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BackgroundWomen who terminate pregnancies drink more subsequent to the pregnancy than women who give birth, including women who give birth after seeking to terminate a pregnancy.MethodsData are from the Turnaway Study, a prospective, longitudinal study of 956 women who sought to terminate pregnancies at 30 U.S. facilities. This paper focuses on the 452 women who received terminations just below facility gestational limits and 231 who were denied terminations because they presented just beyond facility gestational limits. This study examined whether baseline characteristics moderate the relationship between termination and subsequent binge drinking and whether stress, feelings about the pregnancy, and number of social roles mediate the relationship.ResultsOnly having had a previous live birth modified the termination-binge drinking relationship. Among women with previous live births, binge drinking was reduced among women carrying to term compared to terminating the pregnancy. Among women who had not had a previous live birth, however, the reduction in binge drinking among those denied termination was not sustained over time, and binge drinking of those who had and had not had terminations converged by 2.5 years. Neither stress, negative emotions, nor social roles mediated effects on binge drinking. Positive emotions at one week mediated effects on binge drinking at six months, although positive emotions at two years did not mediate effects on binge drinking at 2.5 years.ConclusionsHigher levels of binge drinking among those who terminate pregnancies do not appear due to stress or to negative emotions. Only parous women - and not nulliparous women - denied terminations experienced sustained reductions in binge drinking over time.

Introduction: Some evidence suggests that cannabis may be a safer substitute for other drugs. Historically, sober living houses (SLHs) have been abstinence-based environments designed for individuals in recovery to live with others in recovery. However, the evolving legal landscape around cannabis use has left SLH operators and managers in a difficult position regarding policies related to cannabis use among residents. The primary aim of this study was to examine how cannabis use relates to alcohol use, other drug use, and related problems among SLH residents., Methods: Baseline (N = 557), 6-month (n = 462), and 12-month (n = 457) data came from SLH residents living in 48 houses in Los Angeles, CA from 2018 to 2021. Longitudinal generalized estimating equation models tested associations between any past six-month cannabis use and alcohol and non-cannabis drug outcomes: any use, number of days of use, and any alcohol- or drug-related problems. Final models adjusted for baseline age, sex, race-and-ethnicity, inpatient substance use treatment, and alcohol/drug use days, and time-varying 12-step attendance and percent of social network using drugs/alcohol heavily., Results: At baseline, 107 (19.2 %) residents reported cannabis use in the past six months. At 12 months, 80 (17.5 %) residents reported cannabis use in the past six months. Across all timepoints, any vs. no past six-month cannabis use was related to significantly (P < 0.05) higher odds of past-month alcohol use (OR = 3.85, 95 % CI: 2.65, 5.59); more drinking days in the past six months (IRR = 1.76, 95 % CI: 1.40, 2.21); higher odds of alcohol problems (OR = 2.74, 95 % CI: 1.99, 3.76); higher odds of past-month drug use (OR = 10.41, 95 % CI: 6.37, 17.00); more drug use days in the past six months (IRR = 1.86, 95 % CI: 1.40, 2.49); and higher odds of drug problems (OR = 14.99, 95 % CI: 9.91, 22.68)., Conclusions: During each assessment period, almost one-fifth of individuals residing in sample of California sober living houses report using cannabis in the past six months. Cannabis does not appear to work as a substitute for alcohol or other drugs in this population because cannabis use is related to increased risk of alcohol and other drug use and problems. SLH managers and operators should consider potential harm that could result from house policies that fail to address cannabis use., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Pregnancy-specific alcohol policies are widely adopted yet have limited effectiveness and established risks. It is unknown whether general population alcohol policies are effective during pregnancy. This study investigated associations between general population policies and alcohol treatment admission rates for pregnant people specifically., Method: Data are from the Treatment Episodes Data Set: Admissions and state-level policy data for 1992-2019 (n=1,331 state-years). The primary outcome was treatment admissions where alcohol was the primary substance, and the secondary outcome included admissions where alcohol was any substance. There were five policy predictors: 1) Government spirits monopoly, 2) Ban on Sunday sales, 3) Grocery store sales, 4) Gas station sales, and 5) Blood alcohol concentration (BAC) laws. Covariates included poverty, unemployment, per capita cigarette consumption, state and year fixed effects, and state-specific time trends., Results: In models with alcohol as the primary substance, prohibiting spirits sales in grocery stores (vs. allowing heavy beer and spirits) had lower treatment admission rates [ IRR =0.88, 95% CI : 0.78-0.99, p =0.028]. States with BAC laws at 0.10% (vs. no law) had higher treatment admission rates [ IRR =1.24, 95% CI : 1.08-1.43, p =0.003]. When alcohol was any substance, prohibiting spirits sales in grocery stores (vs. allowing heavy beer and spirits) was again associated with lower treatment admission rates [ IRR =0.89, 95% CI : 0.80-0.98, p =0.021], but there was no association for BAC laws., Conclusions: Restrictions on grocery store spirits sales and BAC laws were associated with lower and higher alcohol treatment admission rates among pregnant people, respectively, suggesting general population alcohol policies are relevant for pregnant people's treatment utilization.

Introduction: Previous research has found that policies specifically focused on pregnant people's alcohol use are largely ineffective. Therefore, the purpose of this study is to analyze the relationships between general population policies regulating alcohol physical availability and outcomes related to pregnant people's alcohol use, specifically infant morbidities and injuries., Methods: Outcome data were obtained from Merative MarketScan, a longitudinal commercial insurance claims data set. Policy data were obtained from the National Institute on Alcohol Abuse and Alcoholism's Alcohol Policy Information System, the National Alcohol Beverage Control Association, and Liquor Handbooks and merged using policies in effect during the estimated year of conception. Relationships between state-level policies regulating sites, days/hours, and government monopoly of liquor sales and infant morbidities and injuries were examined. Analyses used logistic regression with individual controls, fixed effects for state and year, state-specific time trends, and SEs clustered by state. The study analysis was conducted from 2021 to 2023., Results: The analytic sample included 1,432,979 infant-birthing person pairs, specifically people aged 25-50 years who gave birth to a singleton between 2006 and 2019. A total of 3.1% of infants had a morbidity and 2.1% of infants had an injury. State government monopoly on liquor sales was associated with reduced odds of infant morbidities and injuries, whereas gas station liquor sales were associated with increased odds of infant morbidities and injuries. Allowing liquor sales after 10PM was associated with increased odds for infant injuries. No effect was found for allowing liquor sales in grocery stores or on Sundays., Conclusions: Findings suggest that limiting alcohol availability for the general population may help reduce adverse infant outcomes related to pregnant people's alcohol use., (Copyright © 2024 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: No studies have examined whether alcohol taxes may be relevant for reducing harms related to pregnant people's drinking., Method: We examined how beverage-specific ad valorem, volume-based, and sales taxes are associated with outcomes across three data sets. Drinking outcomes came from women of reproductive age in the 1990-2020 US National Alcohol Surveys (N = 11 659 women $\le$ 44 years); treatment admissions data came from the 1992-2019 Treatment Episode Data Set: Admissions (N = 1331 state-years; 582 436 pregnant women admitted to treatment); and infant and maternal outcomes came from the 2005-19 Merative Marketscan® database (1 432 979 birthing person-infant dyads). Adjusted analyses for all data sets included year fixed effects, state-year unemployment and poverty, and accounted for clustering by state., Results: Models yield no robust significant associations between taxes and drinking. Increased spirits ad valorem taxes were robustly associated with lower rates of treatment admissions [adjusted IRR = 0.95, 95% CI: 0.91, 0.99]. Increased wine and spirits volume-based taxes were both robustly associated with lower odds of infant morbidities [wine aOR = 0.98, 95% CI: 0.96, 0.99; spirits aOR = 0.99, 95% CI: 0.98, 1.00] and lower odds of severe maternal morbidities [wine aOR = 0.91, 95% CI: 0.86, 0.97; spirits aOR = 0.95, 95% CI: 0.92, 0.97]. Having an off-premise spirits sales tax was also robustly related to lower odds of severe maternal morbidities [aOR = 0.78, 95% CI: 0.64, 0.96]., Conclusions: Results show protective associations between increased wine and spirits volume-based and sales taxes with infant and maternal morbidities. Policies that index tax rates to inflation might yield more public health benefits, including for pregnant people and infants., (© The Author(s) 2024. Medical Council on Alcohol and Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Untreated alcohol use disorder (AUD) can have negative outcomes, including premature death. Completing specialty treatment for AUD can improve economic and educational outcomes. However, there are large racial and ethnic disparities in treatment completion, and how these disparities vary intersectionally (e.g., by gender and race and ethnicity) is unknown. Recent studies suggest that not using an intersectional approach can mask important disparities. We estimated disparities in AUD nonintensive outpatient treatment completion by gender alone, race and ethnicity alone, and intersectionally in a gender-by-race-and-ethnicity model. Accurately quantifying treatment completion disparities is critical not only for understanding healthcare disparities but reducing them to advance health equity., Methods: Data are from SAMHSA's 2017 to 2019 Treatment Episode Dataset-Discharges for adults aged 18+ who entered nonintensive outpatient treatment primarily for alcohol (n = 559,447 episodes; 30.3% women; 63.7% White, 18.0% Black, 14.4% Hispanic/Latinx, 2.1% American Indian/Alaska Native [AIAN], 1.0% Asian/Pacific Islander). Using the rank-and-replace method, treatment completion disparities were estimated by gender, race and ethnicity, and gender-by-race-and-ethnicity due to any reason other than differences in need for treatment, consistent with the Institute of Medicine's definition of a healthcare disparity., Results: The intersectional gender-by-race-and-ethnicity model identified the widest range of disparities among all models tested. Using this model, the largest disparities were identified for minoritized women's treatment episodes. Compared to White men whose completion rate was 60.79% (95% confidence interval [CI]: 60.06, 60.98), Black, Hispanic/Latina, AIAN, and Asian-American/Pacific Islander women had treatment episode completion rates that were 12.35 (CI: 12.33, 12.37), 9.08 (CI: 9.06, 9.11), 10.27 (CI: 10.22, 10.32), and 4.87 (CI: 4.78, 4.95) percentage points lower, respectively., Conclusions: In the United States, treatment completion rates for non-intensive outpatient alcohol treatment episodes are significantly lower for minoritized women than White men. The extent of the disparity is not apparent in univariate models, highlighting the importance of an intersectional approach to understanding disparities in the completion of non-intensive outpatient treatment for AUD., (© 2024 Research Society on Alcohol.)

