Policy matters| Volume 29, ISSUE 3, P213-221, May 2019

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State Policies Targeting Alcohol Use during Pregnancy and Alcohol Use among Pregnant Women 1985–2016: Evidence from the Behavioral Risk Factor Surveillance System

Published:March 12, 2019DOI:



      Most states have at least one policy targeting alcohol use during pregnancy. The public health impact of these policies has not been examined. We sought to examine the relationship between state-level policies targeting alcohol use during pregnancy and alcohol use among pregnant women.


      Data include state-level alcohol and pregnancy policy data and individual-level U.S. Behavioral Risk Factor Surveillance System data about pregnant women's alcohol use from 1985 to 2016 (N = 57,194). Supportive policies include mandatory warning signs, priority substance abuse treatment, reporting requirements for data and treatment purposes, and prohibitions on criminal prosecution. Punitive policies include civil commitment, Child Protective Services reporting requirements, and child abuse/neglect. Analyses include logistic regression models that adjust for individual- and state-level controls, include fixed effects for state and year, account for clustering by state, and weight by probability of selection.


      Relative to having no policies, supportive policy environments were associated with more any drinking, but not binge or heavy drinking. Of individual supportive policies, only the following relationships were statistically significant: mandatory warning signs was associated with lower odds of binge drinking, and priority treatment for pregnant women and women with children was associated with higher odds of any drinking. Relative to no policies, punitive policy environments were also associated with more drinking, but not with binge or heavy drinking. Of individual punitive policies, only child abuse/neglect was associated with lower odds of binge and heavy drinking. Mixed policy environments were not associated with any alcohol outcome.


      Most policies targeting alcohol use during pregnancy do not seem to be associated with less alcohol consumption during pregnancy.
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        • Alvik A.
        • Torgersen A.M.
        • Aalen O.O.
        • Lindemann R.
        Binge alcohol exposure once a week in early pregnancy predicts temperament and sleeping problems in the infant.
        Early Human Development. 2011; 87: 827-833
        • Armor D.J.
        • Polich J.M.
        Measurement of alcohol consumption.
        in: Pattison E.M. Kaufman E. Encyclopedic Handbook of Alcoholism. Gardner Press, New York1982: 72-80
        • Centers for Disease Control and Prevention (CDC)
        Behavioral Risk Factor Surveillance System.
        Date accessed: February 26, 2019
        • Centers for Disease Control and Prevention (CDC)
        Alcohol use among pregnant and nonpregnant women of childbearing age - United States, 1991-2005.
        MMWR: Morbidity and Mortality Weekly Report. 2009; 58: 529-532
        • Centers for Disease Control and Prevention (CDC)
        Alcohol use and binge drinking among women of childbearing age--United States, 2006-2010.
        MMWR. Morbidity and Mortality Weekly Report. 2012; 61: 534-538
        • Children & Family Futures (CFF)
        Implementation of CAPTA as a policy and practice tool to reduce the impact of prenatal alcohol exposure: Points of agreement.
        • Chavkin W.
        • Wise P.H.
        • Elman D.
        Policies towards pregnancy and addiction. Sticks without carrots.
        Annals of the New York Academy of Science. 1998; 846: 335-340
        • Cil G.
        Effects of posted point-of-sale warnings on alcohol consumption during pregnancy and on birth outcomes.
        Journal of Health Economics. 2017; 53: 131-155
        • Drabble L.A.
        • Thomas S.
        • O'Connor L.
        • Roberts S.C.
        State responses to alcohol use and pregnancy: Findings from the Alcohol Policy Information System (APIS).
        Journal of Social Work Practice in the Addictions. 2014; 14: 191-206
      1. Eloise Anderson, et al v. Tamara M. Loertscher. No. 2328, 137 (S Ct 2017).

