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. 2021 Nov 17;82(6):710–719. doi: 10.15288/jsad.2021.82.710

Prospective Analysis of Minimum Pricing Policies to Reduce Excessive Alcohol Use and Related Harms in U.S. States

Jennifer LeClercq a, Stephanie Bernard b,†, Francesca Mucciaccio c,†, Marissa B Esser a,*
PMCID: PMC8819621  PMID: 34762030

Abstract

Objective:

Increasing the price of alcohol is an effective strategy for reducing excessive consumption and alcohol-related harms. Limited research is available on how the establishment of a minimum price for alcoholic beverages might be an effective strategy to reduce this health risk behavior and what impact that might have in the United States. This study describes alcohol minimum pricing (MP) policy options for consideration in the United States, assesses implementation feasibility and effectiveness, and discusses implications for implementation.

Method:

Three alcohol pricing policy options for reducing excessive drinking were compared in this prospective analysis: alcohol taxation (status quo in states), minimum unit pricing (MUP) by unit of alcohol (e.g., 0.6 oz. [14 g] of pure alcohol), and MP by specified amount of an alcoholic beverage type (e.g., liter of beer). For each policy, five implementation-related domains were analyzed: political feasibility, public acceptability, implementation cost, health equity, and legal feasibility. Effectiveness was also evaluated based on literature.

Results:

Alcohol MP policies, particularly MUP, could be feasible to implement and cost-efficient for reducing excessive alcohol consumption and related harms in the United States. MP policies are likely to have modest public acceptability in the United States. Although the political feasibility of MP policies is uncertain and would likely vary across states, international research suggests that MP might be a feasible pricing strategy that can be used in conjunction with alcohol taxes.

Conclusions:

Alcohol MP can be part of a comprehensive approach for reducing excessive drinking and related harms; however, factors such as state-level differences in alcohol control regulation may influence policy implementation.

Excessive alcohol use is a leading preventable cause of death in the United States (Mokdad et al., 2004) and is responsible for more than 95,000 deaths annually (Esser et al., 2020). Excessive drinking cost the country $249 billion in 2010, with governments paying 40% of the cost (Sacks et al., 2015).

In the United States, where a standard drink contains 0.6 oz. (14 g) of pure alcohol, beverages can cost less than $1 per ounce of alcohol (DiLoreto et al., 2012). Individuals can drink excessively at a low cost, making alcohol's affordability a risk factor for excessive consumption and related harms (Albers et al., 2013). Alcohol consumption is responsive to price; increasing the price of alcoholic beverages by 10% has been estimated to reduce overall consumption by 7.7% (Elder et al., 2010) to 14% (Xuan et al., 2015). Population-level alcohol pricing policies can therefore significantly reduce alcohol-related deaths, diseases, and injuries (Wagenaar et al., 2010), putting them among the most efficient and cost-effective alcohol control measures, according to the World Health Organization (2018a). The Community Preventive Services Task Force also recommends alcohol tax increases for reducing excessive alcohol use and related harms (Task Force on Community Preventive Services, 2010), and the Centers for Disease Control and Prevention (CDC) identified alcohol pricing strategies among the leading evidence-based and cost-effective community interventions for improving population health (CDC, 2018).

Taxes on alcohol include specific excise taxes (both federal and state), ad valorem excise taxes on alcohol, and general sales taxes (Blanchette et al., 2019). Federal- and state-specific excise taxes are based on a fixed dollar amount per volume of alcohol. Specific excise taxes account for approximately 20% of total state alcohol tax revenues (Blanch-ette et al., 2019), and their value erodes over time if they are not inflation-adjusted (Naimi et al., 2018). In contrast, ad valorem and sales taxes are based on the price of the alcoholic beverage but are not specific to alcohol content.

The World Health Organization (2010) also recommends alcohol minimum pricing (MP) policies, which can complement alcohol taxes, to reduce alcohol-related morbidity and mortality. MP sets a floor price beneath which alcohol cannot be sold and affects alcohol retail prices, potentially influencing consumer decision making. One type of MP policy is minimum unit pricing (MUP), which establishes a floor price by unit of alcohol (e.g., 14 g of pure alcohol). A second type of MP policy is MP based on a specified amount of an alcoholic beverage type (e.g., liter of beer, wine, or distilled spirits) without regard to alcohol content. U.S. alcohol sales are controlled by states through a three-tier alcohol regulation and distribution system encompassing manufacturers for production, wholesalers for distribution, and retailers for sales to consumers (Figure 1). MP generally influences the retail tier of the regulatory system.