Recovery housing is an important resource for those in recovery from substance use disorders. Unfortunately, we know little about its relationship to key community health risk and protective factors, potentially limiting the role it could play as a broader health resource. Leveraging county-level data on recovery residences from the National Study of Treatment and Addiction Recovery Residences (NSTARR), this study used multilevel modeling to examine Community COVID Vulnerability Index (CCVI) scores as well as availability of COVID testing and vaccination sites in relation to recovery housing. CCVI composite scores were positively associated with recovery housing availability. Analyses using CCVI thematic sub-scores found that population density and number of churches were positively associated with recovery housing availability, while epidemiological factors and healthcare system factors were negatively associated with recovery housing availability. In counties with recovery housing, there also was a positive association between CCVI and both COVID testing and vaccination availability. Recovery residences tend to be located in areas of high COVID vulnerability, reflecting effective targeting in areas with higher population density, more housing risk factors, and other high-risk environments and signaling a key point of contact to address broader health issues among those in recovery from substance use disorders., (© 2023. The Author(s).)

Aims: We examined relationships between pregnancy-specific alcohol policies and admissions to substance use disorder treatment for pregnant people in the USA., Methods: We merged state-level policy and treatment admissions data for 1992-2019. We aggregated data by state-year to examine effects of nine pregnancy-specific alcohol policies on the number of admissions of pregnant women where alcohol was reported as the primary, secondary, or tertiary substance related to the treatment episode (N = 1331). We fit Poisson models that included all policy variables, state-level controls, fixed effects for state and year, state-specific time trends, and an offset variable of the number of pregnancies in the state-year to account for differences in population size and fertility., Results: When alcohol was reported as the primary substance, civil commitment [incidence rate ratio (IRR) 1.45, 95% CI: 1.10-1.89] and reporting requirements for assessment and treatment purposes [IRR 1.36, 95% CI: 1.04-1.77] were associated with greater treatment admissions. Findings for alcohol as primary, secondary, or tertiary substance were similar for civil commitment [IRR 1.31, 95% CI: 1.08-1.59] and reporting requirements for assessment and treatment purposes [IRR 1.21, 95% CI: 1.00-1.47], although mandatory warning signs [IRR 0.84, 95% CI: 0.72-0.98] and priority treatment for pregnant women [IRR 0.88, 95% CI: 0.78-0.99] were associated with fewer treatment admissions. Priority treatment findings were not robust in sensitivity analyses. No other policies were associated with treatment admissions., Conclusions: Pregnancy-specific alcohol policies related to greater treatment admissions tend to mandate treatment rather than make voluntary treatment more accessible, raising questions of ethics and effectiveness., (© The Author(s) 2023. Medical Council on Alcohol and Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Sober living houses (SLHs) are abstinence-based environments designed for individuals in recovery to live with others in recovery. Research shows that SLHs help some individuals maintain recovery and that certain SLH-related factors may be particularly protective. Here we assess how SLH housing and neighborhood characteristics are related to abstinence and psychiatric symptoms over time., Method: Baseline, 6-month, and 12-month data were collected from 557 SLH residents. Multilevel mixed models tested associations between house and neighborhood characteristics and individual-level percent days abstinent (PDA) and the number of psychiatric symptoms (measured with the Psychiatric Diagnostic Screening Questionnaire [PDSQ]) as outcomes. Final models adjusted for sex, age, and race/ethnicity; ratings of house characteristics; and objective measurements of neighborhood-level exposures., Results: Both PDA and PDSQ improved significantly ( p s ≤ .05) over time in both unadjusted and adjusted models. More self-help groups and fewer alcohol outlets within one mile were significantly protective for PDA, whereas walkability was significantly related to worse PDA and PDSQ ( p s ≤ .05). For house-level factors, better ratings of house maintenance were related to significantly fewer psychiatric symptoms, whereas higher scores on SLH's safety measures and personal or residence identity were related to more psychiatric symptoms ( p s ≤ .05). No house-level factor was significantly related to PDA., Conclusions: Neighborhood-level factors such as increased availability of self-help groups and fewer nearby alcohol outlets may increase abstinence among individuals living in SLHs. House-level factors related to better maintenance may also facilitate improved mental health.

Background: Sober living houses are designed for individuals in recovery to live with others in recovery, yet no guidelines exist for the time needed in a sober living house to significantly impact outcomes. Objectives: To examine how the length of stay in sober living houses is related to substance use and related outcomes, focusing on early discontinuation (length of stay less than six months) and stable residence (length of stay six months or longer). Methods: Baseline and 12-month data were collected from 455 sober living house residents (36% female). Longitudinal mixed models tested associations between early discontinuation vs. stable residence and abstinence, recovery capital, psychiatric, and legal outcomes. Final models were adjusted for resident demographics, treatment, 12-step attendance, use in social network, and psychiatric symptoms, with a random effect for house. Results: Both early discontinuers ( n  = 284) and stable residents ( n  = 171) improved significantly (Ps ≤ .05) between baseline and 12 months on all outcomes. Compared to early discontinuation, stable residence was related to 7.76% points more percent days abstinent (95% CI: 4.21, 11.31); 0.88 times fewer psychiatric symptoms (95% CI: 0.81, 0.94); 0.84 times fewer depression symptoms (95% CI: 0.76, 0.92); and lower odds of any DSM-SUD (OR = 0.65, 95% CI: 0.47, 0.89) and any legal problems (OR = 0.58, 95% CI: 0.40, 0.86). Conclusion: In this study of sober living houses in California, staying in a sober living house for at least six months was related to better outcomes than leaving before six months. Residents and providers should consider this in long-term recovery planning.

Background: Policies specific to alcohol use during pregnancy have not been found to reduce risks related to alcohol use during pregnancy. In contrast, general population alcohol policies are protective for the general population. Here, we assessed whether US state-level general population alcohol policies are related to drinking outcomes among women of reproductive age., Methods: We conducted secondary analyses of 1984-2020 National Alcohol Survey data (N = 13,555 women ≤44 years old). State-level policy exposures were government control of liquor retail sales, heavy beer at gas stations, heavy beer at grocery stores, liquor at grocery stores, Sunday off-premise liquor sales, and blood alcohol concentration (BAC) driving limits (no law, 0.10 limit, 0.05-0.08 limit). Outcomes were past 12-month number of drinks, ≥5 drink days, ≥8 drink days, and any DSM-IV alcohol abuse/dependence symptoms. Regressions adjusted for individual and state-level controls, clustering by state, and included fixed effects for survey month and year., Results: Allowing Sunday off-premise liquor sales versus not was related to having 1.20 times as many drinks (95% CI: 1.01, 1.42), 1.41 times as many ≥5 drink days (95% CI: 1.08, 1.85), and 1.91 times as many ≥8 drink days (95% CI: 1.28, 2.83). BAC limits of 0.05-0.08 for driving versus no BAC limit was related to 0.51 times fewer drinks (95% CI: 0.27, 0.96), 0.28 times fewer days with ≥5 drinks (95% CI: 0.10, 0.75), and 0.20 times fewer days with ≥8 drinks (95% CI: 0.08, 0.47)., Conclusions: US state-level policies prohibiting Sunday off-premise liquor sales and BAC limits of 0.05-0.08 for driving are related to less past 12-month overall and heavy drinking among women 18-44 years old., (© 2023 Research Society on Alcohol.)

