcohol use cost Minnesota an estimated $7.85 billion in 2019, which equates to $1,383 per Minnesota resident. When compared with the number of standard drinks consumed in Minnesota during 2019, the cost per drink was $2.86. Table 1 shows the cost breakdown by type of cost, type of excessive drinking pattern, and alcohol-related crime.
      Table 1Cost Breakdown by Type of Excessive Drinking and Crime and Minnesota 2019.
      Cost itemGroup-specific cost estimates ($)
      Total costBinge drinkingUnderage drinkingDrinking while pregnantCrime-related
      Health care915,172,650366,087,234145,225,45832,493,167127,307,393
       Hospitalization (including physician services)319,878,97517,276,44446,382,4515,300,03231,422,621
       Pharmaceutical, nondurable medical equipment, other professional services165,456,63193,482,99728,293,0846,121,89532,098,586
       Ambulatory care116,532,17883,216,91119,927,0027,87414,243,496
       Nursing homes101,238,56457,199,78923,284,8700
       Specialty care for abuse/dependence74,528,88551,052,2868,198,177
       Health insurance administration41,696,99623,558,8037,130,1861,542,7898,089,217
       Crime victims’ treatment40,010,64440,010,644
       EMS care23,577,97923,009,6372,051,2842361,442,828
       Fetal alcohol syndrome19,520,34210,326,2612,869,49019,520,342
       Prevention and research11,807,0316,458,4466,953,022
       Training924,425505,660135,890
      Lost productivity5,592,691,3354,049,305,510312,225,58521,886,363480,443,888
       Impaired productivity—work2,535,205,0621,736,615,46759,393,555
       Impaired productivity—home486,372,504333,165,16515,093,74100
       Impaired productivity—institution116,224,80579,613,99113,443,583408,6871,311,835
       Absenteeism612,489,957612,489,95723,948,07400
       Mortality1,683,179,9271,134,996,726189,498,7017,051,185334,339,464
       Incarceration of perpetrators117,415,190117,415,1902,348,3040117,415,190
       Crime victims27,377,39927,377,3996,378,934027,377,399
       Fetal alcohol syndrome14,426,4917,631,6142,120,69414,426,4910
      Other effects1,343,582,7541,306,368,167289,949,4102,865,1741,306,121,335
       Criminal justice959,339,117923,474,027251,921,4710959,339,117
       Motor vehicle crashes296,191,085296,191,08520,733,3760296,191,085
       Crime victim property damage50,591,13350,591,13311,787,73450,591,133
       Fire losses34,596,24534,596,2455,085,64800
       Fetal alcohol syndrome—special education2,865,1741,515,677421,1812,865,1740
      Total7,851,446,7395,721,760,911747,400,45357,244,7041,913,872,617
      Proportion of total, %72.99.50.724.4
      EMS, emergency medical service.
      Costs were calculated by type of cost. In 2019, healthcare costs owing to excessive drinking were >$915.2 million (Table 1). About 3.0% of inpatient hospital treatments were attributable to alcohol and accounted for 34.9% of the healthcare costs. Pharmaceuticals, nondurable medical equipment, and other professional services accounted for 18.1% of the alcohol-attributable healthcare costs ($165,456.631). About 5% of the ambulatory care visits in Minnesota during 2019 were alcohol attributable, costing $116.5 million or 12.7% of healthcare costs.
      Lost productivity contributed the largest amount to the societal costs of excessive alcohol consumption, at $5.59 billion (Table 1). Impaired productivity at work accounted for 45.3% of the productivity losses ($2.54 billion). Productivity losses because of premature mortality (764 acute deaths and 1,387 chronic deaths in 2019) were $1.68 billion and accounted for 30.1% of the lost productivity costs. Productivity losses because of increased absenteeism accounted for 10.9% of the productivity costs ($612.5 million).
      Criminal justice costs accounted for 71.4% of the other societal costs or $959.3 million, and motor vehicle crashes were the second largest cost, accounting for 22.0% of the other costs or $296.2 million. Alcohol-attributable crime victim property damage cost $50.6 million or 3.8% of other costs during 2019.
      Costs atrributable to excessive alcohol consumption were also calculated by drinking pattern. The overall costs attributed to binge drinking in 2019 were $5.72 billion or 72.9% of the total cost to Minnesota for excessive drinking (Table 1). Binge drinking accounted for 40.0% of the healthcare costs, 72.4% of the lost productivity costs, and 97.2% of the other societal costs.
