Six Steps to Improve Public Health: Using Tax Policies to Reduce Alcohol-Related Harm in Maryland

Legal and policy approaches can be important tools for achieving healthier communities. Resources from the Healthy People 2020 Law and Health Policy project provide evidence-based information and identify priority areas that can help communities achieve Healthy People objectives and improve health for all.

This Bright Spot describes how Vinny DeMarco and David Jernigan collaborated with partners to pass an alcohol sales tax in Maryland.

Challenge: Alcohol use is common and can be dangerous

Alcohol use is very common in the United States. Nearly 70% of Americans age 18 and older report drinking alcohol in the past year¹—and for some, this leads to negative health outcomes. About 90,000 people die from alcohol-related causes each year,² making reducing alcohol use a national public health priority. Alcohol also contributes to other health problems like heart disease and certain cancers.³

In Maryland, alcohol was responsible for about 1,300 deaths per year from 2006 to 2010,⁴ and it played a role in many violent crimes. Measures like educating the public and providing substance abuse treatment weren’t reducing these numbers, so experts decided to focus on a policy approach: increase alcohol sales taxes.

Strategy: Six steps to pass an alcohol sales tax

In 2007, the Community Preventive Services Task Force found that increasing alcohol taxes was an effective approach to reducing excessive alcohol consumption and related harms.⁵ But in spite of the evidence base for this strategy, it has often proved difficult to get these taxes in place. For example, in 2010 advocates in at least 23 states attempted to pass alcohol sales taxes—all without success.⁶

But in 2011, Vinny DeMarco of the Maryland Health Care for All! Coalition and Dr. David Jernigan of the Johns Hopkins Bloomberg School of Public Health were able to change that in Maryland. They worked with partners to successfully advocate for increasing Maryland’s sales tax on alcoholic beverages.

DeMarco assembled a statewide coalition, organized rallies, and generated media coverage—demonstrating widespread public support for raising alcohol taxes to help reduce alcohol-related harms. Meanwhile, Jernigan gathered data to support the policy. To pass the tax, the coalition followed a 6-step approach that DeMarco had created to move health policy through the legislature and overcome concerns from industry and partners—including lobbyist opposition.⁷

1. Develop a policy approach to improve a public health problem. In this case, the policy was increasing statewide alcohol sales taxes in Maryland. Jernigan provided supporting evidence for this approach with 2 research reports.
2. Establish public support before bringing the issue to the legislature. Jernigan’s research gained media attention, and the coalition polled voters to learn their views on the proposal. "We made it clear that these taxes would help make a difference in the community. It’s easy to get public support when people know the taxes would go to a good cause,” says DeMarco.
3. Build a powerful coalition with partners committed to the cause. DeMarco and Jernigan relied on members of the faith community, policymakers, and organizations like the Service Employees International Union, Maryland Developmental Disabilities Coalition, National Council on Alcoholism and Drug Dependence, the American Association of Retired Persons, and the National Association for the Advancement of Colored People. 
4. Use the media to get the message out. “Alcohol taxes save lives” is the message DeMarco and Jernigan pushed out through earned and paid media (unpaid media placements) in Maryland.
5. Turn the issue into an election talking point so voters know which candidates endorse the popular bill. In Maryland, this proved very successful—most of the winning candidates had publicly supported the tax increase.
6. Provide compelling evidence from experts and engaging testimony from community and coalition members. Jernigan achieved this by sharing results from modeling the potential impact of the tax on alcohol use and health in Maryland. Coalition members also shared powerful personal testimony.

Even with this strategic approach, the coalition faced challenges from an influential opponent. “The alcohol lobby is powerful,” DeMarco says, “But once we opened the campaign to the general public, we were able to overcome them.” He stresses that almost any challenge can be tackled with strong evidence, a strong coalition, and public engagement.

Impact: Maryland’s first increase in alcohol taxes in decades

The 2011 tax on the price of an alcoholic drink was the state’s first increase in beer and wine taxes in almost 4 decades, and first increase in liquor taxes in more than 5 decades.⁸ After the sales tax took effect, statewide alcohol sales decreased by 3.8% compared to what trends predicted.⁹ And the state raised about $70 million in additional tax revenue in a single year, which helped fund education programs and services for people with disabilities.

“Passing the alcohol sales tax was a win-win,” DeMarco says. “We did something politically popular that also brought money into the state.” And after the tax was implemented, Maryland rates of motor vehicle crashes involving a driver who’d been drinking gradually decreased by 6% across all ages—and 12% in drivers ages 15 to 34.¹⁰

Other states have successfully increased alcohol taxes using different approaches, like promoting unique messaging, giving the tax varying levels of media attention, and engaging legislators in different ways. But each approach had 2 things in common: broad public support and strong, passionate coalitions.

Looking Ahead: Using the Six Steps to pass health policies nationwide

DeMarco and Jernigan believe that the Six Steps can help build a strong foundation when working on any new public health policy. In fact, DeMarco has used the Six Steps to pass a tax on tobacco in Maryland, as well.¹¹

The pair also thinks that increasing alcohol sales taxes could help reduce alcohol-related harms nationwide. They note that it’s important to calculate the cost of alcohol-related problems. “The narrative is often about how alcohol can revitalize cities by boosting the local economy,” Jernigan says. “But we don’t always consider the cost.” Alcohol-related harms cost the United States $2.05 per standard drink¹²—yet the median state and federal alcohol taxes are just $.21 per drink.¹³

When they reflect on their collaborative success in Maryland, DeMarco and Jernigan say they really complemented each other—DeMarco as the “strategist and organizer” and Jernigan as the “expert.” Their mutual respect is clear, and the relationship is an important reminder that public health wins often depend on a strong team that works together toward a common goal.

About the Law and Health Policy Project

The goal of the Healthy People Law and Health Policy project was to highlight how evidence-based legal and policy interventions and strategies can facilitate progress toward Healthy People 2020 targets by improving community health and well-being. In addition to reports and webinars, the project included "Bright Spots," or success stories, that highlighted successful policy interventions that led to improved health outcomes. The project was a collaboration between the HHS Office of Disease Prevention and Health Promotion (ODPHP), the Centers for Disease Control and Prevention (CDC), the CDC Foundation, and the Robert Wood Johnson Foundation.