        • Friedman A.S.
        • Schpero W.L.
        • Busch S.H.
        Evidence suggests that the ACA's tobacco surcharges reduced insurance take-up and did not increase smoking cessation.
        Health Affairs (Millwood). 2016; 35: 1176-1183
        • Gomez L.E.
        Misconceiving mothers: Legislators, prosecutors, and the politics of prenatal drug exposure.
        Temple University Press, Philadelphia1997
        • Greenfield T.K.
        • Graves K.L.
        • Kaskutas L.A.
        Long-term effects of alcohol warning labels: Findings from a comparison of the United States and Ontario, Canada.
        Psychology & Marketing. 1999; 16: 261-282
        • Hankin J.R.
        • Sloan J.J.
        • Firestone I.J.
        • Ager J.W.
        • Sokol R.J.
        • Martier S.S.
        A time series analysis of the impact of the alcohol warning label on antenatal drinking.
        Alcoholism, Clinical and Experimental Research. 1993; 17: 284-289
        • Kerr W.C.
        • Williams E.
        • Greenfield T.K.
        Analysis of price changes in Washington following the 2012 liquor privatization.
        Alcohol & Alcoholism. 2015; 50: 654-660
        • May P.A.
        • Gossage J.P.
        Estimating the prevalence of fetal alcohol syndrome: A summary.
        Alcohol Research & Health. 2001; 25: 159-167
        • May P.A.
        • Gossage J.P.
        • Marais A.S.
        • Hendricks L.S.
        • Snell C.L.
        • Tabachnick B.G.
        • Viljoen D.L.
        Maternal risk factors for fetal alcohol syndrome and partial fetal alcohol syndrome in South Africa: A third study.
        Alcoholism, Clinical and Experimental Research. 2008; 32: 738-753
        • McGeary K.A.
        The impact of state-level nutrition-education program funding on BMI: Evidence from the Behavioral Risk Factor Surveillance System.
        Social Science & Medicine. 2013; 82: 67-78
        • Meyer-Leu Y.
        • Lemola S.
        • Daeppen J.B.
        • Deriaz O.
        • Gerber S.
        Association of moderate alcohol use and binge drinking during pregnancy with neonatal health.
        Alcoholism, Clinical and Experimental Research. 2011; 35: 1669-1677
        • Murphy S.
        • Rosenbaum M.
        Pregnant women on drugs: Combating stereotypes and stigma.
        Rutgers University Press, New Brunswick, NJ1999
        • Naimi T.S.
        • Blanchette J.
        • Nelson T.F.
        • Nguyen T.
        • Oussayef N.
        • Heeren T.C.
        • Xuan Z.
        A new scale of the U.S. alcohol policy environment and its relationship to binge drinking.
        American Journal of Preventive Medicine. 2014; 46: 10-16
        • National Institute on Alcohol Abuse and Alcoholism
        Alcohol Policy Information System.
        Date: 2016
        Date accessed: January 25, 2017
        • O'Leary C.M.
        • Bower C.
        Guidelines for pregnancy: What's an acceptable risk, and how is the evidence (finally) shaping up?.
        Drug and Alcohol Review. 2012; 31: 170-183
        • O'Leary C.M.
        • Nassar N.
        • Kurinczuk J.J.
        • Bower C.
        The effect of maternal alcohol consumption on fetal growth and preterm birth.
        British Journal of Obstetrics and Gynaecology. 2009; 116: 390-400
        • O'Leary C.M.
        • Nassar N.
        • Zubrick S.R.
        • Kurinczuk J.J.
        • Stanley F.
        • Bower C.
        Evidence of a complex association between dose, pattern and timing of prenatal alcohol exposure and child behaviour problems.
        Addiction. 2010; 105: 74-86
        • Paltrow L.M.
        Punishment and prejudice: Judging drug-using pregnant women.
        in: Hanigsberg J.E. Ruddick S. Mother troubles. Beacon Press, Boston1999: 59-80
        • Popova S.
        • Lange S.
        • Probst C.
        • Parunashvili N.
        • Rehm J.
        Prevalence of alcohol consumption during pregnancy and Fetal Alcohol Spectrum Disorders among the general and Aboriginal populations in Canada and the United States.
        European Journal of Medical Genetics. 2017; 60: 32-48
        • Roberts S.C.M.
        • Pies C.
        Complex calculations: How drug use during pregnancy becomes a barrier to prenatal care.
        Matern and Child Health Journal. 2011; 15: 333-341
        • Roberts S.C.M.
        • Thomas S.
        • Treffers R.
        • Drabble L.
        Forty years of state alcohol and pregnancy policies in the USA: Best practices for public health or efforts to restrict women's reproductive rights?.
        Alcohol and Alcoholism. 2017; 52: 715-721
        • Russell M.
        • Skinner J.B.
        Early measures of maternal alcohol misuse as predictors of adverse pregnancy outcomes.
        Alcoholism, Clinical and Experimental Research. 1988; 12: 824-830
        • Sayal K.
        • Heron J.
        • Golding J.
        • Alati R.
        • Smith G.D.
        • Gray R.
        • Emond A.
        Binge pattern of alcohol consumption during pregnancy and childhood mental health outcomes: Longitudinal population-based study.
        Pediatrics. 2009; 123: e289-e296
        • Sokol R.J.
        • Delaney-Black V.
        • Nordstrom B.
        Fetal alcohol spectrum disorder.
        JAMA. 2003; 290: 2996-2999
        • Stahre M.
        • Naimi T.
        • Brewer R.
        • Holt J.
        Measuring average alcohol consumption: The impact of including binge drinks in quantity-frequency calculations.
        Addiction. 2006; 101: 1711-1718
        • StataCorp
        Stata statistical software: Release 15.
        StataCorp LLC, College Station, TX2017
        • Strandberg-Larsen K.
        • Gronboek M.
        • Andersen A.M.
        • Andersen P.K.
        • Olsen J.
        Alcohol drinking pattern during pregnancy and risk of infant mortality.
        Epidemiology. 2009; 20: 884-891
        • Strandberg-Larsen K.
        • Nielsen N.R.
        • Gronbaek M.
        • Andersen P.K.
        • Olsen J.
        • Andersen A.M.
        Binge drinking in pregnancy and risk of fetal death.
        Obstetrics and Gynecology. 2008; 111: 602-609
        • Subbaraman M.S.
        • Thomas S.
        • Treffers R.
        • Delucchi K.
        • Kerr W.C.
        • Martinez P.
        • Roberts S.C.M.
        Associations between state-level policies regarding alcohol use among pregnant women, adverse birth outcomes, and prenatal care utilization: Results from 1972-2013 Vital Statistics.
        Alcoholism, Clinical and Experimental Research. 2018; 42: 1511-1517
        • Terplan M.
        • Garrett J.
        • Hartmann K.
        Gestational age at enrollment and continued substance use among pregnant women in drug treatment.
        Journal of Addictive Diseases. 2009; 28: 103-112
        • Thomas S.
        • Cannon C.L.
        • French J.
        The effects of state alcohol and pregnancy policies on women's health and healthy pregnancies.
        Journal of Women, Politics, and Policy. 2015; 36: 68-94
        • Thomas S.
        • Rickert L.
        • Cannon C.
        The meaning, status, and future of reproductive autonomy: The case of alcohol use during pregnancy.
        UCLA Womens Law Journal. 2006; 15: 1-46
        • Woodruff K.
        State legislators’ use of evidence in making policy on alcohol use in pregnancy: Preliminary data from qualitative interviews.
        in: Paper presented at the American Public Health Association Annual Meeting Atlanta, Georgia. 2017