      Underage drinking cost Minnesota >$747.4 million in 2019, 9.5% of the total costs. More than one third (38.8%) of these costs were because of productivity losses, with 60.7% of productivity losses related to premature mortality, and an additional 19.0% of the lost productivity costs attributed to underage drinking were because of lowered productivity at work.
      Costs attributed to drinking while pregnant were $57.2 million, <1% of the total cost. These costs were in large part because of healthcare costs (56.8%) and reduced productivity owing to FAS (38.2%).
      About $1.91 billion dollars were attributed to crime, 24.4% of the total cost to Minnesota in 2019. Many of these costs were because of the criminal justice system (50.1%) and motor vehicle crashes (15.5%). Lost productivity due to crime was also a large factor, with premature mortality accounting for 17.5% of all crime costs.
      About 41.1% of the costs owing to excessive alcohol use in Minnesota were borne by federal, state, and local governments, for a total of $3.23 billion in 2019 (Table 2). The state government bore about 14.7% of the costs directly ($1.16 billion), and local governments covered about 8% of the costs or $642.6 million. Private insurance and out-of-pocket payments accounted for 7.7% of the costs ($607.5 million); excessive drinkers and their families bore the second largest share of the burden, for a total of $3.17 billion (40.3% of the total cost). Other members of society paid $770.0 million or nearly 10% of the costs.
      Table 2Cost by Payer Source, Minnesota 2019
      Cost itemGovernment
      Total cost, $Total, $Federal, $State, $Local,a $Private insurance/out of pocket, $Excessive drinker and family, $Others in society, $
      Health care915,172,650321,190,569231,401,16984,820,8074,968,592172,810,291089,671,516
       Hospitalization (including physician services)319,878,97516,837,86613,757,6673,080,19811,922,989
       Pharmaceutical, nondurable medical equipment, other professional services165,456,63178,757,35664,031,71614,725,64052,118,83934,580,436
       Ambulatory care116,532,17855,469,31745,097,95310,371,36436,707,63624,355,225
       Nursing homes101,238,56448,189,55639,179,3249,010,23231,890,14821,158,860
       Specialty care for abuse/dependence74,528,88574,528,88531,326,97538,233,3184,968,5929,688,755
       Health insurance administration41,696,99614,730,77711,317,8793,412,89916,905,954
       Crime victims’ treatment40,010,6440
       EMS care23,577,97911,223,1189,124,6782,098,4407,427,0634,927,798
       Fetal alcohol syndrome19,520,3429,291,6837,554,3721,737,3106,148,9084,079,751
       Prevention and research11,807,03111,807,0319,799,8362,007,195
       Training924,425354,979210,769144,210569,446
      Lost productivity5,592,691,3351,960,826,4311,164,240,693796,585,738056,812,4553,010,408,794564,643,655
       Impaired productivity—work2,535,205,062973,518,744578,026,754395,491,9901,561,686,318
       Impaired productivity–household486,372,5040486,372,504
       Impaired productivity—institution116,224,80544,630,32526,499,25618,131,07071,594,480
       Absenteeism612,489,957235,196,143139,647,71095,548,433377,293,814
       Mortality1,683,179,927646,341,092383,765,023262,576,06956,812,455809,541,016170,485,364
       Incarceration of perpetrators117,415,19045,087,43326,770,66318,316,77072,327,757
       Crime victims27,377,39910,512,9216,242,0474,270,87416,864,478
       Fetal alcohol syndrome14,426,4915,539,7733,289,2402,250,5338,886,718
      Other effects1,343,582,754946,945,63332,322,980276,998,487637,624,166377,896,330157,619,545122,716,086
       Criminal justice959,339,117944,080,45932,108,092275,161,911636,810,45615,258,658
       Motor vehicle crashes296,191,0850208,222,33387,968,752
       Crime victim property damage50,591,133050,591,133
       Fire losses34,596,2450169,673,99754,392,13572,124,953
       FAS—special education2,865,1742,865,174214,8881,836,576813,709
      Total cost7,851,446,7393,228,962,6331,427,964,8421,158,405,032642,592,758607,519,0763,168,028,339777,031,257
      Percentage of total41.1%18.2%14.8%8.2%7.7%40.4%9.9%
      aWhere possible, costs were estimated for all the 3 levels of government (federal, state, and local); however, it was difficult to get local-level estimates. Likely, the estimates of costs borne by local governments are underestimated.
      EMS, emergency medical service; FAS, fetal alcohol syndrome.

