Could temporarily taking away some people's right to drink — after they get in trouble with the law due to alcohol — save lives?
That's the question behind a major new study from RAND Corporation researchers, published in Lancet Psychiatry on Tuesday night. The study examines the 24/7 Sobriety program in South Dakota — and its impact at the county level.
The findings are astounding. RAND researchers found that at the county level, the 24/7 Sobriety program was associated with a 4.2 percent decrease in average adult mortality rates. Not all these deaths were conclusively alcohol-related, but they at least correlated strongly with the implementation of the program at the county level.
The program came about as a result of efforts to reduce South Dakota's incarceration rates, after Gov. Mike Rounds in 2003 set up a task force to reduce the state's prison population. Since alcohol was a factor in so many arrests, the commission homed in on reducing alcohol misuse as one way to lower the prison population. Attorney General Larry Long took up the idea, embracing the innovative 24/7 Sobriety program in 2005.
So far, the RAND study shows the program is working. The findings aren't definitive — the researchers caution that further studies are necessary to evaluate just how much of the 4.2 percent drop in mortality is attributable to the program. But the study gives a lot of credence to a fairly innovative policy, suggesting it might be something that other places in the US want to consider.
The 24/7 Sobriety program essentially revokes someone's right to drink
The 24/7 Sobriety program kicks in when someone demonstrates irresponsible use of alcohol — by, for example, drunk driving or other alcohol-related offenses.
When that occurs, a South Dakota judge can order someone into temporary sobriety, which is enforced with tests for alcohol in someone's system.
Law enforcement have various ways to carry out such evaluations, including twice-a-day, in-person breathalyzer tests and a bracelet that can track blood alcohol level. But the idea is to always punish a violation or a missed test with a night or two in jail — to create a very credible deterrent.
The deterrent apparently works really well: Participants passed more than 99 percent of breathalyzer tests.
The program does not replace treatment. Judges can order offenders to attend both treatment programs and 24/7 Sobriety. So treatment would conceivably help someone learn how to stay off alcohol, and 24/7 Sobriety would enforce it.
The idea is someone will have to quit drinking under the program — or else go to jail
Nearly 17,000 individuals — about 3 percent of the state's adult population — were in 24/7 Sobriety from June 2005 to June 2011, according to the study. They were in the program for around four to six months on average.
Some people will, undoubtedly, take issue with the government revoking someone's right to drink. But the government already takes this kind of action for other rights, from driving to guns, when someone proves incapable of handling the responsibility that comes with them.
"For driving, people will take a test and get a license — but if you drive recklessly, we can take away your license to drive," Beau Kilmer, who co-authored the latest study, previously told me. "So I've been thinking about this with respect to your 'license' to consume alcohol."
There are other concerns. For one, cost: It is one thing to implement this program in a state with 850,000 people, but how could it work in a much larger state that will need much more enforcement? And there are worries about race: With large racial disparities all throughout the criminal justice system, this type of program could disproportionately revoke minority Americans' right to drink.
The latest RAND study does not address these concerns — and, indeed, no one may be able to unless the program expands to larger, more diverse states. But the study does suggest that, at least in South Dakota, the program can have massive benefits, and those benefits may outweigh the costs.
The latest study found a big drop in mortality following 24/7 Sobriety
To evaluate 24/7 Sobriety's effects, RAND researchers Nancy Nicosia, Beau Kilmer, and Paul Heaton looked at county data from January 2000 to June 2011 in South Dakota to evaluate changes in deaths after counties adopted the program. (The program began in 2005, but counties didn't take it up all at once, providing a natural experiment for researchers.)
Specifically, the researchers looked at total deaths and deaths resulting from external injuries, circulatory disorders, and digestive disorders — all issues that can be linked to alcohol. They also threw in cancer "as a potential placebo." (Some cancers are linked to alcohol, but not enough that an anti-alcohol program should have a big impact.)
The conclusion: 24/7 Sobriety was associated with a 4.2 percent drop in all-cause adult mortality, particularly among women and individuals older than 40. Most convincingly, the program was especially associated with a reduction in deaths due to circulatory disorders, which can be linked to alcohol use.
24/7 Sobriety was associated with a 4.2 percent drop in all-cause adult mortality
Other measures did not show statistically significant declines at a 5 percent threshold (a strict statistical standard), but there was a drop in external injury deaths at a 10 percent threshold (a less strict statistical standard).
Still, the authors acknowledged that further research — that uses randomized controlled trials and individual-level data — is needed to validate the findings.
One big gap in this study is how the program led to such a dramatic drop in deaths: Is alcohol linked to more deaths than we know, and did 24/7 Sobriety prevent and deter problematic drinking that would lead to those deaths? Or is something else happening in these counties that isn't directly related to 24/7 Sobriety?
The researchers attempted to control for other factors — including unemployment and snowfall — that could influence the figures, but it's possible unrelated variables still slipped through and influenced the analysis.
Still, the study isn't the first to link major benefits to 24/7 Sobriety. A 2013 study, also from RAND, linked the program to a 12 percent reduction in repeat DUI arrests and a 9 percent reduction in domestic violence arrests at the county level in South Dakota.
Alcohol is a big public health issue — and other policies can help
There's a reason researchers are looking into policies that treat alcohol as a serious public health concern: Alcohol is a serious public health concern.
About 88,000 Americans died on average each year from alcohol-related causes from 2006 to 2010, according to the Centers for Disease Control and Prevention. And that estimate doesn't account for the rise in alcohol-related deaths over the past several years from direct health consequences, or the alcohol-linked crimes and millions of emergency room visits each year that don't result in deaths.
But the 24/7 Sobriety program isn't the only way to save lives from alcohol-related deaths. Here are some other examples:
- A 2015 review of the research by David Roodman, senior adviser at the Open Philanthropy Project, found that increasing the alcohol tax to raise the price of alcohol by 10 percent could save as many as 6,000 lives from liver cirrhosis each year. (To put that in context, paying about 50 cents more for a six-pack of Bud Light could save thousands of lives.)
- The research shows that a higher drinking age can save lives by limiting young people's access to alcohol. And there's no evidence for the claim that higher drinking ages lead to binge drinking as people stash booze to secretly consume all at once.
- A 2014 report from the RAND Drug Policy Research Center suggested state-run alcohol stores (like those in Ohio and Virginia) kept prices higher, cut access to youth, and reduced overall levels of use.
- A 2009 review of the evidence published in the American Journal of Preventive Medicine also found that limiting the number of alcohol outlets in an area can limit problematic drinking and its dangers. But it also found that going too far can have negative results — by, for example, causing more car crashes as people take long drives to outlets and possibly drink before returning home.
As promising as these ideas are, the RAND study suggests the 24/7 Sobriety program can have really strong effects — potentially reducing mortality by 4.2 percent. Mark Kleiman, a drug policy expert at New York University's Marron Institute, noted that if that figure is right and the program can be applied to similar success on a national scale (big ifs, to be sure), 24/7 Sobriety could save 100,000 lives nationwide each year.
Still, the research on the 24/7 Sobriety program is still early — and it definitely needs to be tested in denser, more diverse places in the US. But RAND's latest study is a very promising start — and there are other policies lawmakers can use until South Dakota's program is definitively proven to work across the country.