Wednesday, March 13, 2019 9 A.M. a G E N

OMAHA COALITION MEETING Wednesday, March 13, 2019 9 a.m.

A G E N D A

I. Welcome and Introductions

II. Review of the February 13, 2019 Meeting Minutes (please contact PEM staff with corrections)

III. Guest Speaker: Dr. Noelle LoConte, University of Wisconsin Carbone Cancer Center: Alcohol and Cancer: A Call to Action

IV. Focus Area Updates

A. Policy i. Public Health Day at the Capitol on April 2nd – Register at www.projectextramile.org ii. 2019 Legislative Tracking Sheet iii. Legislative testimony available on our Legislative Tracking webpage

B. Enforcement i. Compliance Check Results ii. Law Enforcement Training Review iii. Report Underage Drinking to 1-866-MUST-B-21

C. Awareness i. Earned media and media releases available at www.projectextramile.org ii. March 2019 Research and News Summaries available at www.projectextramile.org

V. Additional Discussion/Announcements

VI. Adjournment and Next Meeting Date: April 10th, 9 am @ National Safety Council Speaker: Shantel Hoelscher, Douglas County CMHC Detoxification Services Program Manager

IMPORTANT UPCOMING EVENTS Public Health Day at the Capitol – April 2, 2019 12 p.m. Nebraska Liquor Control Commission Hearings – April 2019 TBA PEM Coalition Meeting (DUI Discussion Follow-up) – June 12, 2019

The mission of Project Extra Mile is to advocate for evidence-based policies and practices to prevent and reduce alcohol-related harms. PROJECT EXTRA MILE

OMAHA METRO AREA COALITION MEETING MINUTES February 13, 2019

I. Call to Order: Project Extra Mile Coalition Chair Jennifer Pollock called the meeting to order at the National Safety Council, Nebraska at 9 a.m.

II. Welcome and Introductions: Welcome and introductions took place around the room. Coalition members in attendance: Jen Pollock, Mike Kraus, Paul Letcher, Jeana Tortorilla, Charles Knaup, Tim Owens, Mark Magill, Matt Holtmeyer, Matt Kuhse, Russ Zeeb, Jeff Soukop, Jeremy Leifeld, Jori Jones, June Bear-Noonan, Palistene Gray Moore and Dee Austin. Staff members in attendance: Chris Wagner, Melissa Rotella and Liene Topko. III. Approval of Minutes: The minutes from the January 23, 2019 meeting were reviewed and approved. No additions or corrections were made.

IV. Discussion: Jeff Soukup, Nebraska DHHS Program Manager presented on the tobacco control movement as a model for evidence-based alcohol prevention. Soukup has been with the DHHS for 27 years and is a Tobacco Policy Educator with Tobacco Free Nebraska. Since 1964, comprehensive tobacco control programs and policies have been proven effective for controlling tobacco use. These programs feature evidence-based strategies, including 100% smoke free policies, access to cessation services and programs, and tobacco price increases in tandem with hard-hitting media campaigns. Soukup said comprehensive and sustained tobacco control programs funded at CDC-recommended levels save lives and money. States that sustain and fund tobacco control programs at higher levels see faster and larger decreases in smoking rates. Chris Wagner tied the evidence-based strategies used in tobacco prevention to effective excessive alcohol use prevention, particularly regarding price and availability.

V. Focus Area Updates a. Policy i. Chris Wagner shared Project Extra Mile’s legislative tracking sheet with the coalition. He gave an overview of the bills that Project Extra Mile is supporting and opposing.

ii. Wagner spoke specifically about bills LB 314 and LB 497, which have received substantial coverage in the media lately and about which much misinformation is being spread. He then reviewed research and statistics that contradict the false and misleading narratives that have been shared with the public. iii. Wagner informed the coalition of Policy Work Group meeting regarding DUI’s that will be held on February 26th at 3:30pm. If anyone is interested, he encouraged them to attend.

Omaha Coalition Meeting Minutes February 2019

b. Enforcement i. Wagner indicated that Enforcement Work Group would meet following today’s coalition meeting. The group will discuss enforcement solutions for DUIs and other alcohol-related harms.

ii. Project Extra Mile’s Law Enforcement Training on Controlled Underage Party Dispersal will be held on February 27th. Wagner urged anyone interested in the training to register on our website.

c. Youth i. Project Extra Mile is looking for teen youth volunteers to help with the February Law Enforcement Training. Wagner urged organizations to contact Project Extra Mile if they know of interested youth.

d. Awareness i. Wagner informed everyone the January 2019 Research and News Summary was available online at www.projectextramile.org

VI. Group Discussion/Announcements i. Liene Topko reminded the coalition that the March meeting will be at UNMC College of Public Health.

VII. Adjournment and Next Meeting Date: The meeting was adjourned. The next meeting will take place on Wednesday, March 13th at 9 a.m. at the UNMC College of Public Health, Room 2001.

Omaha Coalition Meeting Minutes February 2019

Project Extra Mile Meeting: Alcohol and cancer

Noelle LoConte, MD March 13, 2019 @loconte

@loconte 1 Wisconsin Comprehensive Cancer Control Program • Coalition: Founded in the 1980s by Dr. Paul Carbone and ACS • Now 110 organizations • Program: 2002 funding from CDC • Plan: Every 5-10 years, current plan 2015-2020 • Funding: CDC, GPR budget item, Carbone NCI P30 “core grant”

@loconte 2 • Action Steps • Develop educational materials that define high risk alcohol consumption and its link to cancer • Support the implementation of media campaigns to increase public awareness of the link between alcohol and cancer • Promote healthcare provider education and training on alcohol use as a risk factor for cancer

@loconte 3 @loconte 4 Action Plan

@loconte 5 Alcohol Action Plan – at a glance

• Gather and examine background data. • Develop alcohol and cancer toolkit, tailored for specific audiences across WI. • Develop alcohol-related fundraising best practices/guidelines. • Pursue provider-specific education opportunities. • Pursue decision maker-specific education opportunities. • Work with schools to integrate cancer prevention into substance use curriculum. • Collaborate with other groups working on alcohol issues.

@loconte 6 @loconte 7 FAQ https://wicancer.org/wp-content/uploads/Alcohol-and-Cancer-FAQ_design_FINAL.pdf

@loconte 8 @loconte 9 @loconte 10 Infographics https://wicancer.org/wp-content/uploads/InfoGraphic_Alcohol_Final.pdf

@loconte 11 @loconte 12 @loconte 13 Alcohol and Cancer slide deck https://wicancer.org/resources/alcohol-slide-bank/

@loconte 14 Alcohol & Cancer Risk Improving the Alcohol Environment to Reduce Wisconsin’s Cancer Burden

@loconte 15 Alcohol and Cancer

• Alcohol use increases the risk of at least 7 different cancers: • Mouth & Throat • Larynx • Esophagus • Breast • Liver • Colorectal

Image: https://wicancer.org/wp-content/uploads/InfoGraphic_Alcohol_Final.pdf

Source: International@loconte Agency on Research on Cancer. IARC Monograph. Volume 96.16 2010. How does alcohol increase cancer risk?

• Many potential pathways, including: • Ethanol –> Acetaldehyde • Blocking absorption of nutrients like folate • Increasing estrogen levels • Cirrhosis of the liver • The International Agency on Research on Cancer classifies alcohol as a known human carcinogen – and has since the late 80s.

Sources: National Cancer Insitute. Alcohol and Cancer; International Agency on Research on Cancer. IARC Monograph.@loconte Volume 96. 2010 17 How much is too much?

• Even light drinking can increase your cancer risk for some cancers, including breast. • But, drinking heavily, especially over a longer period of time, has the greatest impact on risk. Especially for head and neck cancers. Image: https://wicancer.org/wp-content/uploads/InfoGraphic_Alcohol_Final.pdf

@loconte Source: LoConte N, et al, Journal of Clinical Oncology 36, no. 1,8318 -93. So, what is “high risk”?

High-risk drinking includes: • Heavy drinking – 8+ per week for women, 15+ per week for men • Binge drinking – 4+ on one occasion for women, 5+ on one occasion for men • Underage drinking

Image: https://wicancer.org/wp-content/uploads/Alcohol-and-Cancer-FAQ_design_FINAL.pdf

@loconte Source: Centers for Disease Control and19 Prevention Why is alcohol use an important risk factor?