Figure 1.

Figure 1.

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U.S. three-tier alcohol regulatory system

Although some states have established pricing policies aimed at the wholesale level that indirectly affect alcoholic beverage prices (National Institute on Alcohol Abuse and Alcoholism, 2019), no state has implemented a comprehensive MP policy that sets a threshold below which alcoholic products cannot be sold (ChangeLab Solutions, 2018). However, Oregon introduced an MUP policy for distilled spirits that is scheduled to go into effect in the second half of 2021 (Radnovich, 2021). The MUP policy will increase the price of more than 100 distilled spirits beverages by an average of 16.3%; the MUP per standard drink will vary by proof and container size (e.g., 80-proof liquor at $0.46 in a 1.75 liter container or $0.59 in a 0.375 liter container) (Oregon Liquor Control Commission, 2021).

Evidence on the effectiveness of alcohol MP policies for reducing alcohol consumption and its impacts has been documented in other countries. In Canada, a 10% MP increase in British Columbia was associated with a 3% reduction in alcohol consumption (Stockwell et al., 2012a) and reductions in alcohol-related harms, including hospital admissions (Stockwell et al., 2013; Zhao & Stockwell, 2017), traffic violations and crime (Stockwell et al., 2015), and mortality (Zhao et al., 2013). A 10% MP increase in Saskatchewan was associated with an 8% reduction in alcohol consumption (Stockwell et al., 2012b). Although all Canadian provinces have implemented some type of MP (most are not MUP), experts suggest that the full potential of MP has not been realized because of incomplete implementation (e.g., exclusion of beverage categories or certain outlet types), inadequate minimum prices (e.g., below the recommended minimum), or failure to account for inflation or alcohol content in prices (Thompson et al., 2017).

MP has also been implemented, to some extent and particularly for spirits, in several Eastern European countries (World Health Organization, 2020). Furthermore, in the Northern Territory, Australia, an MUP of $1.30/10 g drink (U.S. $1.41/14 g standard drink, based on currency conversions on May 17, 2021) was designed to increase the price of low-cost wine (Taylor et al., 2021). Ireland has also introduced an MUP of €0.10/g of alcohol (BBC News, 2021), or U.S. $1.68/14 g standard drink. Scotland implemented an MUP of £0.50/8 g drink (U.S. $1.23/14 g standard drink) on all alcoholic beverages, and there was a 3.5% reduction in off-premise alcohol sales during the first year (Robinson et al., 2021).

The objectives of this policy analysis are to describe two MP options for consideration in states, assess implementation feasibility and policy effectiveness, and discuss implications for state implementation.

Method

We defined alcohol MP as setting a floor price below which alcoholic beverages cannot be sold (ChangeLab Solutions, 2018). This is distinct from wholesale pricing practices and restrictions, including bans on selling below cost, minimum markup requirements, limits on discounts, and the posting and holding of prices. Although these other pricing practices can establish a floor price in relation to measures affecting wholesalers, their impact may not be fully reflected in the price to consumers (ChangeLab Solutions, 2018) and, therefore, were not included in this analysis.

Selection of pricing policy options

We searched databases (MEDLINE, PubMed, and Google Scholar) for peer-reviewed studies of alcohol MP and searched the internet for gray literature (white papers, policy issue briefs, and technical reports). We compiled case studies of jurisdictions with MP implemented to identify MP options. We identified two distinct MP options that met the definition used for this analysis: MUP (i.e., setting a floor price by unit of alcohol) and MP by specified amount of an alcoholic beverage type (e.g., setting a floor price according to a defined volumetric amount of beer, wine, or distilled spirits, such as per liter). The analysis, therefore, considered two MP options and alcohol taxation (the status quo in the United States).

Analysis criteria and ranking

To examine the pricing policies selected, we adapted existing frameworks (Seavey et al., 2014). For each of the three policies, we assessed the following five domains related to implementation: political feasibility, public acceptability, implementation costs, health equity, and legal feasibility (Table 1). We also assessed effectiveness based on literature. We selected these domains based on their replicability and applicability across different contexts and their relevance to the policy topic, and evaluated them through literature reviews, a stakeholder analysis, and consultation with legal and subject matter experts.