Background: We investigate whether living in a state that expanded Medicaid eligibility is associated with receiving alcohol screening and brief counseling among nonelderly, low-income adults and a subgroup with chronic health conditions caused or exacerbated by alcohol use., Method: Data are from the 2017 and 2019 Behavioral Risk Factor Surveillance System (N = 15,743 low-income adults; n = 7062 with a chronic condition). We used propensity score-weighted, covariate-adjusted, modified Poisson regression to estimate associations between residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling. Models estimated associations in the overall sample and chronic conditions subsample, as well as differential associations across sex, race, and ethnicity using interaction terms., Results: Living in a state that expanded Medicaid eligibility was associated with being asked whether one drank (prevalence ratio (PR) = 1.15, 95% confidence interval (CI) = 1.08, 1.22), but not with further alcohol screening, guidance about harmful drinking, or advice to reduce drinking. Among individuals with alcohol-related chronic conditions, expansion state residence was associated with being asked about drinking (PR = 1.13, 95% CI = 1.05, 1.20) and, among past 30-day drinkers with chronic conditions, being asked how much one drank (PR = 1.28, 95% CI = 1.04, 1.59) and about binge drinking (PR = 1.43, 95% CI = 1.03, 1.99). Interaction terms suggest that some associations differ by race and ethnicity., Conclusions: Living in a state that expanded Medicaid is associated with a higher prevalence of receiving some alcohol screening at a check-up in the past 2 years among low-income residents, particularly among individuals with alcohol-related chronic conditions, but not with the receipt of high-quality screening and brief counseling. Policies may have to address provider barriers to delivery of these services in addition to access to care., (© 2023 The Authors. Alcohol: Clinical and Experimental Research published by Wiley Periodicals LLC on behalf of Research Society on Alcohol.)

Background: Simultaneous alcohol and cannabis (SAC) use is associated with more negative consequences than independent use of alcohol or cannabis. Contextual characteristics of drinking episodes are associated with the quantity of alcohol consumed and related risk. This study examined whether drinking contexts may also be associated with SAC use., Methods: National Survey on Drug Use and Health (NSDUH) 2010-2019 data from past 30-day drinkers aged 12-20 (n = 39,456) were used. A weighted multivariable logistic regression model examined associations between contextual characteristics (alcohol source, number of people, drinking location) and SAC use during their most recent drinking occasion. Models adjusted for survey year, heavy episodic drinking, age, sex, race/ethnicity, student status, and metropolitan area status., Results: More than one-in-five drinkers reported SAC use. Compared to getting alcohol from parents/family, those who took it from a home (OR = 1.51,95 %CI = 1.24,1.84), got it for free another way (OR = 2.30,95 %CI = 2.05,2.59), paid someone else for it (OR = 2.83,95 %CI = 2.46,3.25), or purchased it themselves (OR = 3.12,95 %CI = 2.66,3.67) had higher odds of SAC use. Compared to drinking alone, drinking with more than one person was associated with higher odds of SAC use (OR = 1.36,95 %CI = 1.12,1.66). Compared to drinking in their home, drinking in a bar (OR = 0.51,95 %CI = 0.41,0.64) had lower odds of SAC use, whereas drinking in someone else's home (OR = 1.12,95 %CI = 1.02,1.22), a car (OR = 1.36,95 %CI = 1.04,1.77), or multiple locations (OR = 1.29,95 %CI = 1.09,1.53) had higher odds of SAC use., Conclusions: Findings suggest that alcohol-related contextual characteristics are associated with SAC use among underage drinkers. Laws addressing underage alcohol consumption, including social host liability and sales to minors laws, may also decrease simultaneous cannabis use., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Aims: To assess whether associations between alcohol availability and consumption, drinking to drunkenness, and negative drinking consequences vary among individuals with elevated depressive symptoms., Methods: 10,482 current drinkers in 2005-2015 National Alcohol Surveys (50.0% female; 74.4% White, 8.7% Black, 11.1% Hispanic). Elevated depressive symptoms was defined as having symptoms suggestive of major depressive disorder (above CES-D8/PHQ-2 cut-offs) versus no/sub-threshold symptoms (below cut-offs). Inverse probability of treatment weighted and covariate adjusted Poisson models with robust standard errors estimated associations of ZIP-code bar density and off-premise outlet density (locations/1,000 residents), elevated depressive symptoms, and their interaction with past-year volume consumed, monthly drinking to drunkenness, and negative drinking consequences. Models were then stratified by sex and race and ethnicity., Results: Overall, 13.7% of respondents had elevated depressive symptoms. Regarding density, the only statistically significant association observed was between off-premise density and volume consumed (rate ratio = 1.3, 95% confidence interval = 1.0, 1.7). Elevated depressive symptoms were associated with higher volume consumed, prevalence of drinking to drunkenness, and prevalence of negative consequences when controlling for off-premise density or bar density. However, there was no evidence of interaction between symptoms and density in the full sample nor among subgroups., Conclusion: This study suggests that, while elevated depressive symptoms do not alter associations between alcohol availability and alcohol use and problems, they remain associated with these outcomes among past-year drinkers in a U.S. general population sample even when accounting for differential availability. Addressing depressive symptoms should be considered along with other policies to reduce population-level drinking and alcohol problems., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Kerr has received funding and travel support from the National Alcoholic Beverage Control Association. Dr. Kerr has been paid as an expert witness regarding cases on alcohol policy issues retained by the Attorney General’s Offices of the US states of Indiana and Illinois under arrangements where half of the cost was paid by organizations representing wine and spirits distributors in those states. The remaining authors have no interests to report., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Recovery housing is an important resource for many in their recovery from alcohol and other drug use disorders. Yet providers of recovery housing face a number of challenges. Many of these challenges are rooted in stigma and bias about recovery housing. The ability to describe the service and purported mechanisms of action vis-a-vis an overarching framework, approach, or orientation could also go a long way in adding credence to recovery housing as a service delivery mechanism. Several aspects of social model recovery are often explicitly built or organically reflected in how recovery housing operates, yet describing recovery housing in these terms often does little to demystify key features of recovery housing. To more fully cement social model recovery as the organizing framework for recovery housing this article aims to: review the history, current status, and evidence base for social model recovery; comment on challenges to implementing the social model in recovery housing; and delineate steps to overcome these challenges and establish an evidence base for social model recovery housing.

Objective: Aims of this study are to examine (a) whether consumer knowledge about their health insurance coverage for alcohol-related services has changed over time and (b) whether racial, ethnic, and income disparities in known coverage have changed over time., Method: This was a general population study comparing the 2015 and 2020 National Alcohol Surveys ( N = 12,076 combined 2015 and 2020; 7,215 women, 4,858 men). Knowledge of alcohol treatment coverage ( insured with coverage, insured without coverage, insured with coverage unknown, uninsured , or insurance status unknown ) was estimated and compared for the total sample ages 18-64 and compared separately by subgroups. Multinomial logistic regression was used to formally test changes in knowledge of coverage over time. Regression models were adjusted for sociodemographics, health insurance type, and current alcohol use disorder. All bivariate and multivariable analyses were survey-weighted to account for probability of selection., Results: Between 2015 and 2020, the prevalence of those reporting being insured without alcohol treatment coverage decreased (-2.8%, p < .001), and the prevalence of those insured with coverage unknown increased (8.1%, p < .001). Compared with White respondents, foreign-born Hispanic respondents were more likely to report being insured without coverage, and Black or African American respondents were less likely to be insured with coverage and had a steeper decrease in knowledge of coverage status over time., Conclusions: Results suggest some persistent disparities in known alcohol treatment coverage. They also suggest a need for both greater insurance coverage of alcohol-related services and greater efforts by employers, insurers, and practitioners to inform their constituents and increase knowledge about what alcohol-related services are available to them.