      DISCUSSION

      Excessive alcohol use exacts a large economic, social, and public health burden on the state of Minnesota. In 2019, excessive drinking cost Minnesota $7.85 billion, which is $1,383 per resident or $2.86 per drink of alcohol consumed. In comparison, a 2010 study estimated that tobacco use cost Minnesota $5 billion in direct and indirect costs (about $7.1 billion in 2019 dollars).

      Rumberger J, Hollenbeak C, Kline D. Potential costs and benefits of smoking cessation for Minnesota. State College, PA: Penn State University. https://www.lung.org/getmedia/aebd97aa-dc3b-4f62-8791-d6c891603d63/economic-benefits.pdf.pdf?ext=.pdf. Published April 30, 2010. Accessed April 19, 2022.

      The current estimate is substantially higher than the cost estimate from the national study by Sacks and colleagues (Table 3).
      • Sacks JJ
      • Gonzales KR
      • Bouchery EE
      • Tomedi LE
      • Brewer RD.
      2010 national and state costs of excessive alcohol consumption.
      That study used an apportionment strategy to estimate costs owing to excessive alcohol use in Minnesota in 2010, $3.89 billion ($5.52 billion in 2019 dollars). However, some changes were incorporated into the methodology used in the national study. For example, state data allowed the estimate of costs for alcohol-attributable ambulance services. In addition, the methodology used to calculate AAFs in this study was updated.
      • Esser MB
      • Sherk A
      • Subbaraman MS
      • et al.
      Improving estimates of alcohol-attributable deaths in the United States: impact of adjusting for the underreporting of alcohol consumption.
      However, the proportion of costs estimated to be covered by the government was similar between the 2 estimates (41.1% for this study and 39.5% for the Sacks study), as was the proportion attributed to binge drinking (72.9% compared with 74.6%).
      Table 3Comparing the Minnesota-Specific Cost Estimate to the Estimate Apportioned to Minnesota From the National Cost Study
      Variables2010 Estimate(in 2019 USD
      2010 cost estimates were cost forwarded using the percentage change in gross domestic Product. USD, U.S. dollar.
      ), $
      2019 Estimate (this study), $
      Total cost5,519.5 Million7,851.4 Million
      Cost per drink2.472.86
      Cost to government2,177.9 Million3,229.0 Million
      % of total cost39.541.1
      Attributed to binge drinking4,116.2 Million5,721.8 Million
      % of total cost74.672.9
      a 2010 cost estimates were cost forwarded using the percentage change in gross domestic Product.USD, U.S. dollar.
      Most of the alcohol-attributable costs were attributed to binge drinking (72.9%). Almost 10% of the costs were allocated to underage drinking, and 0.7% of the costs were attributed to drinking while pregnant. These proportions do not reach 100%, which is likely in part because of imprecise measurement of excessive drinking patterns and the methodologies used to allocate costs to different types of excessive drinking. However, it is also possible that chronic consumption of lower amounts of alcohol is associated with increased rates of alcohol-related illness and injury, and this was not captured in this study. For example, even smaller amounts of alcohol are associated with an increased risk of 7 types of cancer,
      • Baan R
      • Straif K
      • Grosse Y
      • et al.
      Carcinogenicity of alcoholic beverages.
      and the effects of alcohol on an individual's behavior increase with each drink consumed, so lower levels of drinking may also be associated with increased injury or violence. In addition, previous research shows that excessive drinking has a greater impact on the health and safety of individuals with lower SES than it does for higher SES individuals.
      • Probst C
      • Kilian C
      • Sanchez S
      • Lange S
      • Rehm J.
      The role of alcohol use and drinking patterns in socioeconomic inequalities in mortality: a systematic review.
      These differences are likely because of a synergistic effect of multiple environmental and behavioral contexts, but further research is needed.
      The economic burden from excessive alcohol use for state and local governments far exceeded the alcohol tax revenue collected. In 2019, Minnesota collected $97,716,000 in liquor gross receipt taxes (2.5% of sales) and $93,553,000 from alcoholic beverage taxes (also called excise taxes) for a total of just over $190 million.

      State tax collections by type of tax. Minnesota Department of Revenue. https://www.revenue.state.mn.us/state-tax-collections-type-tax. Accessed April 19, 2022.

