Q & A: Dangerous Spirits

None for the road: Cook advocates using economic principles to curb the high costs of alcohol abuse. Megan Morr

Philip Cook, ITT/Sanford Professor of public-policy studies and professor of economics and sociology, has, over the course of his career, applied the economist's touch to many public-health and policy issues. His latest book, Paying the Tab: The Costs and Benefits of Alcohol Control, out in September, explores the body of research—including some of his own studies—on alcohol and alcohol abuse, as well as the history of alcohol policy in the U.S. Cook is no teetotaler; rather, he argues that controls in the forms of supply-side regulations and taxes, long undervalued, should be a part of an effective national strategy for dealing with alcohol abuse.

How do current levels of alcohol consumption in the U.S. compare with historical trends?

Average consumption in recent times peaked in 1980. It has dropped substantially, by 25 percent, since then. And it's plateaued in recent years.

What accounts for that drop?

It's very hard to say. It is partly, I think, having to do with the increased concern about health and safety. It's not simply a demographic change because the reduction is not just overall but also for youths, for example. I was here on campus in the 1970s, and for all of the problems there are in connection with alcohol now, they were much more intense then.

Talk a little bit about the title of your book Paying the Tab. What tab does that refer to?

The idea was to convey the sense that this was a book grounded in economics and that it was concerned with the fact that even though alcohol is much cheaper than it used to be, the full social costs of drinking have to be paid by somebody.

Can you elaborate on these costs?

The costs show up in the form of injuries; in the risks attendant to drinking to intoxication and coupling that with dangerous circumstances like driving or getting into fights; in child abuse. And that shows up then in the form of public costs that include higher insurance rates or the medical costs that are shared widely. But more important, just in the fact that we live in a riskier environment on the highways and on the streets because of heavy drinking than we would otherwise.

How does alcohol control play out in the world of public policy?

One way to conceptualize the history is that there's always been this mixture of public response to alcohol problems. On the one hand, there's a focused response to the problems themselves, on people who are public drunks or routinely drinking to excess and the various problems that intoxication causes. The other approach is to restrict the availability of alcohol generally through taxes and regulations and prohibitions of various kinds.

The most famous, or infamous, approach was Prohibition. Why didn't Prohibition work?

While there was broad support for Prohibition, neither the federal government nor
the state governments focused any resources on enforcing it. And so people were able to get their drinks during the Prohibition, albeit with a good deal of criminal enterprise involved. That's one account of what was happening.

But the other thing to be said is that it was successful [in some ways]. Obviously, it was a political failure. Obviously, it created a lot of criminal activity. But the fact was that people drank a lot less during the 1920s than they would have if there had been no Prohibition.

That's not the story usually told.

Alcohol prices were much higher as a result of the fact that it was illegal. But the upper crust was able to pay the extra cost of illegal liquor. One account I read in a social-history journal was that the reporters then, as now, were focused on the elites. So it was true that if your focus was on the Yale campus, for example, you didn't see people drinking less. You may well have seen them drinking more. It was the flapper era. It was the era when people were carrying hip flasks and women started to drink, which they hadn't done before. The "Roaring Twenties" effect produced a lot of drinking at the high end.

But if you went out to Iowa and said, What are the farmers doing?…the answer was, they were drinking a lot less. The same for the factory workers, the ordinary people. Social workers at the time around the country were reporting many fewer problems with alcohol than had occurred previously.

What lessons can those who are working on alcohol policy now take from that success?

That was the question, interestingly enough, that was the focus during the Repeal effort, led by John D. Rockefeller Jr. He took a personal interest in this because he and his friends were angry about the fact that they were paying income taxes. They remembered the good old days, when it was actually the liquor tax that was financing the federal government to a very large extent. So Rockefeller personally financed a very systematic and sophisticated study of what sort of alcohol-control system should be put in place once Prohibition was repealed.

People who do research in my tradition often get called "Neo-Prohibitionists," but actually that's bad history. We are much more reflecting back to that 1930s era effort to create alcoholic-beverage control following the repeal of Prohibition. The lesson [of Prohibition] is not that you can't "legislate morality," which is often the way it's put. You can legislate morality. You can influence the amount of drinking or smoking or drug abuse by raising prices and limiting availability. Those commodities are not unique or unusual. They follow the same laws of economics that all the others do.

Is it surprising that those principles apply?

Not to me, but I think that it's generally ignored in the public discussion. One of the interesting things is that it used to be denied in the area of tobacco control and now it's been embraced. All of the state legislatures express their belief that higher taxes are a good thing because they keep kids from starting to smoke and encourage smokers to quit. Evidence in support of the fact that higher taxes on tobacco reduce smoking is no stronger [than evidence] that raising taxes on alcohol reduces excess drinking.

What about for alcoholics?

Alcoholism became the focus of attention thanks to Alcoholics Anonymous, which was started in the 1930s and emerged as probably the most successful self-help organization in history. But there is this interesting debate over whether its view of losing control is really an accurate characterization of what it means to be alcoholic. I've been fascinated by the experiments that have been done in patient clinics with alcoholics, which suggest that in a certain sense, they haven't lost control, and if you put a price on their drinking, an immediate price, then they are as responsive as anybody else. My own research suggests that when you raise prices, it cuts in to the cirrhosis fatality rate, cirrhosis being a marker for alcoholism long-term. But the much more important point here is that alcoholism is not the whole story, that a lot of the alcohol-related problems are outside of the scope of alcoholism.

What is the current state of the public discussion on drinking?

For a long time, it has focused on drunk driving and on underage drinking. The conversation about alcohol-related problems, under the leadership of Mothers Against Drunk Driving and other organizations like that, got galvanized and focused around the safety issue, highway safety. And it's been very successful in that respect. That's why we had this national twenty-one-year-old minimum drinking age. That's why we have a graduated license. And that's why we have greatly strengthened penalties for DUI. These days all the states have the zero-tolerance law, so that kids who get caught with more than a negligible fraction of alcohol in their blood can lose their license. That's been very effective. It even has cut down on [all] drinking among teenagers.

Alcohol doesn't feel like a crisis; it's been with us forever. It's endemic. It's something we're all used to. Often people get more excited about the latest drug of abuse, methamphetamine or whatever it is. But the prevalent source of drug-related trouble in the U.S. is alcohol. And I think that it deserves more attention than it's getting right now.