Alcohol screening is one of the most cost-effective clinical preventive services and important for intervening in the development of alcohol problems. We examine predictors of the quality of alcohol screening, approximated by alcohol quantity screening, which is a prerequisite for appropriate counseling, and compare conventional regression approach with Classification and Regression Trees (CART). Data come from the 2020 National Alcohol Survey, a population survey of US adults aged 18 years and over. Analyses focus on those reporting any alcohol screening at all (N = 989). The primary outcome was whether a healthcare profession had ever asked how much they drink, which is necessary to identify heavy drinking. We examined 12 potential predictors of alcohol quantity: gender, age, race and ethnicity, education, marital status, having a usual source of primary care, insurance, and health conditions. Analyses were replicated in heavy episodic drinking (HED) and high intensity drinking (HID) subgroups, both warranting alcohol counseling. Logistic regression results show that having diabetes and not having a college degree predict missed alcohol quantity screening in the sample overall, and younger age predicts missed alcohol quantity screening in the HED/HID subgroups. CART identified Black and Hispanic respondents who had not attended college at high risk of missed screening for heavy drinking in the overall sample, and those with public insurance at high risk of missed screening for heavy drinking in the HED/HID subgroups. The quality of alcohol screening needs improvement in general, and to avoid unintended disparities in alcohol-related health services., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Background: Recovery housing generally refers to alcohol- and drug-free living environments that provide peer support for those wanting to initiate and sustain recovery from alcohol and other drug (AOD) disorders. Despite a growing evidence base for recovery housing, relatively little research has focused on how recovery housing may benefit individuals accessing outpatient substance use treatment., Methods: Using administrative and qualitative data from individuals attending an outpatient substance use treatment program in the Midwestern United States that provides recovery housing in a structured sober living environment, this mixed methods study sought to: (1) determine whether individuals who opted to live in structured sober living during outpatient treatment (N = 138) differed from those who did not (N = 842) on demographic, clinical, or service use characteristics; (2) examine whether living in structured sober living was associated with greater likelihood of satisfactory discharge and longer lengths of stay in outpatient treatment; and (3) explore what individuals (N = 7) who used the structured sober living during outpatient treatment were hoping to gain from the experience., Results: Factors associated with the use of recovery housing during outpatient treatment in multivariate models included gender, age, and receiving more services across episodes of care. Living in structured sober housing was associated with greater likelihood of satisfactory discharge and longer length of stays in outpatient treatment. Focus group participants reported needing additional structure and recovery support, with many noting that structure and accountability, learning and practicing life, coping, and other recovery skills, as well as receiving social and emotional support from others were particularly beneficial aspects of the sober living environment., Conclusions: Findings underscore the importance of safe and supportive housing during outpatient substance use treatment as well as the need for future research on how housing environments may affect engagement, retention, and outcomes among individuals accessing outpatient substance use treatment., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Excessive drinking and opioid misuse exact a high toll on U.S. lives and differentially affect U.S. racial/ethnic groups in exposure and resultant harms. Increasing access to specialty treatment is an important policy strategy to mitigate this, particularly for lower-income and racial/ethnic minority persons who face distinctive barriers to care. We examined whether the U.S. Affordable Care Act's Medicaid expansion improved treatment utilization in the overall population and for Black, Latino, and White Americans separately., Methods: We analyzed total and Medicaid-insured alcohol and opioid treatment admissions per 10,000 adult, state residents using 2010-2016 data from SAMHSA's Treatment Episode Data Set (N = 20 states), with difference-in-difference models accounting for state fixed effects and time-varying state demographic characteristics, treatment need, and treatment supply., Results: Total treatment admission rates in the overall population declined for alcohol and remained roughly flat for opioids in both expansion and non-expansion states from 2010 through 2016. By contrast, estimated Medicaid-insured alcohol and opioid treatment rates rose in expansion states and decreased in non-expansion states following Medicaid expansion in 2014. The latter results were found for alcohol treatment in the total population and in each racial/ethnic group, as well as for Black and White Americans for opioid treatment., Conclusions: Medicaid expansion was associated with greater specialty treatment entry at a time when alcohol and opioid treatment rates were declining or flat. Findings underscore benefits of expanding Medicaid eligibility to increase treatment utilization for diverse racial/ethnic groups, but also suggest an emerging treatment disparity between lower-income Americans in expansion and non-expansion states., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Home is essential to recovery, and recovery housing can play an important role for individuals seeking a supportive environment. The National Study of Treatment and Addiction Recovery Residences (NSTARR) Project constitutes the largest and most diverse study of recovery housing to date. We describe the development of a national sampling frame to study recovery housing, as well as findings on availability and distribution of recovery housing across the U.S., Methods: Data from publicly available sources and lists maintained by entities tracking recovery housing were compiled. Residences for which locating information was available were geocoded and linked with U.S. Census data and drug and alcohol mortality data. We used hot spot analysis and multilevel models to describe the geographic distribution of recovery residences and assess whether residences are located in areas of high need., Results: The NSTARR database contains information on 10,358 residences operated by 3628 providers in all 50 states. Residences were more likely (p < 0.05) to be in urban areas and in counties with higher substance use mortality; they were less likely to be in economically disadvantaged areas. Recovery housing density also was greater in urban areas and areas with a greater proportion of non-White residents, but lower in economically disadvantaged areas., Conclusions: Despite a wealth of research on some types of recovery housing, critical gaps in the field's understanding about the nature of recovery housing remain. The NSTARR Project represents an important first step to expand research on recovery housing across the country., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Self-reported alcohol consumption in U.S. public health surveys covers only 30%-60% of per capita alcohol sales, based on tax and shipment data. To estimate alcohol-attributable harms using alcohol-attributable fractions, accurate measures of total population consumption and the distribution of this drinking are needed. This study compared methodological approaches of adjusting self-reported survey data on alcohol consumption to better reflect sales and assessed the impact of these adjustments on the distribution of average daily consumption (ADC) levels and the number of alcohol-attributable deaths., Method: Prevalence estimates of ADC levels (i.e., low, medium, and high) among U.S. adults who responded to the 2011-2015 Behavioral Risk Factor Surveillance System (BRFSS; N = 2,198,089) were estimated using six methods. BRFSS ADC estimates were adjusted using the National Alcohol Survey, per capita alcohol sales data (from the Alcohol Epidemiologic Data System), or both. Prevalence estimates for the six methods were used to estimate average annual alcohol-attributable deaths, using a population-attributable fraction approach., Results: Self-reported ADC in the BRFSS accounted for 31.3% coverage of per capita alcohol sales without adjustments, 36.1% using indexed-BRFSS data, and 44.3% with National Alcohol Survey adjustments. Per capita sales adjustments decreased low ADC prevalence estimates and increased medium and high ADC prevalence estimates. Estimated alcohol-attributable deaths ranged from approximately 91,200 per year (BRFSS unadjusted; Method 1) to 125,200 per year (100% of per capita sales adjustment; Method 6)., Conclusions: Adjusting ADC to reflect total U.S. alcohol consumption (e.g., adjusting to 73% of per capita sales) has implications for assessing the impact of excessive drinking on health outcomes, including alcohol-attributable death estimates., Competing Interests: None of the authors have any conflicts of interest or financial disclosures.

Background: The US national surveys and data from legal adult use cannabis states show increases in the prevalence of cannabis use among older adults, though little is known about their manner of cannabis consumption. Here, we examine cannabis use frequency, routes of cannabis administration, and co-use with alcohol, focusing on adults aged 50-64 and ≥65., Methods: Data come from a general population survey conducted January 2014-October 2016 (N=5492) in Washington state. We first estimate prevalence and trends in cannabis frequency, routes of administration, and co-use with alcohol in gender by age groups (18-29, 30-49, 50-64, ≥ 65). To test associations between cannabis frequency, route of administration, and co-use with alcohol, we then use sample-weighted multinomial regression adjusted for gender, race/ethnicity, marital status, education, employment, and survey year. Sampling weights are used so results better represent the Washington state population. Regressions focus on the 50-64 and ≥65 age groups., Results: Among men and women 50-64, the prevalence of no cannabis use in the past 12 months decreased significantly (84.2% in 2014 to 75.1% in 2016 for women, 76.8% in 2014 to 62.4% in 2016 for men). Among those who report past-year cannabis use, oral administration and vaping and other routes of administration increased by 70% and 94%, respectively each year. Almost one-third of women aged 50-64 and one-fifth of women aged ≥65 who use cannabis reported daily/near daily use, and more than one-third of men who use cannabis in all age groups reported daily/near daily use, including 41.9% of those ≥65. Among men, the prevalence of edibles, drinks, and other oral forms of cannabis administration went up significantly with age (6.6% among 18-29, 21.5% among ≥65). Vaping and other administration are more strongly related to regular and daily/near daily use than infrequent use among those ≥65. The pattern of associations between cannabis frequency and co-use with alcohol differed for women vs. men., Conclusions: In a general population representative sample of adults living in a state with legal adult use cannabis, the prevalence of cannabis use increased among those aged 50-64 between 2014 and 2016, the prevalence of daily use is substantial, and oral administration and vaping are increasing.

In the United States, some racial/ethnic minorities suffer from higher rates of chronic alcohol problems, and alcohol-related morbidity and mortality than Whites. Furthermore, state-level alcohol policies may affect racial/ethnic subgroups differentially. We investigate effects of beverage-specific taxes and government control of spirits retail on alcohol-related mortality among non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic American Indians/Alaska Natives (AI/AN) and Hispanics using death certificate and state-level alcohol policy data for 1999-2016. Outcomes were analyzed as mortality rates (per 10,000) from 100% alcohol-attributable chronic conditions ("100% chronic AAD"). Statistical models regressed racial/ethnic-specific logged mortality rates on state-level, one-year lagged and logged beer tax, one-year lagged and logged spirits tax, and one-year lagged government-controlled spirits sales, adjusted for mortality trends, fixed effects for state, and clustering of standard errors. Government control was significantly (P < 0.05) related to 3% reductions in Overall and non-Hispanic White mortality rates, and 4% reductions in Hispanic mortality rates from 100% chronic AAD. Tax associations were not robust. Results support that government control of spirits retail is associated with significantly lower 100% AAD from chronic causes Overall and among non-Hispanic Whites and Hispanics. Government control of spirits retail may reduce both population-level 100% chronic AAD as well as racial/ethnic disparities in 100% chronic AAD., (Copyright © 2021. Published by Elsevier Inc.)

