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Examine: Smoking Bans Saved Numerous Lives – Might They Have Elevated Drunk Driving?

Alcohol has really bad health effects, and the US doesn't take it seriously enough. While America has taken smoking seriously, it kills nearly half a million people every year. The number of alcohol-related deaths is nearly 100,000 annually.

A new job market paper by Anne Burton, a PhD student in economics at Cornell University, examined how smoking bans in bars and restaurants affect alcohol consumption, violent crime and fatal accidents involving drunk drivers. Its most notable result was a 4 percent increase in fatal accidents involving drunk drivers related to the implementation of these bans in high smoke areas. If so, it would be a significant amount of damage for policy makers to consider when drafting other guidelines that seek to curb the use of harmful substances.

While indoor smoking bans have become pretty ubiquitous, This research could have new relevance as states begin to liberalize marijuana laws and crack down on e-cigarettes and vaping. Policy makers need to determine whether reducing or easing drug restrictions will affect the use of other potentially dangerous substances. If marijuana legalization has the unintended consequence of increasing cigarette consumption, or the e-cigarette crackdown, forcing these consumers to smoke more cigarettes, it is a major problem. Burton's research examines whether policies that helped quit smoking could actually have led people to drink more and led to a measurable increase in deaths from drunk driving.

A woman released from prison because of the coronavirus pandemic smokes a methamphetamine-laden pipe while her boyfriend smokes a cigarette next to Freeway 110 in Los Angeles on May 25, 2020.

Apu Gomes / Getty Images

But first – from one drinker to another (probably) – why drinking and smoking are actually very, very bad, and why we should care when more of them happens:

From 1999 to 2017, a study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recorded nearly one million alcohol-related deaths in the United States. In a 2010 paper by the National Bureau of Economic Research, researchers systematically reviewed the evidence available for the link between alcohol and violent crime and concluded that the "well-documented links" between alcohol and crime were "true" causal effects of the Represent alcohol consumption on the criminal commission. “This is a big deal. That means the researchers believe that it's not just an association and that another factor is causing people to drink heavily and commit crimes. Alcohol is a major factor in whether some crimes even occur.

"The main substance used in arrests and incarceration in America is alcohol," said Keith Humphreys, a drug policy expert and a professor of psychiatry at Stanford University. "In terms of harm – people view illegal drugs as drivers of the criminal justice system, (but) none of them come close to alcohol."

As a country, however, we have largely focused on regulating other drugs. My colleague German Lopez wrote an article entitled "Imagine the media covered alcohol like other drugs." Here is my favorite extract:

What is worse, the public use of this drug is widespread in some circles. In New Orleans, several men and women in their twenties and thirties shouted that they were being "wasted," a slang term for the effects of alcohol. Some have even made drinking alcohol a game that involves table tennis balls and cups. A popular holiday, St. Patrick & # 39; s Day, appears to be around to celebrate the dangerous drug …

No other drug comes close to the amazing deaths of these two. Illegal fentanyl, which has received widespread media attention in recent years due to the opioid epidemic, has been linked to fewer than 30,000 overdose deaths in 2017, deaths over the past few thousand years.

Cigarettes are also extremely harmful to health – although as a country we have done more to combat their use. They remain the leading cause of preventable death in the United States, killing more than 480,000 people each year. The Centers for Disease Control and Prevention add that "for every person who dies from the effects of smoking, at least 30 people are living with a serious smoking-related illness".

Are more people driving drunk after smoking bans are in place?

Burton was not the first to delve into smoking bans and their relationship to alcohol use, as well as alcohol-related events such as drunk driving and violent crime.

University of Wisconsin Milwaukee and UW Oshkosh economists, Scott Adams and Chad Cotti, respectively, examined the relationship between smoking bans and drunk driving between 2000 and 2005. They began their study by stating that “the expected impact of smoking bans on drunk driving is ambiguous “As smokers may go out less, reducing the total number of people drinking. However, their research shows that "fatal accidents with a drunk driver increased by about 13 percent" after a smoking ban was introduced – an astonishing finding.

