The estimates of the mean %ABV of beer, wine, and spirits for each state and the District of Columbia for selected years are presented in Table 3. The mean %ABV of each beverage type are seen to vary by state in each year, reflecting the variation in preferences and mean %ABV for each beverage sub-type across states and time. All states and the District of Columbia showed an increase in the mean %ABV of beer between 2003 and 2016, and most states followed the national trend. The states with the least amount of change over the 2003-2016 period were North Dakota, Virginia, and Iowa with percent increases of 1.2%, 1.1%, and 0.9%, respectively, while New Mexico, Montana, and Maine experienced the greatest percent increases of 4.9%, 4.4%, and 4.3%, respectively. For wine, all states showed an increase in mean %ABV and followed the national trend. The states with the greatest increases between 2003-2016 were Idaho, Virginia, and Tennessee with increases of 6.8%, 6.8%, and 6.7%, respectively. The states with the lowest percent change were Illinois, North Carolina, and Mississippi with increases of 3.1%, 3.0%, and 2.9%, respectively. For spirits, 45 states and the District of Columbia showed increases in the mean %ABV of spirits, and of these the vast majority followed the national trend. Ohio, Rhode Island, and Nebraska had the largest percent increases at 10.5%, 7.9%,and 6.6%, respectively, while West Virginia, Mississippi, and Alabama had the largest decreases in %ABV for spirits of 0.4%, 0.5%, and 1.8%, respectively. State mean %ABVs and market shares for beverage sub-types. The change in the mean %ABV of beer, wine, and spirits was driven by changes in beverage sub-type mean %ABVs and preferences, and these %ABVs and preferences varied by state. To describe these state-level beverage sub-type %ABV and preference changes in relation to state-level changes in mean beverage-specific %ABV,horticulture solutions we present data for the states with the largest change in mean %ABV for each beverage type.
The increase in %ABV of beer for New Mexico, which had the largest percent increase of 4.9%, is attributable to a decline in the market shares of beer with relatively low mean %ABV and an increase of relatively higher mean %ABV beer sub-types. Between 2006 and 2016 the market shares of light beer declined from 51.5% to 37.6%. The market shares of the super premium, micro/specialty, and FMBs sub-type category increased from 6.8% in 2006 to 11.9% in 2010, and between 2011 and 2016 the market shares of craft beer increased from 8.2% to 14.9%. Similar to the national trends in the mean %ABV of wine, state-level trends were driven by the increase in the mean %ABV and the market shares of table wine. Idaho, which had the largest percent change in mean %ABV of wine of 6.8%, had the largest market share of table wine for most years between 2003 and 2016, where market shares of table wine were 97.3% in 2003 and 97.4% in 2016. Comparable to national trends in the mean %ABV of spirits, state level trends were driven by declines in the market shares of low %ABV spirit sub-types and increases in high %ABV spirit sub-types. Between 2003 and 2016, Ohio had the largest increase in mean spirits %ABV of 10.5%. Unlike the national trend, it showed a marked increase between 2012 and 2014 after which it leveled off. The increase in %ABV between 2012 and 2014 was driven by a decline in the market shares of prepared cocktails from 9.3% in 2012 to 0.2% in 2014 and a concomitant increase in the market shares of cordials and liqueurs, straight whiskey, tequila, and brandy & cognac. The new beverage-specific %ABV-variant PCC estimates for selected years for each state are presented in Table 3. The estimates varied by state while trends for each beverage type were consistent across states. The total PCC estimates for each state with comparisons to AEDS estimates for 2003 and 2016 are presented in Table 4. The estimates varied by state in each year, representing the range in total PCC by state. Table 4 also shows the percent change in total PCC for each state for both our new estimates and the AEDS estimates. The ranking by percent change varies by the new and AEDS estimates. North Dakota has the largest percent change in total PCC according to both estimates, however, the new estimates rank Vermont second followed by Idaho while the AEDS estimate rank Idaho second followed by Vermont.
The vast majority of states showed an increase in total PCC, although 2 more states, Nebraska and Illinois, showed a decline according to AEDS estimates than did according to our new estimates. For all beverage types, our mean %ABV estimates increased nationally and for all but five states. These increases were driven by an increase in national and state preferences for beverages with a higher and increasing %ABV and a decrease in preferences for lower %ABV beverages. The estimates of PCC from wine and spirits utilizing variable %ABV conversion factors were lower than AEDS estimates, while consumption from beer was higher. While our total PCC estimates were also lower than AEDS estimates, the trends in PCC showed a more dramatic increase in pure alcohol volume than those using ABV-invariant methods. Researchers have used PCC estimates to try to understand the observed increases in alcohol-related morbidity and mortality in the U.S. over the first part of the 21st century. For example, White et al noted an increase of 1.7% in PCC and concluded that it did not appear to be related to the 47% increase in the rate of alcohol-related ED visits from 2006 to 2014 . Using our ABV variant method, PCC between 2006 and 2014 increased by 3.6%, over double the increase using the ABV invariant method. This difference and the absolute increase using the ABV variant method may not alone explain the increase in the rate of alcohol-related ED visits. However, because the change in PCC was likely underestimated, it suggests PCC should not be dismissed and may be one of many factors driving the increase in alcohol-related emergency room visits. This example also highlights the importance of the rate of change in PCC trends,grow shelving and is consistent with findings from an Australian study that similarly showed the value of including time-varying ABV values to ensure precision in PCC estimates so change over time can be accurately measured . It is important to note that cohort and lag effects may also be drivers of the disparity between changes in alcohol-related morbidity and mortality and changes in PCC.