Table 1.

Evaluation domains related to the implementation of minimum pricing policies in the United States

graphic file with name jsad.2021.82.710tbl1.jpg

Domains Definition Measurement Evaluation method
Political feasibility Assessing whether a policy option is likely to be adopted, accounting for the political climate. Low, Medium, High as measured by the likelihood of adoption, given political stakeholders’ views on the policy. Stakeholder analysis,a subject matter expert interviews, and review of literature
Public acceptability Assessing whether a policy option is likely to be adopted based on social context and public perceptions. Low, Medium, High as measured by the likelihood of adoption, given the level of public acceptance of the policy. Review of peer-reviewed studies on social context of alcohol-related norms and public acceptability of alcohol control policies, media reports on minimum pricing policies implementation
Costs Approximated costs of policy implementation to the economy, to private and public sector and individual revenues or spending. Low, Medium, High as measured by the likelihood of adoption, given policy implementation costs. A policy option rank of high indicates minimal implementation costs and higher likelihood of adoption. Review of peer-reviewed literature on policy implementation and cost analyses of policy options, stakeholder analysisa
Health equity Health equity refers to social allocation of burdens and benefits. Low, Medium, High as measured by evidence of the disproportionate negative health impact of a policy on a segment of society. Review of peer-reviewed studies on social context of alcohol-related norms
Legal feasibility Effectiveness Legal feasibility is determined by the presence of legal challenges or barriers which could impact the likelihood of policy adoption.
Effectiveness is a measure of whether a policy option will have its intended effect—in this case, reduction in alcohol consumption and alcohol-related harms.		 Low, Medium, High as measured by the presence of legal challenges or barriers, based on legal precedent.
Low, Medium, High as measured by available evidence conveying positive public health impact resulting from the policy.		 Internal minimum pricing policy legal reviewb and review of literature on other pricing policies (e.g., minimum pricing for other products, alcohol taxes)
Review of peer-reviewed literature on minimum pricing policy implementation
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a

The stakeholders included academic institutions; enforcement organizations (e.g., public safety, criminal justice); public health organizations; governmental organizations; and alcohol producers/importers, distributors, and retailers. The stakeholder analysis included an assessment of the policy impact on stakeholders’ operations; whether stakeholders’ stance is in support of or against the implementation of minimum pricing policies; the level of influence that stakeholders are expected to have on alcohol producers/importers, distributors, and retailers; the stakeholders’ influence on policy development and implementation; and the stakeholders’ financial resources based on annual revenue. The stakeholder analysis was informed by interviews with four subject matter experts in alcohol policy and public health, as well as reviews of organization websites and documents.

b

The legal review was prepared by ChangeLab Solutions (Oakland, CA) for the authors of this study. ChangeLab Solutions is a national organization that assesses laws and policies that could improve health.

Upon consensus among three raters, we ranked each domain as low, medium, or high (weighted as 1, 2, or 3) for each policy option. A fourth reviewer independently reviewed the rankings. For each policy, we summed the five implementation-related scores and compared total scores across policy options to assess the potential feasibility of their implementation in the United States, with higher total scores implying higher total feasibility (e.g., rank of “high” on the implementation cost domain indicated minimal implementation costs, or highly feasible). Policy effectiveness for reducing excessive drinking and related harms was scored separately because a policy could be feasible to implement but ineffective.

To inform the political feasibility and cost evaluations, we assessed the stakeholder landscape by grouping key organizations by sectors and conducting an environmental scan (e.g., review of literature, media and news reports, stakeholders’ websites, and input from subject matter experts), following established methods (Brugha & Varvasovszky, 2000; Seavey et al., 2014). We considered the possible impacts of MP implementation on each stakeholder group, stakeholders’ stated positions on MP, and their policy influence. We consulted legal experts to inform the legal feasibility domain. The legal experts investigated existing U.S. laws to determine whether any states had implemented an alcohol MP policy and to identify possible legal barriers to MP implementation. Their review included internet searches, literature reviews, and consultation of alcohol policy resources (e.g., the Alcohol Policy Information System) to examine legal feasibility of MP based on other legal precedents.

After assigning scores to each of the domains across all policies, we analyzed implications for policy implementation in states and other considerations to inform the use of MP as a policy option.

