The reduction in underage drinking and drunken driving accidents among young people is widely viewed as one of the greatest public health achievements in the United States. But data suggest that among people who are middle age, another problem involving excess drinking has been quietly brewing.

The problem is contributing to the alarming trend of white Americans dying younger than they used to. The rise was driven by drug overdoses and suicides, but also by alcohol poisoning, chronic liver disease and cirrhosis. It has been observed only in the U.S.

Anne Case and Angus Deaton, who are spouses and Princeton University economists, have found that the trend began among people ages 45 to 54 in 1999 and continued through 2013, resulting in an increase of 134 deaths per 100,000 people.

These findings and others from the Centers for Disease Control and Prevention have been used as evidence for the U.S. to accelerate its actions to combat the opioid epidemic. Congress poured funding into the effort and passed legislation to increase access to treatment. Health and Human Services Secretary Tom Price recently participated in a listening tour on opioids, and President Trump established a task force.

But when it comes to tackling alcohol misuse in middle age, the route for public health strategists has been less clear. Part of the dilemma is that, unlike opioids such as heroin, alcohol is a legal product that studies suggest can contribute to better heart health. Calls for restricting access to alcohol through taxes or other means can look a lot like Prohibition-era methods and can be damaging to the financial health of small businesses. Restrictions also can affect people who drink moderately.

To the alcohol industry, some of the calls for restrictions on alcohol availability signal their product is under fire.

"There is a concerted effort among folks in the public health industry and in the government to demonize alcohol," said Sarah Longwell, managing director of the American Beverage Institute, a trade group that represents restaurants.

For instance, long-held beliefs about the benefits of moderate drinking are becoming muddled. Public health officials in other countries increasingly are warning that alcohol is a risk factor for cancer. While the latest U.S. dietary guidelines state moderate alcohol use can be part of a healthy diet, they no longer tie it to cardiovascular benefits.

"They are suddenly coming out and saying that it leads to breast cancer and melanoma," Longwell said. "There is a massive body of research on alcohol's benefits, and then you have these small, individual studies popping up lately and grabbing headlines."

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Such studies can affect policy. Former Surgeon General Vivek Murthy, who was recently asked to resign as part of the Trump transition, released a report in November on addiction that recommended strategies for tackling alcoholism and binge drinking. It cited taxes on alcohol, limiting where alcohol can be sold and how often, and reducing marketing and advertising. To the industry, these proposals represented an anti-alcohol approach that would affect people who drink moderately.

Though the trend in the U.S. has been to loosen regulations on alcohol access, state-level restrictions involving blood alcohol content are being weighed in Hawaii and may also be considered in Washington state. Massachusetts has been cracking down on stores that sell alcohol for less than what they paid, and a bill introduced in Oregon would ban imbibing on beaches.

Various members of the public health community believe that restrictions on alcohol are an important tool for reducing alcohol-related deaths. Thomas Babor, head of the Department of Community Medicine and Health Care at the University of Connecticut, who has conducted research on alcohol restrictions, argues that the laws don't get in the way of moderate drinkers, but of impulse buyers.

"It's not the retired couple having a glass of wine in the evening with a meal that is going to be disadvantaged," Babor said. "If anything, it will prevent them from being rear-ended by a drunk driver."

Yet advocates are concerned that a war on alcohol could actually make the problem worse, while creating disadvantages for casual drinkers.

Drinking to death

U.S. dietary guidelines still say that moderate drinking for those of legal drinking age means up to one drink per day for women and two drinks per day for men. "For those who choose to drink, moderate alcohol consumption can be incorporated into the calorie limits of most healthy eating patterns," the guidelines say.

But data suggest some Americans are struggling to follow these recommendations. According to the National Institute on Alcohol Abuse and Alcoholism, an estimated 88,000 people die from alcohol-related causes annually, making alcohol the fourth-leading preventable cause of death in the U.S.

And some evidence suggests that alcohol-linked deaths are trending upward.

For instance, a recent CDC report shows that such deaths among whites grew by 50 percent from 2005 to 2015 and by 28 percent overall. The deaths range from alcohol poisonings and injuries to chronic, long-term use. While death rates were highest among Latinos, whites showed the sharpest increase.