      Sarah C.M. Roberts, DrPH, is Associate Professor at University of California, San Francisco. Dr. Roberts studies how policies and our health care system punish rather than support vulnerable pregnant women, including women seeking abortion and women who use alcohol and/or drugs.


      Amy A. Mericle, PhD, is a Scientist at the Alcohol Research Group, Public Health Institute. Dr. Mericle studies recovery support services for alcohol and drug use disorders as well as research methods and measurement issues in psychiatric services research.


      Meenakshi S. Subbaraman, PhD, MS, is a Biostatistician and Co-Director of Statistical and Data Services at the Alcohol Research Group, Public Health Institute. Dr. Subbaraman studies cannabis and alcohol policy and the methods for studying mediators/mechanisms of action.


      Sue Thomas, PhD, is Senior Research Scientist and Director, PIRE-Santa Cruz. She specializes in the intersection of law and social science research. Her specialties include fetal alcohol spectrum disorders policy, reproductive rights, and methodologic questions about using legal data for research.


      Ryan D. Treffers, JD, is a legal policy researcher for the Pacific Institute for Research and Evaluation. His work largely involves conducting legal research where the law and public health intersect.


      Kevin L. Delucchi, PhD, is Professor at the University of California, San Francisco. Dr. Delucchi is a quantitative research expert whose research focuses on using sophisticated statistical methods for addressing problems common in human-based research, including missing data and comorbid conditions.


      William C. Kerr, PhD, is a Senior Scientist and Center Director at the Alcohol Research Group, Public Health Institute. Dr. Kerr is an expert in alcohol control policy and policy evaluation as well as in the methodology of alcohol use measurement.