Eleven years ago, two days before Christmas, my 24-year-old brother, who was a university graduate and former law student, died from a self-inflicted gunshot wound. After a decade of hard and continuous drinking interspersed with addiction and mental health treatment, he could not sustain his recovery. His suicide came on the heels of my mother’s death a year before, and just weeks later, my grandfather died in a car accident. My family’s holidays would never be the same.
Like so many others who survived the loss of someone dear from the chaos of severe substance use disorder (SUD), I am too familiar with unspeakable grief. But I have found meaning through it and purpose in passing that on.
I was a medical resident when I dropped my brother off at an addiction treatment facility for the first time. Later, I became an addiction specialist physician, focusing on treating people with SUD and helping them manage their disease and find remission and recovery. My work has taught me something important: To help stop the addiction crisis that has brought so much sorrow to families like mine, policymakers must prioritize prevention at all levels and support evidence-based prevention initiatives — including raising federal excise taxes on alcohol.
Experiencing social adversity, such as structural inequities and childhood trauma, creates vulnerability to behavioral risks for harmful substance use and SUD. My brother, who moved from high school to high school due to our many relocations, struggled to make lasting friendships. As a freshman, he started to use alcohol for entry into teenage social circles. When he was banned from playing football his junior year due to a recruiting regulation, it caused a crisis in his young identity. He continued to use alcohol to cope with our mother’s illness. Only now do I fully appreciate that my brother did not have the benefit of many of the factors that help protect youth from the harms of alcohol use and the development of alcohol use disorder (AUD).
Alcohol-related causes are the nation’s fourth leading cause of preventable death. At the federal level, policies can be enacted that not only protect our families but also generate significant revenue, which can be used to support efforts to increase access to evidence-based addiction treatment. Vastly underutilized levers can deter alcohol use by reducing consumer demand through higher prices. One of these is the federal excise tax on alcoholic beverages, which has not been increased since 1991.
In 1991, a doubling of the beer tax, combined with an increased tax on wine from 17 cents to $1.07 per gallon and on liquor from $12.50 to $13.50 per proof gallon, increased alcohol prices by 6%, which reduced related injury deaths by 4.7% across the U.S. In high-income countries like ours, the inverse relationship between higher prices and drinking prevalence, frequency, and intensity decreases harms of excessive drinking, like car accidents and fatalities, deaths from liver cirrhosis, alcohol dependence, and other diseases caused by excessive drinking, crime and violence, and workplace accidents. A recent analysis on the World Health Organization European Region — which has the highest level of alcohol consumption of all WHO Regions — notes there is strong and compelling evidence in Europe that increasing the price of alcoholic beverages through taxation is one of the most effective (and cost-effective) policies used to lower alcohol-attributable harm. Just this month WHO released new data on the low rate of global taxes being applied to alcohol and found that the majority of countries are not using taxes to incentivize healthier behavior. To help support those countries, WHO is releasing guidance on how to implement alcohol tax policy.
A lot has changed in the U.S. since 1991 — but federal alcohol taxes have not increased. Because the legislation President George H.W. Bush signed at the time did not index it to inflation, alcohol tax rates actually dropped a whopping 36% in the years to 2017. Rates are now surely even lower in real terms given the inflation we’ve seen since the beginning of the pandemic (a time period which corresponds to a significant rise in alcohol-related deaths). Though the U.S. has some of the lowest alcohol excise taxes in the OECD, in 2020, Congress actually passed federal alcohol excise tax relief.
In December 2022, the Congressional Budget Office described promising options for increasing federal excise taxes on alcoholic beverages which could create billions in new federal revenue over nine years. In our country, this revenue should be used to build an addiction treatment infrastructure that meets the magnitude of today’s crisis and helps to prevent the next one.
My young son recently had a profound insight when he told me, “I think the reason some people use drugs is to steal happiness from tomorrow for today.” For my brother, he reached a point where his tomorrow had no happiness left. Indeed, SUD brings higher risk of dying by suicide and that risk dramatically increases with severity.
I would love to tell my kids that our country has taken meaningful steps towards prevention, like enacting a higher federal alcohol excise tax to improve and save the lives of people like their uncle. Tax money, appropriately allocated to increase treatment funding, may have funded access to treatment for my brother, who was never offered FDA-approved medications to treat his alcohol use disorder. Increased alcohol costs deter youth, who are often “opportunistic” users. When the cost becomes prohibitive, they cannot drink.
With such overwhelming evidence of the benefits of substance use prevention, advancing policy in this area, including by increasing the federal alcohol excise tax, which is decades overdue, will give more people their tomorrows.
If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.
Cara Poland is an addiction medicine physician at Michigan State University College of Human Medicine. She is a member of the Board of Directors for the American Society of Addiction Medicine and chair of its public policy committee.