Background: Whether alcohol and cannabis complement or substitute each other has been studied for over two decades. In the changing cannabis policy landscape, debates are moving rapidly and spill-over effects on other substances are of interest., Aims: update and extend a previous systematic review, by: (a) identifying new human behavioural studies reporting on substitution and/or complementarity of alcohol and cannabis, and (b) additionally including animal studies., Methods: We replicated the search strategy of an earlier systematic review, supplemented with a new search for animal studies. Search results were crossed checked against the earlier review and reference lists were hand searched. Findings were synthesised using a narrative synthesis., Results: Sixty-five articles were included (64 in humans, one in animals). We synthesised findings into categories: patterns of use, substitution practices, economic relationship, substance use disorders, policy evaluation, others and animal studies. Overall, 30 studies found evidence for substitution, 17 for complementarity, 14 did not find evidence for either, and four found evidence for both., Conclusions: Overall, the evidence regarding complementarity and substitution of cannabis and alcohol is mixed. We identified stronger support for substitution than complementarity, though evidence indicates different effects in different populations and to some extent across different study designs. The quality of studies varied and few were designed specifically to address this question. Dedicated high-quality research is warranted.

Background and Aims: Alcohol taxation and availability restrictions are among the most effective methods for reducing alcohol use and problems, yet may affect demographic subgroups differently. Understanding who responds to specific policies can inform approaches for reducing disparities. We examined how state-level beverage-specific taxes and availability restrictions in the United States are associated with consumption and alcohol-related problems across subgroups defined by gender and race/ethnicity., Design, Setting and Participants: Data came from the 2000-15 National Alcohol Surveys (n = 28 251), computer-assisted telephone cross-sectional surveys of United States residents aged 18+. African Americans and Hispanics were oversampled., Measurements: Primary outcomes were beverage-specific (beer, wine, spirits and total) volume, DSM-IV alcohol dependence and alcohol-related consequences. Analyses entailed survey-weighted log-log and logistic regressions adjusting for state-level beer tax, spirits tax, government-controlled spirits sales and sales tax; respondent ZIP-code-level density of off-premise beer outlets, off-premise spirits outlets and on-premise bars; respondent individual-level age, marital status, education, employment and income; and fixed effects for wet/moderate/dry US region and year., Findings: Higher beer tax was significantly (P < 0.05) associated with lower odds of any drinking among white women [odds ratio (OR) = 0.98] and lower beer volume (price-elasticity = -0.40), total volume (price-elasticity = -0.50) and odds of alcohol-related consequences (OR = 0.84) among African American women. Higher spirits tax was significantly (P < 0.05) associated with both lower beer and total volume among Hispanic women (price-elasticities = -0.73 and - 1.04, respectively) and men (price-elasticities = -1.19 and - 0.92, respectively) and decreased wine volume among Hispanic women (price-elasticity = -0.62). Apparent protective effects of living in a state with government-controlled spirits sales or a neighborhood with lower bar density was greater among white men than other groups., Conclusions: The effects of beverage-specific taxes and alcohol availability policies may vary across subgroups, highlighting the importance of considering differential policy impacts in future research and intervention., (© 2020 Society for the Study of Addiction.)

In 2011, Washington State voters approved Initiative 1183 (I-1183), the privatization of liquor sales. The aim here was to examine how voter support for privatization has changed since I-1183 passed. Data came from five state-representative surveys, with recruitment between 2014 and 2016 (N = 4,290). Primary outcomes were voting on I-1183 (vs. not), voting for (vs. against) I-1183, and changing vote for I-1183 to against among those who voted for it (vs. not changing). Bivariate and multivariable logistic regressions were used for analyses. Results show that voting for (vs. against) I-1183 was related to 2.59 ( P  < 0.001) times greater odds of wanting to change one's vote. This difference was large enough to have changed the result of the election if voters could know their later opinions. Among those who voted for I-1183, odds of retracting support were positively related to total past 12-month drink volume. Those who agreed that number of stores selling liquor should decrease were more likely to change votes from for to against, while those who considered that youth alcohol abuse has remained the same since privatization were less likely to change votes. Thus, in the years immediately following liquor privatization in Washington State, public opinion has changed enough to shift the result of the election from supporting privatization to rejecting it. Findings are especially relevant for other US states and countries considering privatization., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 Published by Elsevier Inc.)

Background: Valid measurement of alcohol use can be difficult in surveys, which are subject to biases like underreporting and differential nonresponse. Still, monitoring trends, policy impacts, disparities, and related issues all require valid individual- and state-level drinking data collected over time. Here, we propose a double-adjustment approach for improving the validity of the Behavioral Risk Factor Surveillance System (BRFSS) alcohol measures., Methods: Validity analyses of the 1999 to 2016 BRFSS, a general population survey of U.S. adults. Measures are aggregated to state level for N = 918 observations, single-adjusted for BRFSS methodologic changes, and double-adjusted by per capita consumption. Fixed-effects models: (i) assess predictive validity using adjusted BRFSS drink volume to predict mortality outcomes and (ii) assess outcome validity using state-level alcohol taxes to predict adjusted BRFSS volume., Results: Neither the raw nor the single-adjusted BRFSS drinking measures were related to mortality in the expected direction, while double-adjusted BRFSS volume and 5+ days were significantly positively related to mortality, as expected. Spirits and beer taxes were not related to single-adjusted BRFSS drinking in the expected direction. However, spirits and beer taxes were both significantly related to double-adjusted BRFSS volume in the expected directions., Conclusions: Future studies should consider using the double-adjusted BRFSS measures to ensure the validity of drinking survey data in analyses where variation over time is considered., (© 2020 by the Research Society on Alcoholism.)

Context: Previous research finds that some state policies regarding alcohol use during pregnancy (alcohol/pregnancy policies) increase low birth weight (LBW) and preterm birth (PTB), decrease prenatal care utilization, and have inconclusive relationships with alcohol use during pregnancy., Objective: This research examines whether effects of 8 alcohol/pregnancy policies vary by education status, hypothesizing that health benefits of policies will be concentrated among women with more education and health harms will be concentrated among women with less education., Methods: This study uses 1972-2015 Vital Statistics data, 1985-2016 Behavioral Risk Factor Surveillance System data, policy data from National Institute on Alcohol Abuse and Alcoholism's Alcohol Policy Information System and original legal research, and state-level control variables. Analyses include multivariable logistic regressions with education-policy interaction terms as main predictors., Results: The impact of alcohol/pregnancy policies varied by education status for PTB and LBW for all policies, for prenatal care use for some policies, and generally did not vary for alcohol use for any policy. Hypotheses were not supported. Five policies had adverse effects on PTB and LBW for high school graduates. Six policies had adverse effects on PTB and LBW for women with more than high school education. In contrast, 2 policies had beneficial effects on PTB and/or LBW for women with less than high school education. For prenatal care, patterns were generally similar, with adverse effects concentrated among women with more education and beneficial effects among women with less education. Although associations between policies and alcohol use during pregnancy varied by education, there was no clear pattern., Conclusions: Effects of alcohol/pregnancy policies on birth outcomes and prenatal care use vary by education status, with women with more education typically experiencing health harms and women with less education either not experiencing the harms or experiencing health benefits. New policy approaches that reduce harms related to alcohol use during pregnancy are needed. Public health professionals should take the lead on identifying and developing policy approaches that reduce harms related to alcohol use during pregnancy.

Introduction and Aims: Alcohol-related harms to others (AHTO) are consequences of alcohol use borne by persons other than the drinker. This study assessed whether the odds of experiencing AHTO are associated with alcohol availability and taxation policies., Design and Methods: This study pooled data from four waves of the National Alcohol Survey (n = 20656 adults). We measured past-year AHTO exposure using three binary variables: physical (pushed/hit/assaulted or property damage by someone who had been drinking), family or financial (family/marital problems or financial harms by someone who had been drinking) and driving AHTO (riding in a vehicle with a drink-driver or being in a drink-driving crash). Policies included bar and off-premise alcohol outlet density (separately), alcohol retail hours, beer and spirits taxes (separately) and monopoly on retail/wholesale alcohol purchases., Results: Monopolies were associated with 41.2% lower odds of physical harms [adjusted odds ratio (aOR) = 0.59, 95% confidence interval (CI) 0.45, 0.77, q < 0.001 correcting for multiple analyses], and a 10% increase in bar density was associated with a 1.2% increase in odds of driving-related harms ( e ln(1.1) * β =1.01, 95% CI 1.00, 1.02, q = 0.03). Among men, beer taxes were associated with lower odds of physical harms ( e ln(1.1) * β =0.93, 95% CI 0.88, 0.98 q = 0.03) and monopolies were associated with lower odds of physical (aOR = 0.45, 95% CI 0.35, 0.59, q < 0.001) and driving harms (aOR = 0.66, 95% CI 1.00, 1.02, q = 0.03)., Discussion and Conclusions: Monopolies, taxes and outlet density are associated with odds of some AHTO. Future longitudinal research should test whether physical availability and taxation policies may be protective for bystanders as well as drinkers., (© 2020 Australasian Professional Society on Alcohol and other Drugs.)