• Approximately 3.5% of all cancer deaths in the U.S. (~20,000 deaths per year) are attributed to alcohol use. • Alcohol use is a common avoidable risk factor, especially in Wisconsin! • 68% drink alcohol • 17% smoke cigarettes • 19% no physical activity • 24% veggies <1x/day

Sources: Nelson et al, Am J Public Health. 2013; 103(4): 641-648; Parkin DM et al, Br J Cancer. 2011;105:S77@loconte-81; Centers for Disease Control and Prevention. BRFSS. 2015/2016.20 Burden of alcohol-related cancers in Wisconsin Cancer Type Average Annual Cases Average Annual Deaths Mouth & Throat 790* 164* Larynx 234* 55 Esophagus 352* 321* Breast 4,312 767 Liver 428 355 Colorectal 2,570 950 * Rate is above the national average Find County-level data here: https://tinyurl.com/WICountyCancer

@loconte 21 Source: American Cancer Society. Facts and Figures: Cancer in Wisconsin. 2016. Why should we discuss alcohol and cancer?

• Awareness of the connection is low. • Only 30% of adults in US know that alcohol is a cancer risk factor • Compared to 78% for tobacco and 66% for sun exposure • Until recently, many cancer organizations were not discussing. • Increased awareness of the connection is shown to: • Encourage behavior change. • Increase support for policies that prevent and reduce excessive drinking.

Sources: ASCO National Cancer Opinion Survey 2017; Hawkins et al., Health Educ Behav. 2010; 37(4): 490-503;@loconte Buykx et al., BMC Public Health, 2018, 18(688). 22 American Society of Clinical Oncology (ASCO) Alcohol and Cancer Statement

• ASCO statement in November 2017 discussed: • Evidence of alcohol and cancer link • Areas of needed research • Public health strategies to reduce excessive drinking • Role of the oncologist in addressing this issue

@loconte 23 Meta-analysis of alcohol use and cancer risk

2-4 4+ 0-1 drink/d drinks/d drinks/d

@loconte Source: LoConte N, et al, Journal of Clinical Oncology 36, no.24 1,83-93. Strategies endorsed by ASCO in statement

• Support clinical strategies to reduce high-risk alcohol consumption. • Regulate alcohol outlet density. • Increase alcohol taxes and prices. • Maintain limits on days and hours of sale. • Enhance enforcement of laws prohibiting sales to those under 21. • Restrict youth exposure to advertising of alcoholic beverages. • Resist further privatization of retail alcohol sales. • Include alcohol strategies in state Comprehensive Cancer Control Plans. • Support efforts to eliminate “pinkwashing.”

@loconte Source: LoConte N, et al, Journal of Clinical Oncology 36,25 no. 1,83-93. ASCO: Role of the oncologist

• Assist patients in reducing their high-risk alcohol use • Identify most effective strategies to intervene, especially among cancer patients and survivors • Support alcohol-related research, including impact of alcohol use on cancer treatment/treatment outcomes • Address disparities in alcohol use/alcohol-related cancers • Raise public awareness of the alcohol and cancer connection • Support policy efforts to reduce excessive alcohol use

@loconte Source: LoConte N, et al, Journal of Clinical Oncology 36,26 no. 1,83-93. Media attention from ASCO statement

• New York Times – Cancer Doctors Cite Risks of Drinking Alcohol • WI State Journal – Alcohol Increases Cancer Risk, Says Report Led by UW Doctor • Time – Drinking A Lot Has Been Linked to Cancer, Doctors Warn • Fox News – Cutting Back on Alcohol Can Prevent Cancers, Experts Claim • Mother Jones – Did Drinking Give Me Breast Cancer? • NPR (All Things Considered) – Drinking Alcohol Can Raise Cancer Risk. How Much Is Too Much?

@loconte 27 What is “pink-washing”?

• “Pink-washing” = using the color pink or the pink ribbon to market products associated with breast cancer. • Alcohol fundraising by cancer-related organizations: • Devalues message • Undermines fundraising of others

@loconte 28 Source: Alcohol Justice, Pinkwashed Drinks: Problems & Dangers Expert information on alcohol and cancer

• WI Cancer Council Alcohol Action Plan: https://wicancer.org/action- plans/alcohol-and-cancer/ • American Society of Clinical Oncology (ASCO) Alcohol and Cancer Statement: http://ascopubs.org/doi/abs/10.1200/JCO.2017.76.1155 • Cancer.net (patient-facing ASCO resources): https://www.cancer.net/navigating-cancer-care/prevention-and-healthyliving/alcohol • National Cancer Institute: https://www.cancer.gov/about-cancer/causes- prevention/risk/alcohol/alcohol-fact-sheet • American Cancer Society: https://www.cancer.org/cancer/cancer- causes/diet-physical-activity/alcohol-use-and-cancer.html

@loconte 29 Policy strategies to reduce excessive drinking

Policies shown to reduce excessive drinking are those that affect alcohol… • Availability – i.e. seller licensing • Acceptability – i.e. norms and perceptions • Affordability – i.e. prices • Attractiveness – i.e. marketing

@loconte 30 Source: WI Alcohol Policy Project, UW Law School Key messages

• Alcohol use increases the risk of at least seven different cancers. • Even low levels of drinking can increase cancer risk, but the greatest risk if with heavy, long-term use. • Policy strategies that are shown to reduce excessive drinking – heavy, underage, and binge drinking – have the potential to decrease the burden of cancer across Wisconsin. • To reduce your cancer risk, drink less. If you do not drink, do not start.

@loconte 31 @loconte 32 County Fact Sheets

@loconte 33 @loconte 34 @loconte 35 Thank you!

@loconte 36

Alcohol & Cancer

An Underappreciated Risk Factor for a Deadly Disease

Alcohol use is one of the leading preventable causes of cancer, yet many Americans, including health professionals, are not aware of this or are underinformed.1 According to a 2017 American Institute for Cancer Research (AICR) survey, only 39% of Americans recognize this link.2

Facts about the Alcohol-Cancer link

 Alcohol consumption is a causal risk factor for several types of cancer, including cancers of the head and neck, female breast, stomach, liver, and colorectum.3

 Every high-level cancer research body – including the WHO’s International Agency for Research on Cancer (IARC),4 the American Institute for Cancer Research (AICR),5 the American Cancer Society,6 the American Society for Clinical Oncology (ASCO),7 and the National Cancer Institute (NCI)8 – has determined that alcohol beverages are causal risk factors for cancer.

 The U.S. National Toxicology Program (the U.S. agency charged with officially identifying carcinogens) has identified “alcoholic beverage consumption” as “known to be a human carcinogen” – its highest category of carcinogenicity, indicating that there is “sufficient evidence of cancer from human studies showing a cause-and-effect relationship between exposure to the substance and human cancer.”9 Other examples of human carcinogens include: arsenic, asbestos, formaldehyde, Hepatitis B and C viruses, and tobacco.10

Cancer Site Alcohol-related % Percentage of Mouth, pharynx, & larynx 27 Cancer Deaths Esophagus 34 which are Liver 15 Alcohol-Related Colorectum 5 Female Breast 11

Source: WCRF/AICR11

 Alcohol is a risk factor for three of the deadliest cancers in terms of recalcitrance: those of the liver (18% 5-year relative survival rate), esophagus (21%), and stomach (31%).12

1 ASCO (2017); AICR (2017); Oh, Kumar, & Cruz (2008) 2 AICR (2017) 3 AICR (n.d.) 4 IARC (2010) 5 American Institute for Cancer Research (n.d.) 6 Islami, et al. (2017) 7 LoConte, et al. (2017) 8 National Cancer Institute (2013) 9 National Toxicology Program (2014) 10 American Cancer Society (n.d.) 11 WCRF/AICR (2009) 12 Deadliest Cancers Coalition (n.d.)

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 Even low-to-moderate levels of consumption confer risk for some of these cancers. In fact, there is no completely “safe” level of alcohol use with regard to cancer risk, with risk for some cancers (most notably female breast cancer) beginning at just one drink a day.13 Accordingly, AICR offers the following recommendation regarding alcohol use and cancer:

Even small amounts of alcohol pose some cancer risk, so for lowest risk, AICR recommends not drinking alcohol at all. However, if you do drink alcohol, limit your intake to no more than two drinks a day for men and one drink a day for women.14

 Furthermore, no specific type of alcohol (beer, wine, or hard liquor) is more associated with the risk of cancer than others.15

The Truth about Alcohol’s “Health Halo”

While some past studies have shown a relationship between red wine and other alcohol consumption and decreased heart disease risk and reduced overall death rates, a growing number of researchers believe this relationship has been overstated.16

The improved health outcomes may be better explained (or at least partially explained) by other healthy behaviors and advantages enjoyed by light-moderate drinkers – like regular exercise, better diet, and access to preventive health care.17 Regardless, the American Heart Association does not recommend that anyone drink for heart health. Moreover, binge and heavy drinking can cause serious heart problems, including alcoholic cardiomyopathy18 and arrhythmias.19

An in-depth meta-analysis of studies about effects of moderate drinking on mortality backs up the contention that many of the studies finding health benefits from drinking are not carefully designed. The researchers found that “low-volume alcohol consumption [that is, regular, moderate drinking] has no net mortality benefit compared with lifetime abstention or occasional drinking.”20

Furthermore, there have been misleading claims circulating about red wine because of the presence of resveratrol, an anti-oxidant. In reality, the (carcinogenic) ethanol in a glass of wine is over 100,000 times more potent than the resveratrol.21

13 AICR/WCRF (2017) 14 American Institute for Cancer Research (n.d.) 15 LoConte, et al. (2017) 16 Wisconsin Cancer Council (n.d.) 17 Barefoot, et al. (2002); Naimi, et al. (2005) 18 Maisch (2018) 19 Brunner, et al. (2018) 20 Stockwell, et al. (2016). Emphasis added. 21 Lachenmaier, et al. (2014)

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The Nebraska Experience

The cancers for which alcohol consumption is a risk factor (in shaded cells, below) are among the most deadly to Nebraskans, both in terms of numbers of deaths and recalcitrance (five-year survival rate).