Adams and Cotti looked at what could happen here and, after reviewing the case studies, decided on two theories. The first is "cross-border shopping," where smokers are willing to continue to a bar in a neighboring jurisdiction that allows smoking, increasing the number of miles driven after drinking. One example they refer to is Minneapolis and St. Paul, Minnesota, a large metropolitan area that is divided into two counties. Hennepin County, where Minneapolis is located, passed a smoking ban in 2005. Then there was a 12 percent increase in fatal accidents in Ramsey County, where St. Paul is located.

The second theory is that bars within jurisdictions differentiate themselves from smoking bans by providing outdoor seating or not enforcing the ban, and this leads to more smokers driving too.

A "No Smoking" sign on the side of a brick building in downtown Nashville, Tennessee.

Robert Alexander / Getty Images

Building on this research, Burton's study looked at smoking bans in bars and restaurants from 2004 to 2012. It relied on the Behavioral Risk Factor Surveillance System (BRFSS) and the Nielsen Consumer Panel to assess alcohol consumption and the location of alcohol consumption measure smoke status. She reached out to the Uniform Crime Reports (UCR) for information on alcohol-related crimes.

Burton found no statistically significant effects of the bans on whether people remained smokers or on violent crime. However, it found that for those who drink, the bans increased alcohol consumption and that in areas with high smoking prevalence, the number of fatal accidents involving drunk drivers increased by 4 percent, but only among high-prevalence smokers. There was no increase in accidents in any of the test subjects. This means that there was a slight decrease or no effect on drunk driving in the other subgroups. However, Burton told me that the 4 percent finding in high prevalence smokers was the only statistically significant finding.

Burton concluded that the 4 percent increase in alcohol consumption observed was likely to have occurred in bars and restaurants, as there was no impact or a slight decrease in home-bought alcohol. She said she wasn't very concerned about the increase in alcohol consumption seen in her study – it's roughly the equivalent of one drink a month, and there was no evidence that people suddenly became binge drinking or engaged in particularly dangerous drinking behaviors.

However, there are concerns about the results of drunk driving that other researchers have pointed out.

Drunk driving may not be affected by smoking bans. If it does, it can be fixed

Before going into the arguments against the Adams, Cotti, and Burton findings, let me be clear: Ultimately, the documented health benefits of smoking bans, such as reducing second-hand smoke exposure, largely outweigh the costs, such as a slight increase in drunk driving some places. Additionally, there are simple ways to avoid potential increases in drunk driving.

After Adams and Cotti's research (which originally showed a link between smoking bans and fatal accidents involving drunk drivers) was published, several researchers responded to the question to test their findings.

The 2013 NIAAA-funded study looked at the impact of statewide smoking bans for bars and restaurants in New York and California on "alcohol-related car accidents" and found no association. They tested Adams and Cotti's hypothesis about jurisdiction shopping by examining communities along the Pennsylvania-New York border, but found no effects on drunk driving accidents.

Andrew Hyland, chair of the Department of Health Behavior at Roswell Park Comprehensive Cancer Center, who was one of the authors of the 2013 paper, told me that his team's biggest concern with Adams and Cottis results was that their research did not include districts in They did not find any drunk road deaths, which could have influenced their observed effect upwards.

"Zero events are very important information," Hyland told me.

Importantly, Hyland's research only looked at nationwide bans. That said, it doesn't rule out the most plausible jurisdiction shopping story: one where a city banned smoking but the state hasn't. So it's easy to find a bar just a few miles away where people can indulge in both vices.

Figure 5 in Burton's article "The Impact of Smoking Bans in Bars and Restaurants on Alcohol Consumption, Smoking and Alcohol-Related External Effects" published November 13, 2020.

Anne Burton

As statewide smoking bans have increased over the years, this jurisdiction-shopping effect is becoming less and less plausible, highlighting a simple way to resolve these concerns – to pass smoking bans nationwide.

Looking at Burton's research, concerns about her results can be reduced to measurement errors and whether she was actually able to isolate the effects of smoking bans.