Results

Comparison of selected alcohol pricing policy options

Alcohol taxes. The primary alcohol pricing strategy used in the United States, nationally and in states (Blanchette et al., 2019), is alcohol taxation; therefore, we included it to represent the status quo. Alcohol taxes ranked “high” on the domains of low implementation costs, health equity, legal feasibility, and effectiveness but ranked “low” on political feasibility and public acceptability (Table 2). These pricing policies have been shown to be cost-effective and to lead to consistent reductions in consumption across alcoholic beverage types (Chisholm et al., 2004; Elder et al., 2010). However, state-specific excise taxes have not kept up with inflation in recent decades; average state-specific excise taxes were $0.05 or less per standard drink across all beverage types in 2015, suggesting that substantial excise tax increases would be necessary to reduce alcohol consumption in the short term (Naimi et al., 2018). For alcohol excise taxes to effectively prevent increases in alcohol consumption and related harms in the long term, the World Health Organization (2009) indicates that taxation levels should account for inflation fluctuations, income, and the prices of other commodities.

Table 2.

Scores related to the potential implementation and effectiveness of selected pricing policy options for reducing excessive alcohol use in the United States, by evaluation domains

graphic file with name jsad.2021.82.710tbl2.jpg

Policy options Political feasibility Public acceptability Low implementation costa Health equity Legal feasibility Total feasibility score Effectiveness
Alcohol taxation (status Low Low High High High 11 High
 quo with no minimum pricing) 1 1 3 3 3 3
Minimum unit price by Medium/ Medium High High High 12.5 Medium/
 unit of alcohol low 1.5 2 3 3 3 high 2.5
Minimum price by Medium Medium High Medium High 12 Medium
 specified amount of an alcoholic beverage type (e.g., per liter of beer) 2 2 3 2 3 2
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a

For this domain, a high ranking indicates that the policy option has low or minimal associated implementation costs.

Political feasibility ranked low because, traditionally, alcohol tax increases have been difficult to implement, facing political challenges (Diepeveen et al., 2013) and substantial opposition from consumers and economic operators (e.g., alcohol manufacturers, distributors, and retailers). Although several states and localities have introduced legislation to increase alcohol taxes in recent years, few jurisdictions have implemented alcohol tax increases (Esser et al., 2016; Wagenaar et al., 2015), largely a result of opposition from stakeholders (Diepeveen et al., 2013). Similarly, evidence suggests little public support for government alcohol pricing policies globally (Diepeveen et al., 2013), informing the low public acceptability ranking.

Health equity concerns have fueled some public opposition to alcohol pricing policies. One concern is that they might adversely affect lower socioeconomic groups; another is that they are unfair to people who drink in moderation. However, studies indicate that costs to purchase alcohol typically increase with the amount of alcohol consumed, as do potential adverse consequences (Holmes et al., 2014). Thus, people who drink excessively would pay the most, and excessive drinking is most common among people with higher incomes (Kanny et al., 2018). However, people in lower-income groups may have fewer resources to handle the harmful effects of excessive drinking and may be disproportionately affected by other people's drinking; they may therefore experience greater alcohol-related harms compared with higher-income individuals (Chalmers, 2014; Holmes et al., 2014). Overall, taxation ranked high on the health equity domain because lower-income drinkers who experience more alcohol-related adverse outcomes are most likely to benefit from increasing alcohol prices (e.g., reduced violence, injuries, liver cirrhosis mortality) (Holmes et al., 2014).

Minimum pricing. Unlike alcohol taxation, raising the price of alcoholic beverages by setting an MP likely increases revenue for economic operators involved in alcohol manufacturing, distribution, and retail. Revenue from alcohol MP could also benefit the government in places with government-controlled alcohol sales (e.g., control states; Figure 1). Thus, economic operators might support the implementation of MP more than alcohol taxation. Comprehensive MP policies could have a greater effect on alcohol consumption than taxes because they tend to influence prices for relatively inexpensive alcoholic beverages.