Other patterns have been observed. A 2015 report stunned researchers when it revealed that most alcohol poisoning deaths are concentrated among middle-aged white men, not college students, as they had expected. The vast majority of these deaths had no other known substance involved.

County-by-county data compiled by the Institute for Health Metrics and Evaluation at the University of Washington found that even though the percentage of people who drink alcohol has remained relatively unchanged, those who drink are more likely to be heavy drinkers and binge drinkers. The trend, they concluded, was driven largely by women. The data show that women saw a 17.5 percent rise from 2005 to 2012 in binge drinking, which is defined as at least four drinks on a single occasion, such as over dinner or at a party, at least once during the last month. For men, the rates increased by 4.9 percent during the same time period.

Steven Schmidt, spokesman for the National Alcohol Beverage Control Association, which provides research, analytics and regulatory information regarding alcohol, said such outcomes suggest a thoughtful approach is needed.

"There is little doubt this is a product that needs to be viewed from a public health perspective," he said. "Policymakers need to balance what is in the best public health and safety interest versus the interest of the economics."

But complicating the conversation around what approach to take is that experts admit the mortality and drinking data from various sources are imperfect.

"There are areas that, if we improve our measurement, we can learn better," said Ralph Hingson, director of the division of epidemiology and prevention research at the National Institute on Alcohol Abuse and Alcoholism.

For instance, the National Survey on Drug Use and Health data show a slight rise in binge drinking among women, but also notes that changes in the methodology have occurred that make it difficult to compare with previous years.And with alcohol misuse, the evidence for chronic illness is less clear-cut than when injuries are involved, Hingson points out. For instance, a car accident involving alcohol offers clear evidence of harm, but with cancer or obesity, the cause could involve a variety of other factors. Even with injuries or overdose, the possibility that opioids were also involved raises additional questions.

"It's possible that an opioid, or some other drug, was involved in some deaths where the underlying cause was alcohol-induced," said Margaret Warner, a health scientist at the CDC's National Center for Health Statistics. "And both contributed to the death, but one is the underlying cause of death, and the other is contributory. Usually when both drugs and alcohol are involved and reported on the death certificates, the drugs are the underlying cause. It is also possible that medical certifiers may not report the alcohol on the death certificate if a potent drug, such as heroin or cocaine, is involved."

It's unclear what is driving the mortality trend. Case and Deaton have raised some possibilities that may be fueling the increase, including the notion that people are struggling with mental health issues, distress and physical pain. They noted as well that deaths were increasing primarily among people who have a high school degree or less education.

"Increased alcohol abuse and suicides are likely symptoms of the same underlying epidemic and have increased alongside it," they wrote. While they noted that the increasing mortality began before the Great Recession, they also concluded that "ties to economic insecurity are possible."

The alcohol industry said these points underscore the need to address such deaths is more complicated than implementing restrictions.

"If societal dysfunction is the problem, then the cure isn't restricting access to a product. The cure needs to be addressing something deeper within society," Longwell said.

But those who advocate for restrictions say they can be effective at reducing drinking among those who struggle with misuse. The greater the availability of alcohol, they say, the more consumption will increase.

David Jernigan, whose research at Johns Hopkins University has focused on alcohol policy, supports public health approaches toward alcohol that are similar to those that were used to combat tobacco.

"Self-medicating or having too much fun, whatever the reason is [for over-consuming], alcohol is the most readily available drug," he said. "It's not seen as a drug. It's seen as an everyday thing. Drink it at the gym, at the movie theater, get it at your local fast-food restaurant."

"We are surrounded by it, and the research is very clear," he said. "The easier alcohol is to get, in general, the more people will drink."

Babor said three factors contribute to how much a population drinks: "It's availability, availability and availability … Until you can change the expectations, norms and availability, you're not going to affect the rates of alcohol poisonings and traffic accidents."

He cited the example of the United Kingdom, which has one of the highest rates of binge drinking in the world. Several studies and health officials in the United Kingdom attribute this to the deregulation of alcohol: It can be sold at any time of day, it is inexpensive, and it is sold in many places.