Est. number of deaths, Cancer site Nebraska, 2017 Lung/Bronchus 900 Colorectum 330 Pancreas 250 Female Breast 230 Prostate 180 Leukemia 150 Liver 130

Source: American Cancer Society22

The Nebraska Comprehensive Cancer Control Program has identified the need to address excessive alcohol consumption in order to reduce alcohol-related cancers. The Nebraska Cancer Plan (2017-2022) includes objectives to reduce binge drinking, as well as raise awareness of the alcohol-cancer link among medical professionals and the general public.23

Solutions

The most effective way to reduce alcohol-related cancers is through the implementation of population- level alcohol control policies. These policies include:24

. Increasing the price of alcohol through taxation;

. Reducing the availability of retailed alcohol through regulation of alcohol outlet density;

. Restricting alcohol advertising and marketing.

The American Society of Clinical Oncology – America’s cancer doctors – also calls for the elimination of pinkwashing:

… Pinkwashing is a form of cause marketing in which a company uses the color pink and/or pink ribbons to show a commitment to finding a cure for breast cancer. Given the consistent evidence that shows the link between alcohol consumption and an increased risk of breast cancer, alcoholic beverage companies should be discouraged from using the symbols of the battle against breast cancer to market their products.25

For more on alcohol-related cancer prevention from the CDC: https://www.cdc.gov/cancer/dcpc/prevention/policies_practices/alcohol/index.htm

22 American Cancer Society (2017) 23 Nebraska DHHS (2017) 24 WHO (2017); The Community Guide (2017) 25 LoConte, et al. (2017)

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References

American Cancer Society (n.d.) Known and probable human LoConte, N. K., Brewster, A. M., Kaur, J. S., Merrill, J. K., & carcinogens. Available at Alberg, A. J. (2017). Alcohol and cancer: A Statement of the https://www.cancer.org/cancer/cancer-causes/general- American Society of Clinical Oncology. Journal of Clinical info/known-and-probable-human-carcinogens.html Oncology, JCO-2017. Available at: http://ascopubs.org/doi/full/10.1200/JCO.2017.76.1155 American Institute for Cancer Research (n.d.). The facts Maisch, B. (2018).Alcoholic Cardiomyopathy: The Result of about alcohol [brochure]. Available at Dosage and Individual Predisposition.” Herz, 41(6), 484– http://www.aicr.org/assets/docs/pdf/brochures/facts-about- 493. alcohol.pdf Naimi, T. S., Brown, D. W., Brewer, R. D., Giles, W. H., American Institute for Cancer Research (2017).” Fewer than Mensah, G., Serdula, M. K., et al. (2005). Cardiovascular half of Americans know alcohol, processed meats affect risk factors and confounders among nondrinking and cancer risk.” Available at http://www.aicr.org/cancer- moderate-drinking US adults. American Journal of research-update/2017/02_08/cru-fewer-than-half-of- Preventive Medicine, 28(4), 369-373. Americans-know-alcohol-processed-meats-affect-cancer- National Cancer Institute (2013). Alcohol and cancer risk risk.html?referrer=https://www.google.com/ [fact sheet]. Available at https://www.cancer.gov/about- cancer/causes-prevention/risk/alcohol/alcohol-fact-sheet AICR/WCRF (2017). Diet, nutrition, physical activity and breast cancer. Available at http://www.aicr.org/continuous- NTP (National Toxicology Program) (2014). Report on update-project/reports/breast-cancer-report-2017.pdf Carcinogens, Thirteenth Edition. Research. Triangle Park, NC: U.S. Department of Health and Human Services, Public Barefoot, J. C., Grønbæk, M., Feaganes, J. R., McPherson, Health Service. Available at: R. S., Williams, R. B., & Siegler, I. C. (2002). Alcoholic http://ntp.niehs.nih.gov/pubhealth/roc/roc13/ beverage preference, diet, and health habits in the UNC Alumni Heart Study. The American Journal of Clinical Nebraska Dept. of Health and Human Services (2017). Nutrition, 76(2), 466-472. Nebraska Cancer Plan: 2017-2022. Available at http://dhhs.ne.gov/publichealth/Documents/Nebraska%20Ca Brunner, S., Herbel, R., Drobesch, C., Peters, A., Massberg, ncer%20Coalition%20Plan%202017%20-%202022.pdf S., Kääb, S., & Sinner, M. F. (2017). Alcohol consumption, sinus tachycardia, and cardiac arrhythmias at the Munich Oh, J., Kumar, J., & Cruz, G. (2008). Racial and ethnic Octoberfest: Results from the Munich Beer Related disparity in oral cancer awareness and examination: 2003 Electrocardiogram Workup Study (MunichBREW). European New York State BRFSS. Journal of Public Health Dentistry, heart journal, 38(27), 2100-2106. 68(1), 30-38, p. 37

Community Guide (2017). Excessive alcohol consumption. Stockwell, T., Zhao, J., Panwar, S., Roemer, A., Naimi, T., & Available at Chikritzhs, T. (2016). Do “moderate” drinkers have reduced https://www.thecommunityguide.org/topic/excessive-alcohol- mortality risk? A systematic review and meta-analysis of consumption alcohol consumption and all-cause mortality. Journal of Studies on Alcohol and Drugs, 77(2), 185-198. Deadliest Cancers Coalition (n.d.). “What are the deadliest, or recalcitrant, cancers?” [webpage]. Available at Wisconsin Cancer Council (n.d.) Alcohol & cancer: You http://www.deadliestcancers.org/what-are-deadly- asked. We’ve answered. [fact sheet]. Available at: cancers.html https://wicancer.org/wp-content/uploads/Alcohol-and- Cancer-FAQ_design_FINAL.pdf IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. (2010). Alcohol consumption and ethyl World Cancer Research Fund/American Institute for Cancer carbamate. IARC monographs on the evaluation of Research (2009). Policy and action for cancer prevention. carcinogenic risks to humans. World Health Organization, Food, nutrition, and physical activity: A global perspective. International Agency for Research on Cancer, 96, 3. Table A2, p. 152

Islami, F., Goding Sauer, A., Miller, K. D., Siegel, R. L., World Health Organization (2017). Tackling NCDs: ‘Best Fedewa, S. A., Jacobs, E. J., et al. (2017). Proportion and buys’ and other recommended interventions for the number of cancer cases and deaths attributable to prevention and control of noncommunicable diseases. potentially modifiable risk factors in the United States. CA: a Geneva: WHO. Available at cancer journal for clinicians. http://apps.who.int/iris/bitstream/10665/259232/1/WHO- NMH-NVI-17.9-eng.pdf?ua=1 Lachenmeier, D. W., Godelmann, R., Witt, B., Riedel, K., & Rehm, J. (2014). Can resveratrol in wine protect against the carcinogenicity of ethanol? A probabilistic dose‐response Contact Information assessment. International Journal of Cancer, 134(1), 144- 153. Project Extra Mile 11620 M Circle Omaha, NE 68137 Ph: (402) 963-9047 Email: [email protected]

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JOURNAL OF CLINICAL ONCOLOGY ASCO SPECIAL ARTICLE

Alcohol and Cancer: A Statement of the American Society of Clinical Oncology Noelle K. LoConte, Abenaa M. Brewster, Judith S. Kaur, Janette K. Merrill, and Anthony J. Alberg

Author affiliations and support information ABSTRACT (if applicable) appear at the end of this article. Alcohol drinking is an established risk factor for several malignancies, and it is a potentially modi- Published at jco.org on November 7, fi 2017. able risk factor for cancer. The Cancer Prevention Committee of the American Society of Clinical Oncology (ASCO) believes that a proactive stance by the Society to minimize excessive exposure to Reprint requests: American Society of Clinical Oncology, 2318 Mill Rd, Suite 800, alcohol has important implications for cancer prevention. In addition, the role of alcohol drinking on Alexandria, VA 22314; e-mail: outcomes in patients with cancer is in its formative stages, and ASCO can play a key role by [email protected]. generating a research agenda. Also, ASCO could provide needed leadership in the cancer com- Corresponding author: Noelle K. LoConte, munity on this issue. In the issuance of this statement, ASCO joins a growing number of in- MD, University of Wisconsin Madison, ternational organizations by establishing a platform to support effective public health strategies in 600 Highland Ave, Madison, WI 53792; this area. The goals of this statement are to: e-mail: [email protected]. • Promote public education about the risks between alcohol abuse and certain types of cancer; © 2017 by American Society of Clinical • Support policy efforts to reduce the risk of cancer through evidence-based strategies that Oncology prevent excessive use of alcohol; 0732-183X/17/3599-1/$20.00 • Provide education to oncology providers about the influence of excessive alcohol use and cancer risks and treatment complications, including clarification of conflicting evidence; and • Identify areas of needed research regarding the relationship between alcohol use and cancer risk and outcomes.