MUP ranked medium/low on political feasibility, medium on public acceptability, medium/high on effectiveness, and high on low implementation costs (i.e., low-cost option), health equity, and legal feasibility (Table 2). MP by specified amount of an alcoholic beverage type ranked similarly to MUP except political feasibility (medium), health equity (medium), and effectiveness (medium). Effectiveness was ranked medium for MP by specified amount of an alcoholic beverage type because of the potential to encourage alcohol quality substitutions, potentially undermining reductions in consumption. Such policies allow consumers to maintain level spending by purchasing larger amounts of lower-quality products, which typically have similar or higher concentrations of alcohol. Although significant reductions in alcohol sales in response to MP increases have been observed (Stockwell et al., 2012a, 2012b), the potential effects of some MP may be mitigated by beverage substitutions. MUP that focuses on the least expensive alcoholic beverages may prevent drinkers from making substitutions in order to drink more alcohol because it accounts for variability in alcohol content of alcoholic beverages across and within beverage types (Gruenewald et al., 2006). World Health Organization (2009) recommends setting an MUP (e.g., per gram of alcohol) to reduce the availability of low-cost alcohol. MUP also has the potential added benefit of stabilizing prices in the marketplace by alcohol content and may discourage consumers from making quality substitutions (Gruenewald et al., 2006; Holmes et al., 2014).

Alcohol pricing policies are cost-effective for improving public health (Chisholm et al., 2018). MP policies cost little to implement and can help governments increase revenue, particularly in government-led control systems (Stockwell, 2017). Although costs may be incurred for compliance checks (Dickie et al., 2019), an assessment of Scotland's 2018 MUP legislation showed that overall costs incurred by the government in MUP implementation would be minimal—including costs for re-pricing products and issuing policy guidance and education (Scottish Government, 2018)—informing the high ranking of MP for the implementation costs domain.

MP policies have been implemented in other countries, suggesting political feasibility, but MUP is less common (Hawkins & McCambridge, 2020; Thompson et al., 2017). Political feasibility in the United States is likely to vary by state and by factors such as state regulatory systems, the role of alcohol production in the state economy, and stakeholder influence. In control states (e.g., Oregon), MP policy implementation might be more feasible because the government would reap profits from the policy, whereas in jurisdictions where alcohol production has a substantial role in the economy, economic operators’ support for MP might increase the likelihood of implementation. This reasoning informed the political feasibility ranking of medium/low for MUP and medium for MP by specified amount of an alcoholic beverage.

Public acceptability ranked similarly among MP options because there is mixed evidence available on public opinion regarding MP. Some countries have demonstrated public acceptability of MP, especially when the public has information on potential benefits and effectiveness (Pechey et al., 2014; Scottish Government, 2017). Other public opinion research, however, has limited evidence to suggest that people would support MP, describing public skepticism about its effectiveness for reducing excessive alcohol use and related harms (Lonsdale et al., 2012; Scottish Government, 2017). Promisingly, recent findings suggest that public attitudes toward MUP may become more favorable following implementation (Ferguson et al., 2020).

The effects of MP might be mildly income-regressive, with any regressive effects concentrated among people who drink the most alcohol, regardless of income (Vandenberg & Sharma, 2016). However, possible beneficial population-level effects of MP include reductions in excessive drinking (Callinan et al., 2015) and reductions in alcohol expenditures among people with lower incomes who drink excessively, reduced consumption, and, potentially, improved health outcomes (Holmes et al., 2014). In addition, MP policies are associated with more substantial reductions in alcohol-attributable hospitalizations for populations with lower incomes (Zhao & Stockwell, 2017). People with lower incomes tend to spend less per standard drink of alcohol (Meier et al., 2016), and MUP is likely to increase the price of low-cost alcoholic beverages without encouraging beverage substitutions. MUP ranked higher on the health equity domain than MP by amount of an alcoholic beverage.

The legality of such policies for other products (e.g., tobacco, sugar-sweetened beverages) (CDC, 2010; ChangeLab Solutions, 2018) represents the potential for MP policies to become legally acceptable options for alcohol. An assessment of possible legal barriers to MP found no evidence of laws or court cases prohibiting states from establishing alcohol MP (ChangeLab Solutions, 2018). However, a review of case law revealed that states faced legal challenges to similar types of pricing policies relative to state police powers (i.e., state government fundamental rights to make laws to promote health and safety), delegation of powers, and antitrust law (Table 3) (ChangeLab Solutions, 2018). In legal challenges concerning police power, MP laws were deemed invalid if the courts did not find evidence that the MP policies promoted health and safety (ChangeLab Solutions, 2018). MP laws were also deemed invalid when the courts concluded that the legislature provided insufficient authority to agencies propagating a rule or that agencies were not authorized to delegate the power. Finally, challenges based on antitrust violations often dealt with states allowing private industry to oversee the maintenance of price instead of taking on this responsibility directly. Generally, MP laws were struck down on legal grounds because of a policy's construction or implementation, rather than its substance (ChangeLab Solutions, 2018). Legal feasibility, therefore, ranked high for both MP options.