But a United Kingdom analysis of the law that extended hours during which alcohol could be sold determined that findings were generally inconclusive, and government reports on drinking rates show a small decline in binge drinking in recent years as well as an increase in the proportion of people who don't drink at all.

Restrictions on alcohol

How to deal with alcohol-related deaths remains a point of contention. Those who oppose restrictions and those who support them point to studies that bolster their arguments about effectiveness.

In recent years, the U.S. largely has moved in the direction of loosening restrictions on alcohol, which many see as taking a more modernized approach. Minnesota recently passed a law to allow Sunday alcohol sales, Colorado will be gradually phasing in beer, wine and spirits into grocery stores, and Pennsylvania grocery stores will be allowed to sell beer and wine. West Virginia is allowing the sale of alcohol at 10 a.m. on Sunday, rather than 1 p.m. In Florida, a piece of legislation known as the "Take Down the Wall" bill would allow spirits to be sold alongside wine and beer in grocery stores.

"If you look deeply in the political debates, it's about an economic ideology that government shouldn't be involved in anything of this nature, and there is also this belief that people want and desire more convenience and access," Schmidt said.

The alcohol industry does support certain approaches to handling problem drinking. The Distilled Spirits Council, for instance, supports CDC guidance that directs more doctors to talk to their patients about their drinking patterns. In a recent report, the CDC found that among people who binge drink 10 or more times a month, only one in three has ever had a health professional speak with them about alcohol use. The CDC did not recommend that physicians encourage patients not to drink, but that they help patients with problem drinking habits set realistic goals.

"We support evidence-based strategies including screening and brief interventions by health professionals, which has been identified by the CDC as a critical need within the healthcare system," the Distilled Spirits Council said in an email.

The American Beverage Institute supports the use of ignition airlocks devices or Breathalyzers in cars for those with high blood alcohol content and repeat offenders. They also support a 24/7 sobriety program, in which people with alcohol problems must take a breath test to show they are sober.

"I do think there are people who have good intentions, they do want to reduce drunken driving deaths, they do want people to be healthier," Longwell said. "They just have a misguided approach. Sometimes it's a matter of things being too hard. It's too hard to get at this narrow population. It's easier to just go after alcohol in general."

The industry has raised concerns over a law recently passed in Utah, which reduced the legal blood alcohol limit from 0.08 to 0.05. The National Transportation Safety Board for the past few years has recommended this change.

For a 120-pound woman, that equates to having one glass of wine, and industry groups note that the vast majority of drunken driving accidents involve drivers who binge drink.

"That is probably the most significant attack on moderate drinking," Longwell said, noting the repercussions that could come from testing positive at such a low level: fines, possible jail time and a reputational hit that could harm employment.

"This is an anti-alcohol move, not a pro-safety move," she said.

On a global scale, the issue is getting more attention, particularly in Europe, where citizens consume more alcohol than anywhere else in the world. The World Health Organization, in response to the high rates of morbidity and mortality related to alcohol, has been recommending various strategies to curb alcohol-reated harm, some of which involve restrictions. "Studies have found that increases in prices of alcoholic beverages disproportionately reduce alcohol consumption by young people, and also have a greater impact, in terms of alcohol intake, on more frequent and heavier drinkers than on less frequent and lighter drinkers," authors wrote in a policy proposal. A similar report was drafted for the Americas in 2007, and more recent global recommendations exist.

The Distilled Spirits Council has addressed some of the proposals and has presented evidence from various studies suggesting that some of the recommendations are ineffective at deterring abuse.

Even WHO warns of the dangers of over-regulation. "Historical evaluations show that total bans on alcohol production and sales can reduce alcohol-related harm," the authors wrote. "However, where there has been a substantial demand for alcohol, it has been met during prohibition by an informal market often organized by criminal operators."

But if the trend toward alcohol-involved deaths continues in the U.S., restrictions are likely to be considered by states and to be raised by public health officials and experts as a way to fight a growing epidemic. Restrictions, public health experts say, should weigh economics and stigma, but also balance public health needs and medical costs.

"If you are going to take a look at alcohol policy like hours and density, you need to make sure you look at the science and know what you're walking into," Schmidt said. "At the end of the day this is still a substance that causes harm related to decision-making, and how much we consume is impacted by the environment, not just by personal decision making."