INTRODUCTION with preventive interventions at both the policy and the individual levels. Here, we provide an overview of the evidence of the links between alcohol The importance of alcohol drinking as a con- drinking and cancer risk and cancer outcomes. The tributing factor to the overall cancer burden is areas of greatest need for future research are high- often underappreciated. In fact, alcohol drinking lighted. On the basis of this evidence and guide- is an established risk factor for several malig- lines adopted by other cancer-focused organizations, nancies. As a potentially modiﬁable risk factor for ASCO-endorsed strategies for the reduction of high- cancer, addressing high-risk alcohol use is one risk alcohol consumption are presented. strategy to reduce the burden of cancer. For example, in 2012, 5.5% of all new cancer occur- rences and 5.8% of all cancer deaths worldwide EPIDEMIOLOGY OF ALCOHOL USE were estimated to be attributable to alcohol.1 In the United States, it has been estimated that 3.5% of all cancer deaths are attributable to drinking Beyond oncology, alcohol use and abuse to- alcohol.2 Alcohol is causally associated with gether pose a signiﬁcant public health problem. oropharyngeal and larynx cancer, esophageal According to the Centers for Disease Control and cancer, hepatocellular carcinoma, breast cancer, Prevention, approximately 88,000 deaths were and colon cancer.3 Even modest use of alcohol attributed to excessive alcohol use in the United may increase cancer risk, but the greatest risks are States between 2006 and 2010.4 Approximately observed with heavy, long-term use. 3.3 million deaths worldwide result from the Despite the evidence of a strong link between harmful use of alcohol each year.5 Population alcohol drinking and certain cancers, ASCO has surveys demonstrate that 12% to 14% of adults not previously addressed the topic of alcohol and have a current alcohol use disorder and that 29%

DOI: https://doi.org/10.1200/JCO.2017. cancer. In addition, alcohol drinking is a poten- have had such a disorder at some point in their 6,7 76.1155 tially modiﬁable risk factor that can be targeted lifetime. In addition to alcohol use disorder,

Downloaded from ascopubs.org by 74.126.55.246 on November 15, 2017 from 074.126.055.246 Copyright © 2017 American Society of Clinical Oncology. All rights reserved. LoConte et al other measures used to assess the impact of alcohol are excessive ALCOHOL AND CANCER drinking, binge drinking, and heavy drinking. Excessive drinking includes binge drinking and is defined as consumption of four or more drinks during a single occasion for women, or five or more Evidence to Link Alcohol Consumption to Specific drinks during a single occasion for men. Binge drinking is the most Cancers common form of excessive drinking compared with heavy drinking, The relationship between drinking alcohol and cancer risk has which is defined as eight or more drinks per week or three or more been evaluated extensively in epidemiologic case-control and drinks per day for women, and as fifteen or more drinks per week or cohort studies. In a thorough systematic review of the world’s four or more drinks per day for men.8 Recent work has shown that evidence that adhered to prespecified criteria for drawing in- the prevalence of adults who drink more than four to five drinks per ferences, a World Cancer Research Fund/American Institute for occasion, defined as extreme binge drinking, has been increasing Cancer Research (AICR) report judged the evidence to be con- during the past decade.9 This study estimated that 13% of the US vincing that drinking alcohol was a cause of cancers of the oral adult population engaged in extreme binge drinking on at least one cavity, pharynx, larynx, esophagus, breast, and colorectum (in 23 occasion in the previous year. Moderate drinking is defined at up to men). Also, alcohol was judged to be a probable cause of in- 23 one drink per day for women and up to two drinks per day for creased risk of liver cancer and colorectal cancer (in women). An men.1,4 Most individuals who drink excessively do not meet the updated review of the evidence for liver cancer upgraded the clinical criteria for alcoholism or alcohol dependence.10 conclusion for an association between alcohol drinking and liver 24 Alcohol use during childhood and adolescence is a predictor cancer to convincing. The International Agency for Research on 25 of increased risk of alcohol use disorder as an adult.11 College-age Cancer (IARC), a branch of WHO, has assessed the evidence and and younger people who drink are prone to develop an alcohol use come to virtually identical conclusions: that alcohol is a cause of disorder later in life.7 Most adults who engage in high-risk alcohol cancers of the oral cavity, pharynx, larynx, esophagus, colorectum, drinking behavior started drinking before age 21 years. Among US liver (ie, hepatocellular carcinoma), and female breast. For youth age 12 to 20 years, 23% were current drinkers in the past esophageal cancer, the association with alcohol drinking is largely 25 30 days, 10% were episodic drinkers, 2% were heavy episodic specific to squamous cell carcinoma. The more that a person drinkers, and 6% met criteria for alcohol use disorder.11 Among drinks, and the longer the period of time, the greater their risk of 3 childhood cancer survivors, the prevalence of alcohol use in the development of cancer, especially head and neck cancers. past 30 days in adulthood (7.8 mean years since diagnosis of their A valid question is whether these associations are specificto cancer) was 25%, which was lower than that observed in the ethanol per se or whether they vary according to the type of al- general population.12 However, alcohol use among teenage patients coholic beverage (ie, beer, wine, or spirits/liquor). The answer is with cancer is a common occurrence overall and has been observed that the associations between alcohol drinking and cancer risk have to be as high among teens without cancer.13-15 been observed consistently regardless of the specific type of alcoholic beverage.25 The full range of cancers for which alcohol drinking repre- DRINKING GUIDELINES AND DEFINITIONS sents a risk factor remains to be clarified. For example, the index of suspicion is high that alcohol drinking leads to excess risk of 25 26 Internationally, more than 40 countries have issued alcohol pancreatic cancer and gastric cancer. For some malignancies, drinking guidelines; however, these vary substantially.16 The alcohol drinking clearly is statistically associated with increased American Heart Association, American Cancer Society, and US risk but, because of its strong correlation with other risk factors, it Department of Health and Human Services all recommend that is difficult to discern if alcohol drinking is truly an independent risk men drink no more than one to two drinks per day and that factor. For example, alcohol drinking consistently has been sta- 23 women drink no more than one drink per day.17-19 In addition, it is tistically strongly associated with increased lung cancer risk. recommended that drinking alcohol should only be done by adults However, cigarette smokers also are more likely to be alcohol of legal age. People who do not currently drink alcohol should not drinkers, and cigarette smoking is such an overwhelming lung start for any reason. cancer risk factor that confounding by cigarette smoking—rather Defining risk-drinking can be challenging, because the than a direct association with alcohol drinking—currently 27 amount of ethanol contained in an alcoholic beverage will vary cannot be ruled out as a possible explanation. As evidence considerably depending on the type of alcohol (eg, beer, wine, or continues to accumulate, the list of alcohol-associated cancers is spirits) and the size of the drink consumed. In addition, the likely to grow. definition of a standard drink varies among countries and ranges from 8 g to 14 g.20,21 The National Institute of Alcohol Abuse and Magnitude of the Associations Alcoholism (NIAAA) defines a standard drink as one that contains Characterization of the dose-response relationship between roughly 14 g of pure alcohol, which is the equivalent of 1.5 ounces alcohol and cancer is important for causal inference, because, if of distilled spirits (approximately 40% alcohol by volume); 5 ounces alcohol increases the risk for a specific cancer, one would expect the of wine (approximately 12% alcohol by volume); or 12 ounces of magnitude of the cancer risk to increase commensurate with in- regular beer (approximately 5% alcohol by volume).22 However, creasing levels of alcohol consumption. Furthermore, the nature evidence shows that drinkers are often unaware of how standard of the dose-response relationship provides useful information drinks are defined and that these standard drink sizes are commonly for communicating with patients about this issue. For alcohol- exceeded.20 associated cancers, Table 1 summarizes results from a large-scale

