Title: Drink Specials, Drink Special Laws, and Fatal Motor Vehicle Crashes in the United States
Description: The adverse health and safety consequences of excessive alcohol consumption are a leading problem around the world. Alcoholic beverages are a routine part of socializing in many societies. However, alcohol is also a significant contributor to worldwide morbidity, disability, and mortality. To lessen the harm produced by alcohol, governments have adopted different alcohol control policies. These control policies can be group into four basic strategies: deterrence, prevention, communications and outreach, and alcohol treatment. Among the prevention measures, restricting physical access to alcohol by limiting the alcohol outlets' density, raising the legal age to purchase alcohol, and reducing the affordability of alcohol through taxation have been extensively shown as cost-effective and feasible measures against alcohol-related harms. However, there are still topics related to the affordability of alcohol that have not been investigated. The role of promotional price practices at on-premises alcohol outlets on health and social outcomes, and the effects of policies enacted to prevent these practices on motor vehicle crashes remained an unexplored research topic.

The main goals of this dissertation were to summarize evidence regarding the health effects of drink specials and to estimate the effects of policies restricting drink special practices as preventive tools for fatal motor vehicle crashes. Specifically, I summarized the research evidence of the effects of drink special practices on health and social outcomes (Aim 1). I examined the association between drink special laws and alcohol-related fatal motor vehicle crashes contrasting results for two methodological approaches, difference-in-difference-in-differences (Aim 2) and synthetic controls (Aim 3). This dissertation contains five chapters. The introduction in chapter one provides a background review of relevant literature that serves as the conceptual framework for this dissertation and an overview of chapters two, three, four, and five. The systematic review of the literature relevant to Aim 1 is presented in chapter two. This review included studies on the effects that drink specials and drink special laws have on alcohol consumption, binge drinking, and alcohol-related harms.

Twelve studies examined the effect of drink specials in seven countries between 1978 and 2018. Consistent evidence supported associations between drink specials and increased alcohol consumption, heavy drinking, alcohol intoxication, and other alcohol-related outcomes. For aims 2 and 3, I examined 36-years of data from the U.S. Department of Transportation, Census Bureau, and NIH’s Alcohol Policy Information System and National Institute on Alcohol Abuse and Alcoholism from 1982 to 2017. In chapter three, I presented results from difference-in-difference-in-differences analyses of the effects of implementing six drink special laws on alcohol- and non-alcohol-related motor vehicle fatal crash rates in the United States (U.S.). I assessed exposure to implementation as any law, number of laws, and each law. Random effects generalized least squares regression models adjusted for the proportion of males in the state, youth involved in fatal crashes, gallons of ethanol per capita among the population age 21 years and older, and autonomy index were fitted across 24 treated and 18 non-treated states.

Results revealed that the implementation of any drink special law was associated with reductions in overall and alcohol-related fatal crash rates compared to untreated states. Also, drink special laws mitigated incremental rates of non-alcohol related crashes among treated states with any drink special law compared to untreated states. In chapter four, I presented results from synthetic control analyses for single and multiple treated units. I assessed the association between drink special laws and alcohol-related fatal motor vehicle crashes and adjusted for the same covariates as in chapter three. Results in chapter four indicated that states treated with any drink special law reduced alcohol-related fatal crash rates only in years three, five, and ten post-implementation compared to the synthetic control trend. The effects of any drink special law were more consistent at different times in the post-implementation for reducing non-alcohol-related fatal crash rates than the synthetic control trend.

Findings for the number of laws implemented and each drink special laws were mixed. Chapter five presents a synthesis and discussion of findings in chapters two, three, and four, as well as policy recommendations for stakeholders and future research.