Introduction
Although alcohol beverages are legal to drink in most parts of the world and often considered socially acceptable, excessive alcohol consumption contributes substantially to morbidity and mortality worldwide. According to the World Health Organization (WHO), alcohol is a toxin and carcinogen, a psychoactive and addictive substance. Its consumption is connected to over 200 types of disease and injury, accounting for approximately 5.1% of the burden of disease and injury across the world, and over 3 million deaths per year.1 In the U.S. alone, excessive alcohol use was estimated to cause over 178,000 deaths per year from 2020 to 2021.Reference Esser2
Wisconsin exceeds the U.S. national average for excessive alcohol consumption, particularly binge drinking.3 The Centers for Disease Control and Prevention (CDC) defines binge drinking as consuming “5 or more drinks on an occasion for men or 4 or more drinks on an occasion for women.”4 The Wisconsin Department of Health Services (DHS) estimates that 21.9% of adults living in Wisconsin binge drink at least once a month, compared to 15.3% nationwide as of 2021.5 The frequency and intensity of alcohol use has created a significant public health problem in Wisconsin. For example, there were over 35,000 emergency room visits recorded for chronic alcohol conditions in Wisconsin in 2021.6 In 2022, 3,331 people in the state died due to an alcohol-attributable cause.7
As part of the Comprehensive Injury Center (CIC) at the Medical College of Wisconsin (MCW), the Wisconsin Alcohol Policy Project (WisAPP) provides technical assistance to communities working on primary prevention efforts to reduce excessive alcohol use. Communities request WisAPP to provide model ordinances, information on which alcohol policies are most effective for prevention and which municipalities are using them. The work of WisAPP is also supported by the CIC’s Division of Data Analytics and Informatics (DASI) through data collection and analysis.
This team initiated a multi-part legal epidemiology project to better understand how local alcohol policies in Wisconsin are related to alcohol use and its associated harms. The effort is focused on collecting local alcohol policies, which for this purpose include formal written laws and regulations (ordinances, resolutions and guidelines), in a searchable database to provide a resource for comparison of those policies. The intent is to create a tool for analyzing the relationship between local policies, alcohol use and health outcomes across the state, as well as to understand how the policies are put into practice. This paper describes the initial development of the Wisconsin Local Alcohol Policy Database (WLAPD) as a tool for collecting and analyzing alcohol policies in Wisconsin.
Background of Wisconsin Alcohol Regulation
In the United States, alcohol sales are controlled through a system of federal, state, and local laws and regulations. At the federal level, the Alcohol and Tobacco Tax and Trade Bureau (TTB) is authorized to regulate many aspects of alcohol production and sales including federal excise taxes, labeling and formulation, advertising, importation, and exportation.8 However, most of the regulation of alcohol sales to consumers occurs at the state or local level. The Twenty-First Amendment provides states with the ability to make laws taxing and controlling the sale and use of alcohol beverages within their borders.9 Enforcement of state alcohol laws falls within the police power reserved by the Tenth Amendment.10 Currently, thirty-three states including Wisconsin license private businesses or individuals to conduct all sales of alcohol beverages, both wholesale and retail, while the other seventeen states have some form of a state-run system.11
Wisconsin law supports use of a three-tier system for regulation of alcohol beverages, covering producers, wholesalers, and retailers, but with many exceptions.Reference Gary12 In Wisconsin, alcohol beverage production and wholesale are regulated through a state- level permit system, while most alcohol beverage retailers (e.g., stores, restaurants, and bars) are licensed locally.13 As a result, Wisconsin has a hybrid system for alcohol regulation that has not been sufficiently studied to understand how specific policies relate to alcohol-related outcomes.14
The Wisconsin Statutes provide municipalities (cities, villages, and towns) with authority for local control of alcohol retail licensing and sales, and grant municipalities and counties the ability to regulate public consumption and possession of alcohol.15 Regulation of retail alcohol sales is “a matter of local concern” and an exercise of the municipality’s police powers that may only be limited by express statutory language.16 Wisconsin has 1,851 municipalities, each of which may enact alcohol-related ordinances, thereby resulting in heterogeneity in alcohol regulation across the state.17 Municipalities also differ in how those formal policies are implemented in terms of enforcement and local practices. In addition, they vary in how they make their policies available to the public, and alcohol policies can be found in a variety of sections of municipal code.
Development and Framework for the Wisconsin Local Alcohol Policy Database
Prior to developing the WLAPD, we examined the Alcohol Policy Information System (APIS) created by the National Institute on Alcohol Abuse and Alcoholism which addresses alcohol policies across states.18 While APIS compares alcohol policy topics at the state level, it does not delve into local policies. The WLAPD is intended to understand variations in local alcohol policy in Wisconsin.