Downloaded from ascopubs.org by 74.126.55.246 on November 15, 2017 from 074.126.055.246 Copyright © 2017 American Society of Clinical Oncology. All rights reserved. ASCO Statement: Alcohol and Cancer meta-analysis28 that show the relative risks of cancer in a com- Does Cessation of Alcohol Consumption Lead to Lower parison of nondrinkers with categories of people with light, Cancer Risk? moderate, and heavy alcohol consumption. The results summa- A key question relevant both to the assessment of causality and rized in Table 1 illustrate several key points. First, the magnitude of the provision of advice and effective interventions to patients is the association between alcohol drinking and cancer risk varied by whether the risk of developing an alcohol-associated cancer is type of cancer. Compared with nondrinkers, the summary relative reduced after one stops drinking alcohol. The results of meta- risks (sRRs) for those classified as heavy drinkers ranged from 1.44 analyses and pooled analyses that have focused directly on this for colorectal cancer to 5.13 for cancer of the oral cavity and question for upper aerodigestive tract cancers indicate that risk of pharynx. The corresponding sRRs were 1.61, 2.07, 2.65, and 4.95 these cancers declines in those who quit drinking alcohol com- for cancers of the breast, liver, larynx, and esophagus, respectively. pared with those who remain alcohol drinkers.32-35 The evidence The strongest associations were observed for upper aerodigestive from these studies suggests that the risk of cancer may be reduced tract cancers (ie, larynx, esophagus, and oral cavity/pharynx), to that seen in never drinkers after long-term ($ 20 years) ces- which involve tissues that come into direct contact with inges- sation from alcohol drinking. Unfortunately, there are limited ted alcohol. Second, monotonic dose-response relationships are existing data on the impact of alcohol cessation on the risk of other evident for cancers of the oral cavity and pharynx, squamous cell alcohol-related cancers. This important topic is in need of more carcinoma of the esophagus, and breast cancer. For liver, laryngeal, thorough investigation, particularly because those who quit and colorectal cancers, the sRRs for the moderate category were drinking alcohol may differ from current drinkers in important intermediate between nondrinkers and heavy drinkers, but there ways that are also associated with cancer risk. For example, similar was no evidence of increased risk in the light-drinker category. to smoking cessation, an increased short-term risk of cancer after In a dose-response meta-analysis, the risk of secondary malig- alcohol cessation may be due to the onset of cancer-related nancies in patients with upper aerodigestive tract cancers in- symptoms that contribute to the individual’s decision to stop creased incrementally by 9% for every increase in alcohol intake drinking. Studies that carefully assess the time period between of 10 g/day.29 alcohol cessation and cancer diagnosis will help disentangle these Clearly, the greatest cancer risks are concentrated in the heavy complex methodological issues. Another potential bias is in- and moderate drinker categories. Nevertheless, some cancer risk troduced by the finding that the category of former drinkers can be persists even at low levels of consumption. A meta-analysis that overrepresented by former heavy drinkers or alcoholics.36 When focused solely on cancer risks associated with drinking one drink present, the risk of cancer after alcohol cessation may be higher or fewer per day observed that this level of alcohol consumption than that observed for current drinkers because of the high alcohol was still associated with some elevated risk for squamous cell exposure doses of those classified as former drinkers. Carefully carcinoma of the esophagus (sRR, 1.30; 95% CI, 1.09 to 1.56), designed prospective cohort studies will help overcome these bias- oropharyngeal cancer (sRR, 1.17; 95% CI, 1.06 to 1.29), and breast based limitations and will lead to a more refined characterization of cancer (sRR, 1.05; 95% CI, 1.02 to 1.08), but no discernable as- the impact of cessation of alcohol drinking on cancer risk by sociations were seen for cancers of the colorectum, larynx, and longitudinally quantifying the amount of alcohol consumed and liver.30 On the basis of the lesser overall cancer risk at the lower end the duration of cessation. of the dose-response continuum, the World Cancer Research Fund/AICR made the following recommendation: “If alcoholic drinks are consumed, limit consumption to two drinks a day for Impact of Smoking in Combination With Alcohol men and one drink a day for women.”23 They also recommend Consumption that, “for cancer prevention, it’s best not to drink alcohol.” Recent Some malignancies are causally linked to both alcohol updates to the AICR report estimate a 5% increase in pre- drinking and cigarette smoking; in some cases, an established menopausal breast cancer per 10 grams of ethanol consumed per synergistic interaction between alcohol drinking and cigarette day (pooled relative risk [RR], 1.05; 95% CI, 1.02 to 1.08). The risk smoking exists. This means that, in cancers for which both alcohol was even greater for postmenopausal breast cancer, which had an drinking and cigarette smoking are causal factors, the cancer risks RR of 1.09 (95% CI, 1.07 to 1.12) for each 10 grams of ethanol per in those who are both alcohol drinkers and cigarette smokers are day.31 much larger than the risks seen for those who only drink alcohol or

Table 1. Summary of Relative Risks From a Meta-Analysis for the Association Between Amount of Alcohol Drinking and Risk of Cancer Relative Risk (95% CI) Type of Cancer Nondrinker Light Drinker Moderate Drinker Heavy Drinker Oral cavity and pharynx 1.0 (referent) 1.13 (1.0 to 1.26) 1.83 (1.62 to 2.07) 5.13 (4.31 to 6.10) Esophageal squamous cell carcinoma 1.0 (referent) 1.26 (1.06 to 1.50) 2.23 (1.87 to 2.65) 4.95 (3.86 to 6.34) Larynx 1.0 (referent) 0.87 (0.68 to 1.11) 1.44 (1.25 to 1.66) 2.65 (2.19 to 3.19) Liver 1.0 (referent) 1.00 (0.85 to 1.18) 1.08 (0.97 to 1.20) 2.07 (1.66 to 2.58) Female breast 1.0 (referent) 1.04 (1.01 to 1.07) 1.23 (1.19 to 1.28) 1.61 (1.33 to 1.94) Colorectum 1.0 (referent) 0.99 (0.95 to 1.04) 1.17 (1.11 to 1.24) 1.44 (1.25 to 1.65)

NOTE. Adapted from results of Bagnardi et al (2015).28

Downloaded from ascopubs.org by 74.126.55.246 on November 15, 2017 from 074.126.055.246 Copyright © 2017 American Society of Clinical Oncology. All rights reserved. LoConte et al only smoke cigarettes. Specific upper aerodigestive tract cancers Classification of Alcohol as a Carcinogen by the WHO provide the strongest examples of robust synergistic interactions On the basis of the sum total of the evidence from research on between alcohol drinking and cigarette smoking. A pooled analysis mechanistic studies of the carcinogenicity of alcohol and the of 17 case-control studies identified a potent interaction between epidemiologic evidence to link alcohol with increased risk of alcohol drinking and cigarette smoking in cancers of the oral cavity, multiple forms of cancer, the IARC classified alcohol as a group 1 pharynx, and larynx,37 and a review identified evidence of robust carcinogen, because they found that it causes cancer in humans.41 interactionin22of24publishedstudiesonoral,pharyngeal,laryngeal, Specifically, IARC concluded that there is sufficient evidence in and esophageal cancers.38 Despite the clear presence of synergistic humans for the carcinogenicity not only of alcohol consumption interaction, the biologic underpinnings of the interaction between but also for the carcinogenicity of acetaldehyde associated with alcohol drinking and cigarette smoking are not well understood. alcoholic beverage consumption.41