Table 3.

Legal challenges to pricing policy implementation in the United States (ChangeLab Solutions, 2018)

graphic file with name jsad.2021.82.710tbl3.jpg

Legal challenge Description Example
State police powers • Unreasonable exercise of police power
• Court fails to find evidence that the policy adequately addressed its defined purpose
• Court determined purpose fell outside of police power		 In Drink v. Babcock, the New Mexico Supreme Court invalidated a requirement that wholesalers minimally markup the price of liquor on the grounds that the state's pricing provisions were designed to protect the profits of the businesses, rather than to promote the public peace, health, welfare and safety (a purpose it reaffirmed as valid). 77 N.M. 277 (1966).
Delegation of powers • Insufficient authority provided to agencies propagating a rule
• Not authorized to delegate the power		 In State ex rel. Anderson v. Megrims, the Florida Supreme Court invalidated a regulation promulgated by the state's alcohol agency that established minimum prices for alcoholic beverages because the state statute only granted the agency authority to determine whether the public welfare would be enhanced by using the police power to establish minimum prices, not to establish them (this power remained reserved to the state). 187 Kan. 611, 358 P.2d 936 (1961).
Antitrust law • States allow private industry to oversee the maintenance of price instead of taking on this responsibility directly William J. Mezzetti Associates, Inc. v. State Liquor Authority, 66 App.Div.2d 800 (1978, 2d Dept).
Theodore Polon, Inc. v. State Liquor Authority, 59 App.Div.2d 946(1977, 2d Dept).
Rice v. Alcoholic Beverage Control Appeals Board, 21 Cal.3d 431 (1978).
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Discussion

Findings from this study suggest that MP policies could be feasible and cost-efficient strategies for reducing excessive alcohol consumption in the United States, complementary to increasing taxes on alcohol. MUP may be more effective than MP by a specified amount of an alcoholic beverage type because it accounts for the variability in alcohol content of alcoholic beverages across and within beverage types (Gruenewald et al., 2006). MUP may, therefore, more effectively reduce excessive alcohol use because consumers might purchase less alcohol without substituting other brands or types of alcoholic beverages to maintain consumption patterns. MP policies have been implemented in other countries despite challenges (Hawkins & McCam-bridge, 2020; Thompson et al., 2017), and Oregon's MUP policy for distilled spirits will go into effect in the second half of 2021 (Radnovich, 2021), suggesting that MUP or MP may be viable for consideration in some states.

Several factors may affect the feasibility of implementing alcohol MP policies in U.S. states, including the state alcohol control environment and regulation model and other state environmental and economic factors. States vary substantially in the strength of their alcohol control policies (Naimi et al., 2014), consumption patterns, public health infrastructure, and factors that affect drinking, such as cultural norms (Brooks-Russell et al., 2014). MP policies may not be ideal if certain other policies are in effect (e.g., if below-cost alcohol sales are permitted or if retailers do not obtain alcohol from distributors). However, certain state characteristics may facilitate the implementation of MP policies, such as a strong policy environment, robust coordination between the public health system and substance use prevention, and strong stakeholder support for alcohol control and regulation as discussed in the following sections.

Strong policy environment

States that have successfully used systems and environmental strategies to address health risk behaviors, particularly related to substance use, may be more receptive to considering population-based policy strategies to prevent excessive alcohol use. Furthermore, states that have successfully implemented evidence-based, population-level alcohol control policies may be able to leverage existing processes to implement additional alcohol pricing policies.

MP policies may be more acceptable to the public and decision makers in control states because the policy could generate government revenue for the provision of public services if minimum prices are greater than current prices. Additional revenue can be a stronger impetus than public health arguments for enacting MP policies in countries with a government monopoly on alcohol distribution (Stockwell, 2014). Economic operators’ support for MP may vary across states, depending on the role of alcohol production in the state economy.