Self-reported measurements of alcohol and cigarette consumption can be unreliable. First, because of what is known as a "tendency towards social desirability," people often say what it reflects better than the truth. In this case, smokers who are ashamed of the habit report possibly fewer cigarettes smoked than is true. Heavy drinkers could do the same with their alcohol consumption.

Second, there is the problem of "recall bias" – it is actually very difficult to remember exact numbers when it comes to such things.

“When you add up all of the alcohol that Americans say they drink, you come to the conclusion that roughly half of all the alcohol goes down the drain because no one claims it is. … That means people aren't very good at reporting their drinking, "Humphreys said.

For tobacco use, researchers were able to confirm survey data with biomarkers (which pollsters cannot lie). However, this type of analysis is not possible with alcohol.

"She's trying to do the best she can with the data available," Hyland said of Burton's research. "The question is, is this enough to make a statement that smoke-free policies lead to a 4 percent increase in (drunk) deaths."

Burton defends her use of survey data here by saying that while there might be errors in self-reporting, those errors likely do not correlate with the implementation of a smoking ban. She believes that the implementation of a smoking ban should not affect how people respond to surveys about their alcohol consumption. Therefore, switching between these two times should still show the effects of smoke-free guidelines.

Measurement errors could also be because Burton relied on data from BRFSS and Nielsen. These sources provide data at the individual or household level. To compare the numbers from county to county, Burton used provided "weights" to extrapolate the information provided. The problem, however, is that none of these datasets are intended to be representative at the county level. So your data from county to county could be fuzzy.

As with most research, the biggest problem is identifying the cause of the effect being studied. Aren't jurisdictions enforcing smoking bans likely to have taken other public health measures at the same time?

Burton oversees some of these, such as state limits on blood alcohol levels while driving while under the influence and whether the state has a cigarette tax, but says it may go further in the future and include workplace smoking bans and other anti-smoking measures Drive results that she finds here.

In particular, Burton did not control alcohol costs or taxes on alcohol in their results. This is worrying as these have well-documented effects on demand and could skew their results.

"I don't think a small increase in alcohol consumption is a bad thing in and of itself," said Burton. "The main concern is comparing the protective effects of second-hand smoke exposure, especially for bar and restaurant workers, with the cost of this potential increase in deaths from drunk driving."

She's right – and luckily, the benefits of the no-smoking laws far outweigh the small increases in alcohol consumption and the ambiguous effects on drunk driving.

A woman smokes at Sophie, a neighborhood bar, on the Lower East Side, New York City, in January 1995, eight years before the city bans the practice.

Andrew Lichtenstein / Getty Images

Smoking bans are actually good

"Smoke-free policies on construction sites and in restaurants have been one of the greatest public health achievements in the past 25 years," Hyland told Vox.

While there is still some debate about the potential increase in drunk driving, there is an extensive, peer-reviewed scientific literature on the harms of inhaling secondhand smoke and the massive health benefits associated with the sharp drop in smoking smoking is partly due to smoking.

We know that smoking bans have been effective in reducing second-hand smoke exposure. Bans in restaurants, bars and other hospitality establishments have the additional advantage that workers are not forced to bear health costs against their will simply because of their job. Bans have also helped reduce smoking and "reduce smoking opportunities, change smoking norms and lower smoking rates".

Smoking and second-hand smoke increase the risk of cardiovascular disease, lung disease, cancer, and death. Research has shown that heart attack uptake "declined rapidly" after the introduction of 100 percent smoking laws.

All of this to say that when there has actually been a small increase in fatal drunk driving accidents as a result of those bans, the bans were still worth it.

It can seem persistent to think about politics in these terms, but the extent to which anti-smoking policies have improved health and general well-being cannot be underestimated. And this benefit far outweighs the potential that the number of road deaths among drunk people will increase slightly. Especially since this risk could be contained by other measures against drunk driving and by universalizing anti-smoking laws in bars, restaurants and other pubs.

"By reading this paper, I am more confident in the value of smoke-free laws," said Humphreys. “Because it shows there is no effect on violence, there is no effect on drunk driving … and the alleged increase in drinking volume to one teaspoon of wine per day. Even if I believed that we could measure alcohol consumption so precisely in big-panel studies, which is not important to me, I don't care. "

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