The Mechanistic Role of Alcohol in Carcinogenesis DISPARITIES IN ALCOHOL USE AND RELATED CANCERS When the evidence of alcohol’s role in carcinogenesis is considered, a key point is that, in biochemical reactions that are Blacks, Asian Americans, and Hispanic individuals have lower rates sequentially catalyzed by alcohol dehydrogenase and aldehyde of current alcohol use disorder than whites. However, rates among dehydrogenase, ethanol is eliminated from the body by its oxi- these groups appear to be increasing overall. The NIAAA has dation first to acetaldehyde and then to acetate. Ethanol per se is accumulated data during two decades by conducting large general- not mutagenic, but acetaldehyde is carcinogenic and mutagenic, by population surveys among US adults age 18 years and older. Their binding to DNA and protein.39 longitudinal surveys from 1991 to 1992 and 2001 to 2002 showed The IARC reviewed the potential role of alcohol in carcino- increases in alcohol abuse among men, women, and young black genesis by synthesizing multiple bodies of evidence that included (1) and Hispanic minorities. Rates of dependence also increased experiments in which ethanol (or aldehyde) is administered to mice among men, young black women, and Asian men, which un- and rats in drinking water; (2) the absorption, distribution, derscores the need to continue monitoring of prevalence and metabolism, and excretion of ethanol and its metabolites; and (3) the trends. It is now known that Hispanics and blacks have a higher genotoxicity of alcohol in various experimental systems, including risk than whites for developing alcohol-related liver disease.42 The biomarkers in humans.23 One key conclusion of the review was that, longitudinal design of the NIAAA surveys enable the collection of in animal models, administration of ethanol or acetaldehyde in data on cultural variables, such as acculturation. In addition to drinking water increased the incidence of various tumors in mice increasing overall rates, blacks and Hispanics are less likely to use and rats; also administration of other known carcinogens with alcohol treatment when it is available.43 ethanol in drinking water enhanced tumor development more.23 All segments of US social strata are affected by alcohol abuse, Another key conclusion was that “the role of ethanol metabolism in but the prevalence of alcohol abuse is particularly high within tumor initiation is implied by the associations observed between American Indian and Alaska Native (AIAN) populations. AIAN different forms of cancer and polymorphisms in genes involved in people drink more alcohol and are more highly affected by alcohol- the oxidation of ethanol.”23 This point about polymorphisms is related illness than other populations.44 Among people age 12 years premised on the fact that genetic predisposition may amplify the and older, the prevalence of binge drinking was 28% for AIAN toxic and mutagenic effects of alcohol consumption. A specific people compared with 23% for whites, 22% for blacks, and 14% example of this line of reasoning is that most of the acetaldehyde for Asian Americans. Findings from the 2000 to 2006 Behavioral generated during alcohol metabolism in vivo is eliminated promptly Risk Factor Surveillance System showed that the rate of binge by aldehyde dehydrogenase-2 (ALDH2). However, a genetic variant drinking was a major difference between non-Hispanic white and of ALDH2 exists ([(rs671]*2) that encodes a catalytically inactive AIAN people, especially men.45 Similarly, rates of heavy drinking protein. Alcohol drinkers with the inactive form of ALDH2 expe- were highest (9%) among AIAN people and lowest (2%) among rience excessive accumulation of acetaldehyde, which amplifies its Asian Americans.44 The Indian Health Service, which provides toxic and mutagenic effects, and the amplification would be expected a large amount of the health care to the AIAN community, addresses to lead to greater susceptibility to alcohol-induced cancer. Several alcohol from a disease-model perspective.46 The Indian Health studies in East Asian populations, who have the highest prevalence of Service identifies alcoholism as a chronic disease with genetic, this high-risk genotype, have documented that alcohol drinking is psychosocial, and environmental factors.47 Individuals with cirrhosis more strongly associated with cancers of the upper aerodigestive and chronic liver disease are at much higher risk of liver cancer, and tract among those with a high-risk genotype.40 The IARC review also the main preventable causes of these conditions are chronic infection invoked mechanisms that included oxidative stress, sex hormones, with hepatitis B and C, chronic alcohol abuse, and nonalcoholic fatty folate metabolism, and DNA methylation as well as cirrhosis for liver disease. Though viral hepatitis prevention and treatment may hepatocellular carcinoma. Alcohol-induced oxidative stress, via the be making a significant health difference already, addressing chronic CYP2E1 pathway, for example, can result in chronic tissue in- alcohol abuse would be an important cancer prevention strategy. flammation.23 Alcohol drinking affects circulating concentrations of Differential rates of alcohol use according to socioeconomic androgens and estrogens, which is a pathway of particular relevance status hypothetically could contribute to cancer disparities. In to breast cancer.23 Consumption of alcohol is associated with lower reality, the relationship between alcohol drinking and socioeco- folate concentrations—a relationship that has been extensively nomic status is complex, because it depends on how alcohol studied in relation to the etiology of colon cancer.41 drinking is measured. When measures of alcohol use are used,

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ASCO Statement: Alcohol and Cancer those of a higher socioeconomic status are more likely to drink and cancer,62 which was higher than the 30% increased risk observed in to drink more heavily.48 However, for reasons that are poorly a multicentered case-control study.63 Other SPTs in patients with understood, measures of adverse consequences of alcohol tend to breast cancer that have been associated with greater alcohol concentrate more among those of a lower socioeconomic status.48 consumption (. 7 drinks per week versus none) include an in- A disproportionate share of the overall burden of cancer occurs in creased risk of subsequent colorectal cancer (hazard ratio [HR], those of a lower socioeconomic status, so alcohol drinking may be 1.92; 95% CI, 1.07 to 3.43) and a decreased risk of ovarian cancer a contributing factor to cancer disparities observed across the (HR, 0.45; 95% CI, 0.21 to 0.98).64 Results of studies to evaluate the spectrum of socioeconomic status; however, this remains a rela- relationship between alcohol consumption and colorectal cancer tively unexplored topic.49 have been mixed; one study observed that heavy drinking was Patterns of alcohol use and treatment also vary by sex and associated with poorer survival,65 whereas the majority of studies sexual orientation; higher rates are seen in sexual and gender have demonstrated either no association between alcohol drinking minority populations (ie, lesbian, gay, bisexual, transgender, and overall and colorectal cancer outcomes66 or a suggestion of better intersex).50 This population also is known to bear a greater burden overall survival with higher levels of wine consumption.67 A recent of cancer incidence.50 For example, although men have a higher meta-analysis of cohort studies among 209,597 cancer survivors prevalence of heavy drinking, women are less likely to use alcohol showed a statistically significant 8% increase in overall mortality treatment services,43 even among those with alcohol dependence.51 and a 17% increased risk for recurrence in the highest versus lowest Lesbian or bisexual female veterans had higher rates of alcohol alcohol consumers.68 More evidence is needed to clarify the impact misuse than heterosexual female veterans did, which may result at of both alcohol drinking and cessation on cancer outcomes. least in part from higher rates of trauma exposure and mental The majority of studies to evaluate the direct effects of alcohol health difficulties experienced by the lesbian/bisexual women.52 use on cancer treatment have focused on patients with upper Lesbian, gay, and bisexual young adults (ages 17 to 19 years) aerodigestive tract cancer, because 34% to 57% continue to drink consume more alcohol both in high school and in college.53 A after diagnosis.69 Smoking and alcohol use during and after ra- study of the National Longitudinal Study of Adolescent Health also diation therapy have been associated with an increased risk of confirmed significantly increased alcohol use and abuse among osteoradionecrosis of the jaw in patients with oral and oropha- lesbian, gay, and bisexual youth.54 A recent ASCO position statement ryngeal cancers.70-73 recommended increased cancer prevention education efforts, in- Alcohol abuse also complicates treatment outcomes among cluding reduction in high-risk alcohol use as a target effort.50 patients with cancer by contributing to longer hospitalizations, increased surgical procedures, prolonged recovery, higher health care costs,74-76 and higher mortality.77 Heavy alcohol use and abuse ALCOHOL AND CANCER: OUTCOMES AND EFFECT are important modifiable risk factors for postoperative morbid- ON TREATMENT ity.78 Heavy alcohol use79 and alcohol abuse,80 compared with no alcohol use, are associated with higher risks of anastomotic Compared with the wealth of evidence about the associations complications after colorectal surgery. Alcohol abuse, compared between alcohol drinking and the risk of developing cancer, re- with no abuse, also has been shown to contribute to low quality-of- search on the impact of alcohol drinking on outcomes in patients life outcomes in patients with head and neck cancer after with cancer is still in its nascent stages. For cancers that have known treatment.81,82 Patients with cancer who abuse alcohol have in- associations with alcohol drinking, it would be expected that al- creased comorbidities that can complicate treatment choices and cohol drinking at the time of diagnosis also would be associated that are affected by alcohol-related subclinical factors, including with risk of cancer recurrence and/or secondary primary tumors nutritional deficiencies, immunosuppression, and cardiovascular (SPTs). This association has been observed for patients with upper insufficiencies that increase treatment morbidity.83-85 aerodigestive tract cancer when nondrinkers are compared with Light alcohol use among cancer survivors has been perceived occasional drinkers. The risk of cancer-specific mortality is in- as potentially beneficial for treatment-related adverse effects, al- creased significantly in moderate drinkers (RR, 1.79; 95% CI, 1.26 though there is little evidence to support this concept. A cross- to 2.53) and heavy drinkers (RR, 3.63; 95% CI, 2.63 to 5.0).55 sectional study of patients with head and neck cancer showed that Among survivors of upper aerodigestive tract cancer, continued patients who reported drinking at least one serving of alcohol in the alcohol use after diagnosis is associated with a three-fold increased past month reported better functional scores and lower levels of risk of upper aerodigestive tract second primary tumors,56 and symptoms, such as fatigue, pain, dysphagia or dry mouth after cessation may reduce the increased risk for SPTs in pre-diagnosis treatment than those who reported that they had not used alco- drinkers compared with pre-diagnosis nondrinkers.29 In breast hol.86 Given the inability to distinguish the sequence of events in cancer survivors, several studies suggest that alcohol drinking is not a cross-sectional study design, it is unclear whether light alcohol associated with decreased overall survival,57 whereas other studies use promotes treatment recovery and well-being or is the result of indicate that breast cancer–specific mortality may be increased in at improved health-related quality of life among survivors. The least some subgroups of the patient population.58-60 The increase consumption of light alcohol for increasing appetite has been in breast cancer–specific mortality or risk of recurrence has been regarded as potentially beneficial for patients with cancer,87 be- observed with moderate to heavy levels of alcohol drinking.60,61 Li cause alcohol can stimulate appetite and snacking in cancer-free et al showed that, among women with estrogen receptor–positive individuals.88 However, a recent study of patients with advanced breast cancer, consumers of seven or more drinks per week versus cancer who had self-reported loss of appetite and who were none had a 90% increased risk of asynchronous contralateral breast randomly assigned to white wine with # 15% alcohol content jco.org © 2017 by American Society of Clinical Oncology 5