Background: The US state of Washington legalized recreational cannabis in 2012; how this impacted the co-use of cannabis and alcohol in the population overall and among key subgroups has not been examined. The aim of this study is to investigate changes in patterns of alcohol- and cannabis use and alcohol-related harms during the rollout of retail recreational cannabis stores., Methods: Data come from six cross-sectional samples recruited between January 2014-October 2016 via Random Digit Dial procedures (N = 5492). Survey-weighted multivariable regression adjusting for gender, age, race/ethnicity, education, employment, marital status, cannabis use, and survey year were used for statistical analyses., Results: In the sample overall, no significant changes were observed in any alcohol use measures between 2014-2016, while the prevalence of cannabis use significantly (P < 0.05) increased from 25.0% to 31.7%, the prevalence of alcohol-related harms at home significantly decreased from 2.1% to 1.0%, and the prevalence of alcohol-related financial harms decreased from 1.5% to 0.8%. Both women and men significantly increased any cannabis use, while women also experienced significantly fewer alcohol-related harms at home and financial harms over time, and increases in the prevalence of cannabis users/non-drinkers. Those 18-29 years old significantly reduced the number of drinking days and overall volume in the past 30 days, and those 30-49 years old significantly decreased alcohol-related harms at home and financial harms. Those 50+ years old significantly increased any cannabis use and simultaneous use of cannabis and alcohol. Non-cannabis users slightly decreased average number of drinks/day, and cannabis users significantly decreased alcohol-related financial harms., Conclusions: Between 2014-2016, the years during and immediately following the introduction of legal recreational cannabis stores in Washington state, there were no significant changes in cannabis and alcohol co-use or overall alcohol consumption. The only significant changes in the sample overall were an increase in any cannabis use and decreases in alcohol-related harms at home and alcohol-related financial harms., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The U.S. Mental Health Parity and Addiction Equity Act (MHPAEA) was a landmark federal policy aimed at increasing access to substance use treatment, yet studies have found relatively weak impacts on treatment utilization. The present study considers whether there may be moderating effects of pre-existing state parity laws and differential changes in treatment rates across racial/ethnic groups., Methods: We analyzed data from SAMHSA'S Treatment Episode Data Set (TEDS) from 1999 to 2013, assessing changes in alcohol treatment admission rates across states with heterogeneous, pre-existing parity laws. NIAAA's Alcohol Policy Information System data were used to code states into five groups based on the presence and strength of states' pre-MHPAEA mandates for insurance coverage of alcohol treatment and parity (weak; coverage no parity; partial parity if coverage offered; coverage and partial parity; strong). Regression models included state fixed effects and a cubic time trend adjusting for state- and year-level covariates, and assessed MHPAEA main effects and interactions with state parity laws in the overall sample and racial/ethnic subgroups., Results: While we found no significant main effects of federal parity on alcohol treatment rates, there was a significantly greater increase in treatment rates in states requiring health plans to cover alcohol treatment and having some pre-existing parity. This was seen overall and in all three racial/ethnic groups (increasing by 25% in whites, 26% in blacks, and 42% in Hispanics above the expected treatment rate for these groups). Post-MHPAEA, the alcohol treatment admissions rate in these states rose to the level of states with the strongest pre-existing parity laws., Conclusion: The MHPAEA was associated with increased alcohol treatment rates for diverse racial/ethnic groups in states with both alcohol treatment coverage mandates and some prior parity protections. This suggests the importance of the local policy context in understanding early effects of the MHPAEA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: State policies regarding alcohol use during pregnancy (alcohol/pregnancy policies) have been in effect for more than 40 years. Previous research finds some policies increase adverse birth outcomes and decrease prenatal care utilization. This research examines whether effects of alcohol/pregnancy policies vary by race; the general hypothesis is that health benefits of policies are concentrated among White women and health harms of policies are concentrated among Black women., Methods: This study uses 1972-2015 Vital Statistics data and policy data from NIAAA's Alcohol Policy Information System and original legal research. The dataset includes more than 150 million singleton births. Outcomes are preterm birth (PTB), low birthweight (LBW), and prenatal care utilization. Logistic regression models include raceXpolicy interaction terms as main predictors, adjust for individual- and state-level controls, include fixed effects for state, year and state-specific time trends, and account for clustering by state., Results: The impact of alcohol/pregnancy policies varied by race for preterm birth, varied in a few cases for low birthweight, and generally did not vary for prenatal care utilization. The hypothesis regarding the direction of differential effects was not supported. Six policies had an adverse impact on PTB and/or LBW for White women. Findings differed for Black women; for Black women, four policies had a beneficial impact for PTB and one had an adverse impact for LBW., Conclusions: The impact of alcohol/pregnancy policies on birth outcomes varies by race. Future research should explore why some policies appear to have opposite effects for White v. Black women., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background and Objective: As of 2016, 43 US states have policies regarding alcohol use during pregnancy. A recent study found that out of eight state-level alcohol/pregnancy policies, six are significantly associated with poorer birth outcomes, and two are not associated with any outcomes. Here we estimate the excess numbers of low birthweight (LBW) and preterm births (PTB) related to these policies and their associated additional costs in the first year of life., Methods: Cost study using birth certificate data for 155,446,714 singleton live births in the United States between 1972-2015. Exposures were state- and month/year-specific indicators of having each of eight alcohol/pregnancy policies in place. Outcomes were excess numbers of LBW and PTB and associated costs in the first year of life. Fixed effects regressions with state-specific time trends were used for statistical analyses in 2018., Results: In 2015, policies mandating warning signs were associated with an excess of 7,375 LBW; policies defining alcohol use during pregnancy as child abuse/neglect were associated with an excess of 12,372 PTB; these excess adverse outcomes are associated with additional costs of $151,928,002 and $582,698,853 in the first year of life, respectively., Conclusions: Multiple state-level alcohol pregnancy policies lead to increased prevalence of LBW and PTB, which cost hundreds of millions of dollars annually. Policymakers should consider adverse public health impacts of alcohol/pregnancy policies before expanding extant policies to new substances or adopting existing policies in new states., Competing Interests: The authors have declared that no competing interests exist.

Background: Most states have at least one policy targeting alcohol use during pregnancy. The public health impact of these policies has not been examined. We sought to examine the relationship between state-level policies targeting alcohol use during pregnancy and alcohol use among pregnant women., Methods: Data include state-level alcohol and pregnancy policy data and individual-level U.S. Behavioral Risk Factor Surveillance System data about pregnant women's alcohol use from 1985 to 2016 (N = 57,194). Supportive policies include mandatory warning signs, priority substance abuse treatment, reporting requirements for data and treatment purposes, and prohibitions on criminal prosecution. Punitive policies include civil commitment, Child Protective Services reporting requirements, and child abuse/neglect. Analyses include logistic regression models that adjust for individual- and state-level controls, include fixed effects for state and year, account for clustering by state, and weight by probability of selection., Results: Relative to having no policies, supportive policy environments were associated with more any drinking, but not binge or heavy drinking. Of individual supportive policies, only the following relationships were statistically significant: mandatory warning signs was associated with lower odds of binge drinking, and priority treatment for pregnant women and women with children was associated with higher odds of any drinking. Relative to no policies, punitive policy environments were also associated with more drinking, but not with binge or heavy drinking. Of individual punitive policies, only child abuse/neglect was associated with lower odds of binge and heavy drinking. Mixed policy environments were not associated with any alcohol outcome., Conclusions: Most policies targeting alcohol use during pregnancy do not seem to be associated with less alcohol consumption during pregnancy., (Copyright © 2019 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Background: The relationships between cannabis use frequency with alcohol use, alcohol-related harms, and persistent alcohol use disorder (AUD) in a general population subsample of individuals previously treated for AUD were examined., Methods: Secondary analyses of the 2005, 2010, and 2015 U.S. National Alcohol Surveys, a nationwide general population sample of individuals ages 18+, were performed. The analytic subsample (N = 772) reported 3+ lifetime DSM-IV alcohol dependence criteria and prior AUD treatment. Primary exposure was past 12-month frequency of cannabis use (weekly or more, or "heavy;" more than monthly/less than weekly or "midlevel;" less than monthly or "light;" none). Primary outcomes were past 12-month total volume, average frequency of 5+ drinks/month, past 12-month alcohol-related harms, and past 12-month DSM-IV alcohol dependence., Results: Multivariable negative binomial and logistic regressions showed that the only cannabis users who consistently differed significantly from cannabis abstainers were midlevel users; specifically, more than monthly/less than weekly cannabis users drank 2.83 times as many drinks (95% CI: 1.43, 5.60); had 2.83 as many 5+ occasions (95% CI: 1.38, 5.79); had 6.82 times the odds of experiencing any harms (95% CI: 2.29, 20.33); and had 6.53 times the odds of persistent AUD as cannabis abstainers (95% CI: 2.66, 16.02; all ps < 0.05). The relationship between midlevel cannabis use and harms remained significant after adjustment for volume and frequency of 5+ (OR = 6.18, 95% CI: 1.35, 28.37)., Conclusions: Among those with lifetime AUD who have been to treatment, only more than monthly/less than weekly cannabis use is related to more alcohol-related harms and persistent AUD compared to cannabis abstinence. Heavier and lighter cannabis use is not related to worse alcohol outcomes compared to cannabis abstinence., (© 2019 by the Research Society on Alcoholism.)

