title: Alcohol Policies and Alcoholic Cirrhosis Mortality in the United States.
abstract: BACKGROUND
  Stronger alcohol policies predict decreased alcohol consumption and binge drinking in the United States. We examined the relationship between the strength of states' alcohol policies and alcoholic cirrhosis mortality rates.
  
  
  METHODS
  We used the Alcohol Policy Scale (APS), a validated assessment of policies of the 50 US states and Washington DC, to quantify the efficacy and implementation of 29 policies. State APS scores (theoretical range, 0-100) for each year from 1999 through 2008 were compared with age-adjusted alcoholic cirrhosis death rates that occurred 3 years later. We used Poisson regression accounting for state-level clustering and adjusting for race/ethnicity, college education, insurance status, household income, religiosity, policing rates, and urbanization.
  
  
  RESULTS
  Age-adjusted alcoholic cirrhosis mortality rates varied significantly across states; they were highest among males, among residents in states in the West census region, and in states with a high proportion of American Indians/Alaska Natives (AI/ANs). Higher APS scores were associated with lower mortality rates among females (adjusted incidence rate ratio [IRR], 0.91 per 10-point increase in APS score; 95% confidence interval [95% CI], 0.84-0.99) but not among males (adjusted IRR, 0.97; 95% CI, 0.90-1.04). Among non-AI/AN decedents, higher APS scores were also associated with lower alcoholic cirrhosis mortality rates among both sexes combined (adjusted IRR, 0.89; 95% CI, 0.82-0.97). Policies were more strongly associated with lower mortality rates among those living in the Northeast and West census regions than in other regions.
  
  
  CONCLUSIONS
  Stronger alcohol policy environments are associated with lower alcoholic cirrhosis mortality rates. Future studies should identify underlying reasons for racial/ethnic and regional differences in this relationship.
authors.affiliation: Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115. Email: scott.hadland@childrens.harvard.edu. Dr Hadland is also affiliated with Harvard Medical School, Department of Pediatrics, Boston, Massachusetts.
authors.forename: Scott E
authors.initials: SE
authors.lastname: Hadland
authors.affiliation: Boston University School of Public Health, Department of Community Health Sciences, Boston, Massachusetts.
authors.forename: Ziming
authors.initials: Z
authors.lastname: Xuan
authors.affiliation: Boston University School of Public Health, Department of Community Health Sciences, Boston, Massachusetts.
authors.forename: Jason G
authors.initials: JG
authors.lastname: Blanchette
authors.affiliation: Boston University School of Public Health, Department of Community Health Sciences, Boston, Massachusetts.
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Heeren
authors.affiliation: School of Public Health, Georgia State University, Atlanta, Georgia.
authors.forename: Monica H
authors.initials: MH
authors.lastname: Swahn
authors.affiliation: Boston University School of Public Health, Department of Community Health Sciences, and Boston Medical Center, Section of General Internal Medicine, Boston, Massachusetts.
authors.forename: Timothy S
authors.initials: TS
authors.lastname: Naimi
mesh_terms: D000428:Alcohol Drinking / Q000453:epidemiology / Q000331:legislation & jurisprudence*; D063425:Binge Drinking / Q000453:epidemiology / Q000331:legislation & jurisprudence*; D016000:Cluster Analysis; D003697:Delphi Technique; D005006:Ethnicity / Q000706:statistics & numerical data; D005260:Female; D006291:Health Policy; D054624:Health Status Disparities; D006801:Humans; D007198:Indians, North American / Q000208:ethnology; D004930:Inuit / Q000208:ethnology; D008104:Liver Cirrhosis, Alcoholic / Q000453:epidemiology / Q000401:mortality*; D008297:Male; D016012:Poisson Distribution; D012044:Regression Analysis; D012737:Sex Factors; D013219:State Government; D014481:United States / Q000453:epidemiology