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LoConte et al twice a day for 3 to 4 weeks versus a nutritional supplement showed an alcohol use disorder in their lifetime, which is a rate similar to no improvement in appetite or weight.89 the general population.102 Burnout, which is very common among oncology providers, also is strongly associated with high-risk alcohol use.103-107 BARRIERS TO ADDRESSING ALCOHOL AND CANCER IN THE ONCOLOGY SETTING RESEARCH NEEDS In addition to the perception that light alcohol use may have a beneficial effect on appetite and tolerance of cancer treatment, Although alcohol is a well-established risk factor for the devel- conflicting data about the heart health of alcohol, especially red opment of certain cancers, very little is known about how current wine, is one additional barrier to addressing alcohol and cancer risk alcohol use affects cancer treatment delivery. Thus, the most in the oncology setting. However, subsequent work has revealed compelling and urgent research need for the oncology community multiple confounders to this conclusion about heart health, in- with regard to alcohol is better definition of the effect of concurrent cluding frequent classification of former and occasional alcohol alcohol use on cancer treatments, including chemotherapy, radi- drinkers as nondrinkers.90 For example, people who now abstain ation, and surgery, as well as on cancer outcomes. Anecdotal stories from alcohol often have underlying health concerns, which ex- from providers about the effect of alcohol on cancer treatment are plains their reasons to cut down on alcohol and thereby makes the intriguing, but rigorous scientific studies are needed to accurately current alcohol drinkers appear healthier than former and occa- quantify the effect. Underexplored research areas include the ef- sional drinkers—a so-called abstainer bias.90 In addition, larger fects of alcohol exposure on postoperative morbidity; on the ef- studies and meta-analyses have failed to show an all-cause mor- ficacy of chemotherapy and radiation; and on novel targeted tality benefit for low-volume alcohol use compared with abstinence therapies, such as immunotherapy and radiation. or intermittent use, which suggests the lack of a true benefit to daily Increased knowledge about the mechanistic effects of alcohol alcohol use.91,92 Differences in alcohol dehydrogenase variants are on cancer-related pathways and treatments may improve un- associated with nondrinking, and nondrinkers have had lower derstanding of its role in disease progression and therapeutic re- rates of coronary heart disease and stroke than even light sponsiveness and toxicity. For example, a preclinical study drinkers.93 As such, the benefit of alcohol consumption on car- demonstrated overlap between alcohol responsive genes and genes diovascular health likely has been overstated.94,95 As reviewed in that are involved in responsiveness to endocrine therapy in breast the Magnitude of the Association section, the risk of cancer is cancer cells.108 The insufficient knowledge about the detrimental increased even with low levels of alcohol consumption,30 so the net or potentially beneficial effects of alcohol use overall, as well as effect of alcohol is harmful. Thus, alcohol consumption should not effects of its dose and frequency, among patients with cancer be recommended to prevent cardiovascular disease or all-cause creates missed opportunities to intervene to improve overall mortality. quality of life and to educate patients about the cancer-specific Low physician knowledge of alcohol use and cancer risk is prognostic role of alcohol. another barrier to addressing alcohol use with patients. This lack of Systems-based research, including research into successful knowledge has been demonstrated among general practitioners, means for the oncology community to identify patients who are who were aware of an association of alcohol with cardiovascular currently using alcohol or who may be at high risk for alcohol health and obesity and who also felt that preventive health was an relapse, will be critical. How to effectively apply evidence-based important aspect of their work; however, the majority of providers clinical interventions to assist patients in reduction of abstention did not ask their patients about alcohol consumption, and most from alcohol use also should be explored. were unaware of alcohol as a carcinogen.96,97 A knowledge deficit was also seen among medical students relative to the role of alcohol as a risk factor in head and neck cancers.98 Knowledge of the PUBLIC HEALTH STRATEGIES TO REDUCE HIGH-RISK ALCOHOL CONSUMPTION association between cancer and alcohol also has been shown to be low among dentists and allied health professionals, who may be evaluating patients for these cancers. For example, dentists and Policies to reduce excessive alcohol consumption should be evi- fi 109 dental hygienists have lower awareness of the association between dence based (such as those identi ed by WHO or the Com- 110 alcohol use and head and neck cancers than family physician do munity Preventive Services Task Force ), culturally sensitive, and (40% for dentists v 94% for family physicians), and this lack of equitable in their implementation. Recognizing that excessive al- knowledge would hamper their ability to counsel patients about cohol use can delay or negatively impact cancer treatment and that alcohol-related cancers.99 reducing high-risk alcohol consumption is cancer prevention, ASCO In addition to a lack of knowledge of alcohol use as a cancer joins the growing number of cancer care and public health orga- risk factor, physicians use different approaches to counseling nizations to support strategies designed to prevent high-risk alcohol 111-129 patients about alcohol use. Just as overweight or obese physicians consumption such as the following and those in Table 2. are less likely to counsel their patients about obesity,100 alcohol use • Clinical strategies of alcohol screening and brief intervention among physicians may make them less likely to counsel patients provided in clinical settings: Health care providers can screen about the risks of alcohol use. In one study of Danish physicians, adults, including pregnant women, for excessive alcohol use to 18.8% of physicians met criteria for risky alcohol consumption.101 identify people whose levels or patterns of alcohol use place Estimates indicate that up to 14% of American physicians will have them at increased risk of alcohol-related harms. Health care

Table 2. Policy Recommendations of International Cancer Care and Public Health Organizations Organization Recommendation Association of European Cancer • Supports minimum pricing legislation Leagues (25 associations)111,112 • Monitoring implementation of the European Union Alcohol Strategy and the impact of the strategy on marketing to young people and reducing alcohol-related harm • Calls for stronger recognition of alcohol causality of cancer and other chronic diseases and European Code Against Cancer Cancer Research UK113 • Supports a comprehensive alcohol strategy to reduce drinking in the United Kingdom to levels where the risks are minimal • Recognizes need for measures to reduce the affordability of alcohol and to restrict young people’s exposure to alcohol advertising are needed if alcohol consumption will be reduced to historic levels and reduce the risk of cancer in the United Kingdom Irish Cancer Society114 • In May 2013, called on government to ban alcohol advertising Cancer Council Australia115-117 • Recommends the increased price of alcohol through taxation and an investigation into the need for the introduction of minimum pricing of alcohol115 • Endorses the need for compulsory warning labels on all alcoholic products116 • Supports a strategy to limit the exposure of marketing and promotion of alcohol overall and speciﬁcally to children117 Cancer Council Victoria (Australia)118,119 • Member of the Alcohol Policy Coalition • Recognizes the harmful link between advertising and harmful drinking in young people, and actively works to implement alcohol advertising restrictions to reduce exposure among people age 18 years and younger Cancer Association of South Africa120 • Advocates against consumption of any alcohol • Does not support any form of pink washing to market any product that contributes to cancer disease and death (including the alcohol industry) World Cancer Research Fund International121 • Recommends policies that will reduce the availability and affordability of alcohol European Society for Medical Oncology123 • Party to the European Chronic Disease Alliance position statement on the need for European Union action to help Europeans reduce alcohol consumption, and supports the following policy goals122: + ensure the implementation of the WHO Global Strategy to Reduce the Harmful Use of Alcohol + ensure achievement of WHO Global noncommunicable disease target for a 10% relative reduction in the harmful use of alcohol + ensure a new comprehensive European Union alcohol strategy + ensure that countries also have national alcohol strategies • Supports both supply- and demand-oriented strategies to reduce alcohol consumption including123: + increasing prices of alcoholic beverages; + limit the number of alcohol outlets (outlet density); + limit the hours of sales and establish regulations for minimum age of purchase; + implement school-based education to inﬂuence drinking behavior; and + restrict advertising, particularly to young people American Medical Association124,125 • Advocates for legislation aimed at minimizing alcohol promotions, advertising, and other marketing strategies by the alcohol industry aimed at adolescents124 • Supports a ban on the marketing of products, such as alcopops, gelatin-based alcohol products, food- based alcohol products, alcohol mists, and beverages that contain alcohol and caffeine and other additives to produce alcohol energy drinks that have special appeal to youths under the age of 21 years and supports state and federal regulations that would reclassify alcopops as a distilled spirit so that they can be taxed at a higher rate and cannot be advertised or sold in certain locations125 American Academy of Family Physicians126 • Supports efforts to reduce the amount of alcohol advertising, particularly content appealing to youth, and the development of educational programs and counter-advertising designed to illustrate more realistic images on the effects of alcohol American Public Health Association127 • Supports the development and adoption of an international framework convention on alcohol control127 • Supports the implementation of the recommendations of the National Research Council and Institute of Medicine’s report entitled “Reducing Underage Drinking: A Collective Responsibility,” including the monitoring of youth exposure to alcohol advertising and the raising of excise taxes128 European Public Health Alliance129 • Supports limitations on advertising of alcohol and product placement to minimize youth exposure to the marketing of these products

