MMWR April 28, 2000 / 49(16);346-9
Alcohol Policy and Sexually Transmitted Disease Rates ---
United States, 1981--1995
In the United States, adolescents and young adults are at higher risk for
acquiring sexually transmitted diseases (STDs) than older adults. In addition, young persons who drink alcohol may be more likely than persons who abstain to participate in
high-risk sexual activity, such as unprotected sexual intercourse or multiple sexual
partners. If alcohol consumption promotes risky sexual behavior (disinhibition caused
by the effects of alcohol), state government alcohol policies, such as alcohol taxation
and minimum legal drinking age requirements, might reduce STD incidence
among adolescents and young adults. Higher alcohol taxes and increases in the
minimum legal drinking age have been associated with lower incidences of adverse
alcohol-related health outcomes (e.g., motor-vehicle crash-related deaths, liver
cirrhosis, suicide, and violent crime, including domestic violence). This report summarizes the findings of a study
that suggest higher alcohol taxes and higher minimum
legal drinking ages are associated with lower STD incidence among certain age groups.
The study examined the association between crude gonorrhea incidence
(new cases per 100,000 population) and alcohol policy indicators (alcohol taxation
and drinking age requirements) in the 50 states and the District of Columbia during
1981--1995. Alcohol policy data were obtained from the Distilled Spirits Council of the
United States, and gonorrhea incidence data were collected by CDC through
surveillance systems in each state. The relation between alcohol policy and gonorrhea
rates was established using a quasi-experimental analysis of a state's gonorrhea rate
during the year before and after a change was made in the state alcohol policy indicators
and a multivariate regression analysis between state gonorrhea rates and state
alcohol policy indicators.
The quasi-experimental analysis compared changes in gonorrhea rates in
states with a beer tax increase (experimental states) with changes in gonorrhea rates
in states without a beer tax increase (control states). An experimental state had a
relative decrease in its gonorrhea rate if the decrease was greater (in percentage) than
the median of the control states. To test the null hypothesis that beer tax increases had
no effect on gonorrhea rates, p-values were calculated as two-tailed tests from
the binomial distribution under the null hypothesis that each change in the gonorrhea
rate in experimental states would have a 0.50 probability of being a relative decrease.
A quasi-experimental analysis of drinking age increases also was conducted.
In the regression analysis, the dependent variable was the state-specific
gonorrhea rate, and the alcohol policy indicators were independent variables. The model
included variables for each state and each year to control for state-specific differences
in gonorrhea incidence and trends in gonorrhea incidence common to all states.
To further control the models for omitted and/or unobservable factors (e.g.,
state-level demographic characteristics and STD-prevention activities) related to
state-specific STD rates and trends, the model included the state's gonorrhea rate during
the previous year as an independent variable.
Most beer tax increases were followed by a relative proportionate decrease
in gonorrhea rates among young adults (24 [66.7%] of 36 instances of beer tax
increases among 15--19-year-olds [p<0.10] and 26 [72.2%] of 36 instances among
20--24-year-olds [p<0.05]) (Table 1). In both age groups, this relation was greater for gonorrhea
rates among men than women. Most minimum legal drinking age increases were
followed by a relative proportionate decrease in the gonorrhea rate, and this majority
was statistically significant among 15--19-year-olds (29 [65.9%] of 44 instances of
legal drinking age increases) but not among 20--24-year-olds (18 [54.5%] of
33 instances). Regression analysis also showed that higher beer taxes were
associated with lower gonorrhea rates among young adults in both age groups, and
that minimum legal drinking age increases were associated with lower gonorrhea
rates among 15--19-year-olds. The regression analysis suggested that a beer tax increase
of $0.20 per six-pack could reduce overall gonorrhea rates by 8.9%.
Reported by: P Harrison, PhD, Brandeis Univ, Waltham, Massachusetts. WJ Kassler, MD,
New Hampshire Dept of Health and Human Svcs. Div of Sexually Transmitted Diseases
Prevention, National Center for HIV, STD, and TB Prevention, CDC.
The findings in this report indicate that more restrictive state
alcohol policies are associated with lower gonorrhea rates among certain age groups.
The two methods of analysis yielded similar results and were consistent under a
wide range of robustness checks and alternative model specifications. The results of this study are consistent with a study that higher minimum legal drinking ages
were associated with decreases in childbearing rates among teenagers.
The findings in this report are subject to at least two limitations. First,
because state gonorrhea reporting practices vary, state-specific gonorrhea rates should
be compared with caution. Second, the analysis may be subject to confounding effects
of unobservable factors (e.g., community norms regarding alcohol consumption
and sexual behavior or dramatic shifts in state-specific STD rates); omitting
variables could cause substantial bias when comparing across states the
association between alcohol policy indicators and alcohol-related health outcomes. Given these limitations, the study findings, particularly the temporal relation between
higher alcohol taxes and a decline in gonorrhea rates, are consistent with but do not prove
a causal relation between higher taxes and declining STD rates.
The postulated causal relation is based on the assumptions that higher
alcohol taxes and a higher minimum legal drinking age can reduce alcohol consumption,
and that reduced alcohol consumption can reduce participation in risky sexual
behavior. With few exceptions, most studies have demonstrated that
alcohol consumption declines after alcohol tax increases and have detected an association between risky sexual behavior and alcohol or drug use.
Reducing alcohol use and risky sexual behavior among young persons are
two national health objectives for 2010. Higher alcohol prices and
improved enforcement of minimum legal drinking age requirements have been highlighted
as potential strategies to reduce alcohol consumption by youth. Alcohol policy also could be used to reduce risky sexual behavior and its adverse medical and
social consequences. Additional research is needed to continue examining the
relation between alcohol policy and risky sexual behavior.
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vols). Washington, DC: US Department of Health and Human Services, January 2000.
- Chesson H, Harrison P, Kassler WJ. Sex under the influence: the effect of alcohol policy
on sexually transmitted disease rates in the US. Journal of Law and Economics 2000 (in press).
- Distilled Spirits Council of the United States. History of beverage alcohol tax changes:
1996. Washington, DC: Distilled Spirits Council of the United States, 1996.
- Distilled Spirits Council of the United States. Minimum purchase age by state and
beverage, 1933--present. Washington, DC: Distilled Spirits Council of the United States, 1996.
- Dee TS. The effects of alcohol use and availability on teen childbearing. Working
paper, Swarthmore College Department of Economics, 2000. Available at http://www.swarthmore.edu/socsci/tdee1.
- Dee TS. State alcohol policies, teen drinking and traffic fatalities. Journal of
Public Economics 1999;72:289--315.
- Mast BD, Benson BL, Rasmussen DW. Beer taxation and alcohol-related traffic
fatalities. Southern Economic Journal 1999;66:214--49.
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