When developing MP policies, states may want to consider addressing the effectiveness of pricing policies in promoting health and safety; the importance of granting adequate power to agencies to establish related rules; and states’ authority to regulate alcohol under the 21st Amendment to avoid potential legal challenges that could arise pertaining to violations of state police powers, delegation of powers, and antitrust law (ChangeLab Solutions, 2018).

Robust public health and substance use prevention coordination

Relatively little attention has been devoted to the implementation of population-level, primary prevention strategies for alcohol consumption and associated harms, and the development of public health infrastructure and capacity it requires (CDC, 2016; U.S. Department of Health and Human Services, 2016). States with integrated or strongly coordinated public health and substance use prevention infrastructure may be better equipped to develop and implement alcohol MP (DeSalvo et al., 2017).

Public health organizations and other state agencies could collect alcohol pricing data, as is done in other countries (World Health Organization, 2018a, 2018b). In the United States, current information on alcohol pricing is limited to individual point-in-time studies, which are not regularly updated (Albers et al., 2013; DiLoreto et al., 2012), although most of the 17 control states have online databases that specify state-specific prices for some alcoholic products sold (DiLoreto et al., 2012). A comprehensive data system to document prices based on alcohol by volume, container size, beverage type, or brand could help states in better understanding current state alcohol pricing policies (Xuan et al., 2015) and in determining appropriate minimum prices.

Stakeholder support

The U.S. alcohol production, distribution, and retail landscape includes different stakeholders who may be affected by MP policy implementation. Stakeholders’ positions on MP policies are likely to depend on several factors. Support from economic operators for MP policies, which can be influential to policy implementation, may be informed by their role in the alcohol regulation system, their revenue derived from the sale of low-cost alcohol, and the diversity of products they sell (Hilton et al., 2014; Holden et al., 2012). On the other hand, the position of noneconomic operators (e.g., governmental agencies, academic institutions, nonprofits) on MP policy implementation may depend on their resources and regulatory authorities (Hawkins & McCambridge, 2019). Leveraging support from key stakeholders and influential champions while mitigating opposition from others may be helpful for implementation of MP policies (Katikireddi et al., 2014a; Patterson et al., 2015).

Limitations

This study has several limitations. First, literature on the implementation of MP policies is primarily based on international settings (e.g., Canada, Europe), which may not be generalizable to the United States. Second, our ability to fully assess the potential for MP policy implementation in states, and specific characteristics of MP that would be most effective, was limited because of the paucity of research. We analyzed two broad types of MP policies but did not assess policy variations that could increase the effectiveness for reducing excessive drinking and related harms (e.g., MP by amount of an alcoholic beverage adjusted by broad categories of alcohol strength [Stockwell et al., 2012b]). Third, combinations of pricing policies (e.g., MP and alcohol taxes indexed for inflation) were not analyzed; such analyses could lead to different feasibility considerations. Last, this policy analysis was partially informed by research on other pricing strategies for alcohol and other products, and assumptions about their relatability to alcohol MP policies may have inadvertently led to imprecise assessments of implementation feasibility.

Conclusions

To inform policy discussions in the United States, studies could estimate the effects of different MP scenarios (e.g., MUP of $0.55 vs. $0.65 per standard drink) and examine the potential for cross-border effects with increasing alcohol sales in neighboring jurisdictions that have lower-cost alcohol. Results from modeling studies have been instrumental to building support for MP policies in other countries, particularly when they include projected effects on consumption and specific harms, costs to society and the government, and societal savings (e.g., effects on unemployment, use of public services) (Angus et al., 2016; Katikireddi et al., 2014b; Scottish Government, 2018).

Scientific evidence suggests the potential effectiveness of alcohol MP policies for reducing excessive drinking in the United States. MP policies could be implemented as part of a multifaceted, evidence-based approach for reducing excessive alcohol use and related harms that also includes strategies recommended by the Community Preventive Services Task Force (e.g., increasing alcohol taxes, regulating alcohol outlet density, having dram shop liability laws) (Community Guide, 2016).

Acknowledgments

The authors thank Dr. Robert Brewer, Ms. Gemma Crompton, Dr. Timothy Naimi, and Dr. Timothy Stockwell for participating in interviews as subject matter experts and contributing information for use in the stake-holder analysis, and ChangeLab Solutions for conducting the legal review for this article.

Footnotes

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Conflict-of-Interest Statement

The authors have no conflicts of interest or financial disclosures to declare.

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