      This tax revenue is about 10% of the costs estimated to be borne by the state and local governments in Minnesota owing to excessive alcohol use. Understanding the costs of alcohol use and its impact on society is increasingly important because adult rates of alcohol use and binge drinking have increased nationwide over the past decade,
      • Grucza RA
      • Sher KJ
      • Kerr WC
      • et al.
      Trends in adult alcohol use and binge drinking in the early 21st-century United States: a meta-analysis of 6 national survey series.
      and studies indicate that alcohol use and the related harms increased even more during the coronavirus disease 2019 (COVID-19) pandemic.
      • White AM
      • Castle I-JP
      • Powell PA
      • Hingson RW
      • Koob GF.
      Alcohol-related deaths during the COVID-19 pandemic.

      Limitations

      The results of this study should be viewed in the context of several limitations. Although recently updated, there remain limitations to the use of AAFs. For example, age-specific AAFs were available only for motor vehicle traffic deaths, although research shows that alcohol consumption varies widely by age and that can have an important impact for deaths and injuries, particularly among youth and young adults.

      Alcohol related disease impact (ARDI) application. Centers for Disease Control and Prevention. https://www.cdc.gov/ARDI. Updated April 2022. Accessed November 9, 2020.

      More recent estimates of the costs of FAS and AAF for criminal offenses were not available. The alcohol-attributable mortality and morbidity estimates were based on the underlying cause of death and the first-listed diagnostic code in hospital discharge data, so individuals who died or were treated for alcohol-attributable conditions that were contributing causes of death or illness/injury were not counted, so it is likely that these estimates were underestimated.
      A significant limitation of the national studies was that productivity losses for women both at work and at home were not calculated because in the underlying analyses, there were no statistically significant differences in employment or earnings between women who experienced alcohol dependence and women without alcohol dependence.

      Lewin Group. Economic costs of excessive alcohol consumption in the United States, 2006. Falls Church, VA: Lewin Group. www.lewin.com/content/dam/Lewin/Resources/Site_Sections/Publications/CDC_Report_Rev.pdf. Published February 2013. Accessed April 19, 2022.

      This may be because of imprecise measurement rather than a true lack of reduction in productivity for women who suffer from alcohol dependence; however, an updated nationally representative (or state-representative) data source was not available. In unpublished analyses assuming similar productivity losses as for males, adding an estimate of lost work and household productivity for women would increase this cost estimate by >$2 billion.

      CONCLUSIONS

      State-specific data can provide additional information to estimate the costs of excessive alcohol use that apportioning costs from a national study does not allow. The results show that the costs of excessive drinking were 10 times higher than the tax revenue collected for the sale of alcoholic beverages in 2019. Implementing evidence-based policies and programs could reduce the rate of excessive drinking and minimize the health and societal costs attributable to excessive alcohol. The Community Preventive Services Task Force

      Excessive alcohol consumption. Community Preventive Services Task Force. https://www.thecommunityguide.org/topic/excessive-alcohol-consumption. Accessed March 23, 2018.

      identified 7 policies and interventions with sufficient or strong evidence of impact. These policies seek to increase the cost of alcohol (increasing alcohol taxes), promote an environment that inhibits excessive drinking (e.g., regulating alcohol outlet density), and motivate individuals to moderate their drinking (e.g., electronic screening and brief intervention).

      CRediT authorship contribution statement

      Kari M. Gloppen: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. Jon S. Roesler: Supervision, Writing – review & editing. Dana M. Farley: Validation, Writing – review & editing.

      ACKNOWLEDGMENTS

      The authors gratefully acknowledge the health economics support provided by Cora Peterson in the Division of Injury Prevention, Centers for Disease Control and Prevention (CDC).
      The contents are those of the author(s) and do not necessarily represent the official views of nor an endorsement by CDC/HHS or the U.S. Government.
      This manuscript is partially supported by CDC of the U.S. HHS as part of a financial assistance award totaling $150,000.
      No financial disclosures were reported by the authors of this paper.

      CREDIT AUTHOR STATEMENT

      Kari Gloppen: Conceptualization, Methodology, Writing – original draft, Writing – reviewing and editing. Jon Roesler: Supervision, Writing – reviewing and editing. Dana Farley: Writing- reviewing and editing, Validation.

      Appendix. SUPPLEMENTAL MATERIAL

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