Relapse to problem drinking or trading up to spirits? Using U.S. national cross-sectional survey data to highlight possible negative impacts of potential tobacco retail changes

Background: According to the National Alcohol Beverage Control Association, twelve states in the United States (U.S.) have government retail monopolies on spirits/liquor sales. With a new federal minimum legal sales age for tobacco (raised from 18 to 21, the minimum legal sales age for alcohol), we examine possible unintended consequences of a hypothetical policy change restricting retail tobacco sales to state-run spirits/liquor stores in alcohol control states, which has been proposed as a tobacco endgame strategy.

Methods: We used cross-sectional survey data from 14,821 randomly-selected adults ages 21 and older who responded to the 2015 or 2020 U.S. National Alcohol Survey (51.8% female; 65.8% identified as non-Hispanic White, 12.4% as Black or African American, 14.2% as Hispanic or Latinx; 34.0% had a low level of education), including 2,274 respondents (18.9%) residing in one of the alcohol control states (representing 42.2 million (M) adults ages 21+). We estimated associations between tobacco measures (lifetime smoking status, lifetime daily smoking, past-year daily smoking) and alcohol measures (drinking status, beverage choices, lifetime alcohol use disorder (AUD) status, recovery status) overall and for specific subgroups.

Results: In control states, 55.1% of people who smoked daily in the past year also reported lifetime AUD, including an estimated 3.56 M adults ages 21 + who reported prior (but not current) AUD. The association of daily smoking with lifetime AUD was stronger among those with low education compared to those with higher education. Further, 58.8% of people in recovery from an alcohol and/or drug problem (1.49 M adults ages 21+) smoked daily, and this was more marked among women than men in control states.

Conclusion: There could be negative consequences of an endgame strategy to restructure tobacco retail sales, including increased risk for relapse to drinking among people who smoke daily, especially among women and people with low levels of education. Strategies to mitigate unintended harms would be needed if such a policy were implemented.