Background: Recent increases in alcohol-related morbidity and mortality have not occurred alongside notable increases in per capita alcohol consumption (PCC). This discrepancy may be partially due to U.S. PCC estimates not including annual estimates of the percentage of alcohol by volume (%ABV) of beer, wine, and spirits, but rather relying on time-invariant %ABV values., Methods: Building on a prior study covering 1950 to 2002, estimates of the annual mean %ABV of beer, wine, and spirits sold in the United States were calculated using the %ABV of major brands and sales of each beverage type for each state and nationally for the period 2003 to 2016. We applied these estimates to the calculation of annual beverage-specific and total PCC, and made descriptive comparisons between our PCC estimates and those estimates using invariant %ABV values., Results: For all beverage types, our mean %ABV estimates increased nationally and for all but 5 states. The PCC estimates from wine and spirits utilizing variable %ABV values were lower than estimates using invariant %ABV, and consumption from beer was higher. Our total PCC estimates were also lower than %ABV-invariant estimates; however, the percent change for %ABV-invariant estimates was 5.8% compared to a 7.9% change in our %ABV-variant estimates over the 2003 to 2016 period., Conclusions: Given the application of PCC estimates to understand changes in alcohol-related morbidity and mortality, the inclusion of annual estimates of the %ABV of alcoholic beverages sold in the United States is necessary to ensure the precision of PCC measures such that the conclusions drawn from these applications are accurate and valid., (© 2019 by the Research Society on Alcoholism.)

Purpose: Alcohol use during pregnancy is a significant public health concern. Nearly all U.S. states have enacted policies targeting alcohol use during pregnancy, but there has been little research examining their impact, particularly across racial/ethnic groups. Methods: Using data from the Behavioral Risk Factor Surveillance System and about eight state-level, pregnancy-specific alcohol policies from 1985 to 2016, the aim of this study was to examine the differential effects of these policies on drinking among pregnant women by race/ethnicity. Results: We found evidence of differential effects for priority treatment, prohibitions on criminal prosecution, and civil commitment policies. In relation to priority treatment policies, effects benefited versus harmed different racial/ethnic groups depending on whether the priority treatment policies were for pregnant women only or if they gave priority to both pregnant women and pregnant women with children. Conclusions: Findings from this study suggest that benefits and harms from these policies do not appear to be equitably distributed across different racial/ethnic groups. Research considering the impact of alcohol/pregnancy policies should consider differential effects by race/ethnicity., Competing Interests: No competing financial interests exist.

Background: Prior research shows that cannabis use during treatment for Alcohol Use Disorders (AUD) is related to fewer abstinent days from alcohol, although only among those who use cannabis 1-2x/month. Here we extend prior research by assessing the relationship between the frequency of cannabis use during AUD treatment and post-treatment alcohol-related consequences., Methods: Data come from the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study, a large US randomized control trial of treatments for AUD. The current analyses include 206 cannabis users and 999 cannabis abstainers and compare longitudinal drinking data between those who used cannabis versus those who abstained during COMBINE treatment. The primary exposure was quartiles of cannabis use (Q1: less than 1x/month during treatment, Q2: 1-2x/month, Q3: 4-8x/month, Q4: 12x/month or more), with cannabis abstainers as the reference group. Outcomes were alcohol-related problems at the end of treatment and one-year post-treatment as measured by the Drinker Inventory Consequences., Results: Compared to cannabis abstinence, the most frequent use during treatment was related to 1.44 times as many physical consequences one-year post-treatment. Cannabis use was not related to physical consequences immediately after treatment, or to intrapersonal, interpersonal, social responsibility or impulse control problems at either post-treatment time point., Conclusions: In a sample of individuals in treatment for AUD, using cannabis 12x/month or more during treatment is associated with increased rates of physical consequences attributed to alcohol use. Individuals in treatment for AUD who also use cannabis might benefit from reducing or stopping cannabis use to avoid alcohol-related physical problems., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Aims: Combined use of alcohol with drugs elevates risk for problems including injury and intoxicated driving. We assessed contributions of heavy drinking (5+ men/4+ women), drug use (cannabis and other drugs) and simultaneous co-use to DSM-5 alcohol use disorder (AUD) and drug abuse (DA). We expected co-use to increase risk for AUD and DA., Methods: Using population-weighted data from adults in the 2014-15 National Alcohol Survey who had never been to treatment (N=3386 drinkers, 50% male, 13% Hispanic, 11% Black, mean age 45; N=439 drug users, 56% male, 20% Hispanic, 15% Black, mean age 36), we tested hypotheses using logistic regression adjusting for demographics, family history of alcohol problems and impulsivity., Results: 10% of drinkers and 26% of drug users met criteria for mild AUD; <1% of drinkers and 4% of drug users met criteria for DA. Heavy drinking significantly increased risk for AUD, as did monthly or weekly use of cannabis. When simultaneous co-use was added, increased risk associated with cannabis use was reduced to non-significance. Weekly cannabis use, weekly use of other drugs and simultaneous drug and alcohol co-use were associated with significantly elevated risk of DA. In bivariate analyses, simultaneous co-use was associated with significantly greater endorsement of each of the separate AUD and DA symptom domains, including alcohol craving, tolerance and withdrawal, as well as drug and alcohol social and physical health problems., Conclusion: Healthcare providers should screen for simultaneous co-use of alcohol and drugs to help identify patients who may benefit from substance abuse treatment., Competing Interests: Declaration of interest Authors declare no conflicts of interest.

Objective: A small body of work has started developing cannabis use "typologies" for use in treatment and prevention. Two potentially relevant dimensions for classifying cannabis use typologies are medical versus recreational cannabis use and the co-use of cannabis and alcohol. Here we compare alcohol use and related problems between cannabis users with and without medical cannabis recommendations., Method: Data come from a larger general population study in Washington State conducted between January 2014 and October 2016. All participants in the analytic sample (n = 991) reported using both alcohol and cannabis in the past 12 months. The primary exposure was having a medical recommendation for cannabis. Outcomes were past-30-day drinking (drinks/day, frequency of 5+ drinks, and maximum number of drinks in a day) and past-12-month Alcohol Use Disorders Identification Test (AUDIT) scores., Results: Compared with those without medical cannabis recommendations, cannabis users with medical cannabis recommendations had 0.59 times fewer drinks/day, 0.44 times fewer occasions drinking 5+, and 0.78 times the average maximum number of drinks in one day (all ps < .05). Those with a recommendation also had 0.87 times lower AUDIT total scores (p < .05) and 0.57 times lower AUDIT problem scores (p < .01)., Conclusions: Cannabis users with medical cannabis recommendations drink less and have fewer alcohol-related problems than those without recommendations, even after adjusting for health status. Future studies should examine nonhealth reasons regarding how medical and nonmedical users use cannabis differently.

Background: In 2012 Washington State ended a wholesale/retail monopoly on liquor, permitting sale of spirits in stores with > 10,000 square feet. Implementation resulted in average price increases, but also five times the stores selling liquor., Objectives: As part of a privatization evaluation, we studied pre-post and between-store-type purchase experiences., Methods: A 2010 Washington State Liquor Control Board (LCB) survey of liquor purchasers (n = 599), and the 2014 baseline of a repeated telephone survey (1,202 residents; n = 465 purchasers), each included 10 LCB questions on satisfaction with purchase experiences, each attribute with graded response scale A = 4 to D = 1 and F (0 = fail). Analyses used t-tests for satisfaction differences by time and analysis of variance (ANOVA) for 2014 between-store satisfaction-level differences., Results: Five purchase features were rated more favorably after privatization (ps < .05-.001), including product supply, staff professionalism, location convenience, store hours, and prices (though price rated lowest both times); selection offered, courtesy, and checkout speed were unaltered, and number of staff and staff knowledge declined (both p < .001). Eight consumer experiences differed by store type: five satisfaction aspects (supply, selection, number of staff, operating hours, and checkout speed) were highest for liquor superstores, while location convenience favored grocery and drug stores, and price satisfaction favored wholesale (Costco) stores, with staff knowledge highest at liquor stores., Conclusions: Satisfaction with liquor purchases increased after privatization for half the consumer experiences. Availability (location convenience and store hours) was important to liquor purchasers. Such results are relevant to sustained support for the policy of privatizing spirits retail monopolies.