Cohort effects may be related in that previous generations may have been drinking at high levels that resulted in death from alcohol-related diseases so that their alcohol consumption would not be included in current PCC estimates . Lag effects may contribute because the time from changes in PCC to the time to first effect for some alcohol-attributable diseases, such as alcohol-related cancers, is at least 10 years . These effects could result in temporally distinct yet still related changes between PCC and changes in alcohol-related morbidities. There are many reasons why the precision of PCC estimates matters. First, the Tax Cuts and Jobs Act of 2017 reduced excise taxes on all alcoholic beverages. A large body of evidence shows that decreases in alcohol taxes can result in increases in alcohol consumption , which can give rise to alcohol-related morbidity and mortality . If there is a further and continued increase in alcohol consumption by the U.S. population over age 15, then further increases in alcohol-related problems may be forthcoming, such as traffic accidents and suicides . Second, the recent legalization of recreational cannabis in many states is of concern in an environment of increasing alcohol use because of the negative impact of simultaneous cannabis and alcohol use, such as drunk driving, social consequences, and harms to self . Third, recent national surveys report a decline in both any alcohol use and binge drinking among youth , suggesting that the noted increase in PCC is due to more alcohol use and binge drinking among middle-aged and older adults. Indeed, recent surveys have observed an increase in self-reported past-month binge drinking and AUD among adults aged 50 and older , and an increase in alcohol-related emergency department visits . This is cause for concern because older adults are more likely to have various co-morbidities and to use medication that contraindicates the use of alcohol. Finally, the national surveys and meta-analysis that showed an increase in binge drinking generally may be particularly concerning if the alcohol content of the beverages being consumed is higher than previously assumed as this may increase the likelihood of negative alcohol-related consequences. This work has limitations that should be considered when interpreting our results. The estimate for PCC from wine may have been underestimated from 2012 to 2016 since we carried forward the %ABV value for 30% of total sales volume from 2011 to 2016 instead of calculating from actual wine %ABV values. This change in methodology was due to changes in the availability of data, which also highlights the challenge of this methodology to identify adequate and reliable sources of information. Relatedly, how we calculated the mean %ABV of wine by identifying the leading brands of wine based on sales in Pennsylvania only is a limitation because it does not represent sales nationally. Since only general brands and not individual brands are reported nationally it is not possible to determine if using leading individual brand sales of wine in Pennsylvania would result in an over or underestimate of the mean %ABV of wine and thus its impact on PCC wine estimates.
Regarding the %ABV of all alcoholic beverages, the %ABV value taken from producer reports or websites may not accurately reflect the actual amount of alcohol. This is less likely for spirits which are taxed based on alcohol content at the federal level, but may still be relevant for beer and wine which are not routinely tested by independent authorities, except in regard to labelling where considerable error is allowed. Regarding other components of the calculation of PCC estimates, population estimates may also represent another source of error as certain under counted groups, often rural and/or racial/ethnic minorities, and those not included in the population such as foreign tourists and undocumented immigrants, may comprise a greater proportion of the population in recent years . The alcohol sales data may also have error due to unaccounted for changes in reporting practices over time, variation by state, and the time delay between actual consumption and the publication of state tax records . Moreover, alcohol sales data will not include unrecorded consumption from illicit production, importation, and sales. Fortunately, unrecorded consumption is likely minimal due to substantial decreases in illicit alcohol production in the U.S. since the 1970s . Similarly, cross-state sales are also present but not likely to have a significant impact on consumption estimates . However, these factors are a reality and may introduce inaccuracies into our PCC estimates . Finally, the likely errors in each component of the PCC calculation, that is, the alcohol sales figures, the %ABV values, and population estimates, would result in errors in the PCC estimates. Since these error values are unknown, however, statistical tests of differences between ABV-variant and ABV-invariant PCC estimates are not feasible. It is noteworthy that the population estimates and alcohol sales data are also components of the AEDS methodology such that the same errors are included in our PCC estimates. Further, the errors in the estimates of components of the PCC calculation beyond the %ABV values represent other possibilities for improving the precision of PCC estimates, such that refinements in alcohol sales figures and population estimates could improve PCC calculations. These refinements, however, would necessitate changes in the reporting and collection of these data, which would likely be more cumbersome than including data on annual changes in %ABV values of beer, wine, and spirits. The inclusion of time-varying %ABV in the calculation of PCC estimates showed increasing %ABVs for all beverage types, preferences for beverages with higher and increasing %ABV, and a greater increase in PCC estimates compared to those using time invariant %ABV values.