In selecting policies for data collection, we drew on several reports that reviewed policies and created recommendations for reducing excessive alcohol use, including Thomas Babor’s Alcohol: No Ordinary Commodity Reference Babor19; the State Performance & Best Practices for the Prevention and Reduction of Underage Drinking Report 20; and the State Council on Alcohol and Other Drug Abuse (SCAODA) report Moving Forward: Policies and Strategies to Prevent and Reduce Excessive Alcohol Use in Wisconsin.21 We also used a WisAPP tool for conducting inventories of municipal alcohol policies.22
In total, we identified 56 policies related to local alcohol regulation, in eight categories: (1) adoption of Wisconsin alcohol law; (2) prevention of underage drinking; (3) local licensing process; (4) temporary licenses and festivals; (5) local regulation of licensees; (6) regulation of public alcohol use; (7) regulation of advertising; and (8) adoption of an ethics code (Table 1). Some of the policies selected are broad, with room for a wide level of policymaking, while others are highly specific. In addition, we have a section for determining the extent to which various policies are being used or enforced in practice.
Table 1 Local Policies Reviewed for Wisconsin Local Alcohol Policy Database
The table identifies 8 general categories, indicated by capital letters and underlining, of policies that can affect alcohol beverage sales and use, and 56 specific policies, grouped by category.
A database was developed in REDCap to track local policies.Reference Harris23 Data collection includes whether the municipality has the policy in place, and if so, collects a citation to the code, ordinance, resolution, or other guidance, and website link, if available. Several dates are also collected depending on availability: policy enactment, most recent revision, and date of entry or modification into the database.
Using the WLAPD
After constructing the framework, we collected policies for Wisconsin’s largest cities (Milwaukee, Madison, and Green Bay) and for communities where WisAPP was already providing technical assistance. Noting that many rural communities had elevated levels of alcohol harms but little engagement with WisAPP, we designed a pilot project to focus on rural northern Wisconsin to test the functionality of the WLAPD database. We selected six counties based on the following factors: northern third of Wisconsin, not adjacent to another state, and maximum variation of population density. The counties varied in binge drinking rates from 18.8% to 22.7% and alcohol attributable death rates from 58.0 to 94.7 per 100,000 persons between 2018 and 2022. Separately, we collaborated with another county on an inventory of its policies and provided access to the WLAPD. In total, to date, we have entered policies for 63 municipalities and counties into the WLAPD, with plans to expand.
In rural areas of Wisconsin, there are locations where the internet is not yet fully adopted for sharing governmental information. Many rural municipalities do not have policies posted online and some do not have websites.
Initial results indicate that alcohol law is handled differently based on municipality class. In Wisconsin, many towns and some villages rely on their county for adopting and enforcing alcohol-related laws, while cities often adopt their own policies. While towns have the right to grant alcohol licenses, many of them do this without ensuring compliance with state and local law. In addition, by relying on the county for enforcement of underage drinking laws, they leave the enforcement to sheriff’s departments that have wide responsibilities for enforcement across the county.
Municipalities also vary greatly in how they share information with the public about their policies. In rural areas of Wisconsin, there are locations where the internet is not yet fully adopted for sharing governmental information. Many rural municipalities do not have policies posted online and some do not have websites. For municipalities that post policies online, there is not one consistent way policies are made publicly available. Methods include static documents, searchable local websites, or links to one of several commercial databases. Finally, even for those municipalities that post their code online, the alcohol policies can be found in multiple locations within that code, including chapters on liquor, fermented malt beverages, public safety, parks, zoning, buildings, and ethics. Lack of consistent information creates challenges for enforcement and compliance. These challenges reinforce the value of centralizing alcohol policy information through WLAPD.
Lessons Learned: Goals and Future Directions for the WLAPD
Going forward, the intent is to substantially increase the number of jurisdictions and policies included in the WLAPD to conduct a variety of alcohol-related legal epidemiological research studies and support local prevention efforts. Our hypothesis is that certain alcohol policies and practices will be more strongly associated with lower levels of excessive alcohol use and other alcohol-related outcomes in Wisconsin. Our goal is to analyze local policies and practices in relation to enforcement, alcohol use, and health outcome data to help us better advise communities seeking to implement policies to reduce excessive alcohol use and implement prevention measures to reduce negative alcohol-related health outcomes.
Notes
The authors gratefully acknowledge and thank Claire Hahn, Alexandra Johns, and Elena Villamagna for technical assistance in identifying and adding alcohol policies to the database. This project was funded in part by the Wisconsin Department of Health Services and in part by the Advancing a Healthier Wisconsin Endowment.