Purpose: We examined whether alcohol-dependent individuals with sustained substance use or psychiatric problems after completing treatment were more likely to experience low social status and whether continued help-seeking would improve outcomes., Short Summary: Ongoing alcohol, drug and psychiatric problems after completing treatment were associated with increased odds of low social status (unemployment, unstable housing and/or living in high-poverty neighborhood) over 7 years. The impact of drug problems declined over time, and there were small, delayed benefits of AA attendance on social status., Method: Alcohol-dependent individuals sampled from public and private treatment programs (N = 491; 62% male) in Northern California were interviewed at treatment entry and 1, 3, 5 and 7 years later. Random effects models tested relationships between problem severity (alcohol, drug and psychiatric problems) and help-seeking (attending specialty alcohol/drug treatment and Alcoholics Anonymous, AA) with low social status (unemployment, unstable housing and/or living in a high-poverty neighborhood) over time., Results: The proportion of participants experiencing none of the indicators of low social status increased between baseline and the 1-year follow-up and remained stable thereafter. Higher alcohol problem scores and having any drug and/or psychiatric problems in the years after treatment were associated with increased odds of low social status over time. An interaction of drug problems with time indicated the impact of drug problems on social status declined over the 7-year period. Both treatment-seeking and AA attendance were associated with increased odds of low social status, although lagged models suggested there were small, delayed benefits of AA attendance on improved social status over time., Conclusion: Specialty addiction treatment alone was not sufficient to have positive long-term impacts on social status and social integration of most alcohol-dependent people.

Aims: The US state of Washington's 333 state-run liquor stores were privatized on 1 June 2012 and purchases began in ~1500 licensed stores of a variety of types. A regime of taxes and fees was implemented to replace the revenues generated by the state stores and, 1 year later, the beer tax was reduced by two thirds. This study evaluates the impact of these changes on total alcohol and spirits consumption in a retrospective pre-test design., Methods: The study sample consists of 2289 adults recruited in three cross-sectional surveys during 2014 and 2015. Retrospective typical past month quantity-frequency measures for before privatization drinking and current past month quantity-frequency measures were compared within subjects, for all alcohol and for spirits only., Results: No change in alcohol volume was seen across privatization while spirits volume was found to decrease, suggesting a shift from spirits to beer. This decline in spirits volume came from a reduction in drinking days while overall drinking days were found to increase. This was offset by a reduction in drinks per drinking day and in heavy occasions., Conclusions: These findings accurately mirror the overall flat trend in per capita alcohol sales but seem to exaggerate the very small shift towards beer seen in sales data. Effects of increased spirits availability appear to have been countered by increased spirits prices and a decreased beer tax, leading to a shift to beer consumption., Short Summary: Survey-based analyses of alcohol use across Washington's spirits privatization, beer tax reduction and marijuana legalization found no change in alcohol volume, a reduction in spirits volume and a shift to more moderate drinking patterns. Reductions in drinking occurred among marijuana users and those with lower educational attainment reduced spirits volume.

Background: Policies regarding alcohol use during pregnancy continue to be enacted and debated in the United States. However, no study to date has examined whether these policies are related to birth outcomes-the outcomes they ultimately aim to improve. Here, we assessed whether state-level policies targeting alcohol use during pregnancy are related to birth outcomes, which has not been done comprehensively before., Methods: The study involved secondary analyses of birth certificate data from 148,048,208 U.S. singleton births between 1972 and 2013. Exposures were indicators of whether the following 8 policies were in effect during gestation: Mandatory Warning Signs (MWS), Priority Treatment for Pregnant Women, Priority Treatment for Pregnant Women/Women with Children, Reporting Requirements for Data and Treatment Purposes, Prohibitions Against Criminal Prosecution, Civil Commitment, Reporting Requirements for Child Protective Services Purposes, and Child Abuse/Child Neglect. Outcomes were low birthweight (<2,500 g), premature birth (<37 weeks), any prenatal care utilization (PCU), late PCU, inadequate PCU, and normal (≥7) APGAR score. Multivariable fixed-effect logistic regressions controlling for both maternal- and state-level covariates were used for statistical analyses., Results: Of the 8 policies, 6 were significantly related to worse outcomes and 2 were not significantly related to any outcomes. The policy requiring MWS was related to the most outcomes: specifically, living in a state with MWS was related to 7% higher odds of low birthweight (p < 0.001); 4% higher odds of premature birth (p < 0.004); 18% lower odds of any PCU (p < 0.001); 12% higher odds of late PCU (p < 0.002); and 10% lower odds of a normal APGAR score (p < 0.001) compared to living in a state without MWS., Conclusions: Most policies targeting alcohol use during pregnancy do not have their intended effects and are related to worse birth outcomes and less PCU., (Copyright © 2018 by the Research Society on Alcoholism.)

Objective: The purpose of this study was to evaluate changes in marijuana use prevalence and user characteristics across the 2012 recreational legalization in Washington State. Differences in change estimates between retrospective and contemporaneous pre-legalization measures are compared and considered in relation to potential social acceptability and illegality effects on reporting., Method: Four representative surveys of the Washington State population 18 years and older were conducted by telephone, two in 2014 and two in 2015, which are combined by year for analyses (N = 3,451). Respondents reported their current past-year use frequency and retrospective frequency of use in 2012 before the election in which legalization was passed. They also provided demographic information and details of alcohol use, including simultaneous use with marijuana., Results: A small and not statistically significant increase of 1.2 percentage points in past-year use prevalence, from 24.3% (22.3-26.5) to 25.6% (23.6-27.6), was found when combining the surveys. No statistically significant change was found in the prevalence of simultaneous use with alcohol, which decreased from 12.9% (11.3-14.7) to 12.6% (11.0-14.4). In contrast, estimates from the National Survey on Drug Use and Health (NSDUH) indicate substantially increased prevalence, from 15.5% (13.8-17.3) in 2010-2012 to 19.1% (16.9-21.4) in 2013-2014, although this change is not statistically significant. Other findings of interest from the Washington State surveys include new users after legalization tending to be older, White, and moderate drinkers who do not use marijuana simultaneously with alcohol., Conclusions: A retrospective pre-legalization measure showed only a small increase in marijuana use prevalence in contrast to larger changes found in prospectively assessed use in the NSDUH. Changes in the social acceptability and legal status of marijuana after legalization may have increased reporting of pre-legalization use compared with concurrent assessments.

Background: Support for the legalization of recreational marijuana continues to increase across the United States and globally. In 2016, recreational marijuana was legalized in the most populous US state of California, as well as three other states. The primary aim of this study was to examine trends in support for recreational marijuana legalization in Washington, a state which has had legal recreational marijuana for almost four years, using data collected over the four years post-legalization. A secondary aim was to examine trends in support for the cultivation of marijuana for personal use., Methods: Data come from geographically representative general population samples of adult (aged 18 and over) Washington residents collected over five timepoints (every six months) between January 2014 and April 2016 (N=4101). Random Digit Dial was used for recruitment. Statistical analyses involved bivariate comparisons of proportions across timepoints and subgroups (defined by age, gender, and marijuana user status), and multivariable logistic regression controlling for timepoint (time) to formally test for trend while controlling for demographic and substance use covariates. All analyses adjusted for probability of selection., Results: Support for legalization in Washington has significantly increased: support was 64.0% (95% CI: 61.2%-67.8%) at timepoint 1 and 77.9% (95% CI: 73.2%-81.9%) at timepoint 5. With each six months' passing, support increased 19% on average. We found no statistically significant change in support for home-growing., Conclusions: Support for marijuana legalization has continued to significantly increase in a state that has experienced the policy change for almost four years., (Copyright © 2017. Published by Elsevier B.V.)

Aims: To compare post-treatment alcohol use between those who use cannabis and those who abstain during treatment for alcohol use disorders (AUD); and to examine potential cannabis use thresholds by comparing post-treatment alcohol use between four frequency groups of cannabis users relative to abstainers., Design: Secondary analyses of the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study, a randomized control trial of AUD treatments. The current study compares longitudinal drinking data between those who used cannabis versus those who abstained during COMBINE treatment., Setting: The COMBINE Study treatments were delivered on an out-patient basis for 16 weeks. The current analyses include 206 cannabis users and 999 cannabis abstainers., Participants: All participants met diagnosis of primary alcohol dependence (n = 1383)., Measurements: Primary exposures were any cannabis use and quartiles of cannabis use (Q1: 1-4 use days during treatment, Q2: 5-9 days, Q3: 10-44 days, Q4: 45-112 days). Outcomes were percentage of days abstinent from alcohol (PDA), drinks per drinking day (DPDD) and percentage of heavy drinking days (PHD), all measured at treatment end and 1 year post-treatment., Findings: Compared with no cannabis use, any cannabis use during treatment was associated with 4.35% [95% confidence interval (CI) = -8.68, -0.02], or approximately 4 fewer alcohol abstinent days at the end of treatment. This association weakened by 1 year post-treatment (95% CI = -9.78, 0.54). Compared with no cannabis use, only those in the second quartile of cannabis use (those who used once or twice per month during treatment) had 8.81% (95% CI = -17.00, -0.63), or approximately 10 fewer days alcohol abstinent at end of treatment, and 11.82% (95% CI = -21.56, -2.07), or approximately 13 fewer alcohol abstinent days 1 year post-treatment. Neither any cannabis use nor quartiles were associated with DPDD or PHD at either time-point., Conclusions: Among individuals in alcohol treatment, any cannabis use (compared with none) is related to a significantly lower percentage of days abstinent from alcohol post-treatment, although only among those who used cannabis once or twice per month., (© 2016 Society for the Study of Addiction.)