providers can then recommend or offer treatment services to • Increase alcohol taxes and prices: Taxes are placed on all those at risk. Brief counseling interventions for adults who alcohol beverages by both individual states and the federal drink excessively have been found to positively affect several government, and a portion of the federal excise tax may or patterns of excessive drinking, including heavy episodic may not be used to support treatment programs. Alcohol taxes (binge) drinking and high average weekly intake of alcohol.130 vary from state to state and also differ in the amount applied • Regulate alcohol outlet density: An alcohol outlet is deﬁned as based on the type of alcohol (eg, beer, wine, or spirits/hard li- any site where alcohol may be legally sold to an individual to quor). Increasing taxes, and therefore the overall price of alcohol, either consume on premises (eg, bars or restaurants) or off has been shown to inversely effect levels of excessive consumption premises (eg, liquor stores or other retail settings).131 Using and related health harms.135-137 Other regulations that may regulatory authority to reduce the number of alcohol outlets in directly or indirectly affect the price of alcoholic beverages, a given area (ie, density) has proven to be an effective strategy for including regulations on wholesale distribution and bans on reducing excessive alcohol consumption.131-134 This is fre- price-related promotions, may have some impact on excessive quently executed through outlet licensing or zoning processes. consumption, though more research is needed.138

• Maintain limits on days and hours of sale: Limiting the days or Pinkwashing is a form of cause marketing in which a company uses hours during which alcoholic beverages can be sold can be the color pink and/or pink ribbons to show a commitment to applied to both outlets where the alcohol is consumed on ﬁnding a cure for breast cancer. Given the consistent evidence that premises and retail outlets where the alcohol is consumed off shows the link between alcohol consumption and an increased risk premises. These policies, made at the state and local levels, are of breast cancer,25,151 alcoholic beverage companies should be intended to prevent excessive consumption by reducing access discouraged from using the symbols of the battle against breast to the alcohol.139 Evidence from several studies has demon- cancer to market their products. strated the positive impact that reducing the number of days or hours that alcoholic beverages are sold generally result in a decrease in related harms.140,141 THE ROLE OF THE ONCOLOGIST • Enhance enforcement of laws prohibiting sales to minors: The minimum legal drinking age is 21 years in all US states. Worldwide, alcohol-related cancers are estimated to be 5.5% of all Enhanced enforcement of the minimum legal drinking age cancers treated annually, which represents a large number of can reduce sales to minors (younger than 21 years) in retail patients. Oncologists frequently are the ones who manage the settings (such as, bars, restaurants, liquor stores), thereby 130 treatment of these patients, and they have a direct interest in helping to reduce youth access to alcohol. promotion of the health of patients. Such promotion likely will • Restrict youth exposure to advertising of alcoholic beverages: include helping patients reduce high-risk alcohol use. Oncologists Early onset of drinking has been associated with an increased 142 also stand in a position to drive the alcohol-related research agenda likelihood of developing dependence on alcohol later in life, as it affects patients with cancer. The most pressing questions and studies have demonstrated that youth exposed to more 143,144 include how active alcohol use affects cancer treatments, how advertisements also show increases in drinking levels. alcohol use affects risk of recurrence and overall prognosis, and The alcohol industry has only voluntary advertising codes how alcohol interacts with oral chemotherapy and supportive created by the major trade groups, and are not subjected to care medications. As front-line providers for these patients, federal restrictions. Currently, industry codes require that at another need to support is identiﬁcation of the most effective least 70% of the audience of the advertisements (including print, strategies to help patients reduce their alcohol use. Ways to radio, television, and internet/digital) consists of adults of legal address racial, ethnic, sex, and sexual orientation disparities that drinking age.145-147 However, the alcohol industry is frequently 148 will place these populations at increased rates for cancer also are noncompliant with its own self-regulation guidelines. needed. Oncology providers can serve as community advisors and • Resist further privatization of retail alcohol sales in com- leaders and can help raise the awareness of alcohol as a cancer risk munities with current government control. Following the end behavior. Finally, because alcohol use is quite common, an ini- of Prohibition in 1933, all states had wholesale of alcoholic tiative to address alcohol use (particularly high-risk alcohol use) “ ” beverages under state control. License states allowed retail is a potential preventive strategy to decrease the burden of cancer. “ ” sales by commercial interests, while some control states Policy efforts are likely to be the most effective way to address this allowed alcohol to be sold, but only through government-run need. retail stores that restrict off-premises sales outlets (ie, outlets where alcohol is sold for consumption elsewhere). In the United States, all states and counties that permit the sale of AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS alcohol allow privatized retail sales of beer, and most allow OF INTEREST privatized retail sale of all alcoholic beverages. Privatization most often affects wine and spirits (eg, vodka and whiskey) in Disclosures provided by the authors are available with this article at 149 the control states. jco.org. • Include alcohol control strategies in comprehensive cancer control plans: State, tribal, and territorial comprehensive alcohol control strategies are not commonly included in comprehensive cancer AUTHOR CONTRIBUTIONS control plans. Supporting the implementation of evidence-based strategies to prevent the excessive use of alcohol is one tool the Administrative support: Janette K. Merrill 150 cancer control community can use to reduce the risk of cancer. Manuscript writing: All authors In addition to these strategies, ASCO supports efforts to Final approval of manuscript: All authors eliminate pinkwashing in the marketing of alcoholic beverages.

potential life lost in the United States. Am J Public 5. World Health Organization: Alcohol. http://www. REFERENCES Health 103:641-648, 2013 who.int/mediacentre/factsheets/fs349/en/# 3. Scoccianti C, Cecchini M, Anderson AS, et al: 6. Hasin DS, Stinson FS, Ogburn E, et al: Prev- 1. Praud D, Rota M, Rehm J, et al: Cancer in- European Code Against Cancer 4th Edition: Alcohol alence, correlates, disability, and comorbidity of cidence and mortality attributable to alcohol con- drinking and cancer. Cancer Epidemiol 39:S67-S74, 2015 DSM-IV alcohol abuse and dependence in the United sumption. Int J Cancer 138:1380-1387, 2016 4. Centers for Disease Control and Prevention: States: Results from the National Epidemiologic 2. Nelson D.E., Jarman DW, Rehm J, et al: Alcohol use and health. http://www.cdc.gov/alcohol/ Survey on Alcohol and Related Conditions. Arch Gen Alcohol-attributable cancer deaths and years of fact-sheets/alcohol-use.htm Psychiatry 64:830-842, 2007

7. Edelman EJ, Fiellin DA: Alcohol Use. Ann In- 27. Alberg, AJ, Brock MV, Ford JG, et al.: Epide- to 2010 national alcohol surveys. Alcohol Clin Exp tern Med 164:ITC1-ITC16, 2016 miology of lung cancer: Diagnosis and management Res 38:2286-2296, 2014 8. National Institute on Alcohol Abuse and Al- of lung cancer—American College of Chest Physi- 44. Vaeth PA, Wang-Schweig M, Caetano R: coholism: Drinking levels defined. https://niaaa.nih. cians evidence-based clinical practice guidelines. Drinking, alcohol use disorder, and treatment access gov/alcohol-health/overview-alcohol-consumption/ Chest J 143:e1S-e29S, 2013 (suppl) and utilization among US racial/ethnic groups. Alco- moderate-binge-drinking 28. Bagnardi V, Rota M, Botteri E, et al: Alcohol hol Clin Exp Res 41:6-19, 2017 9. Hingson RW, Zha W, White AM: Drinking consumption and site-specific cancer risk: A com- 45. Steele CB, Cardinez CJ, Richardson LC, et al: beyond the binge threshold: Predictors, conse- prehensive dose-response meta-analysis. Br J Can- Surveillance for health behaviors of American Indians quences, and changes in the US. Am J Prev Med 52: cer 112:580-593, 2015 and Alaska Natives: Findings from the Behavioral 717-727, 2017 29. Druesne-Pecollo N, Keita Y, Touvier M, et al: Risk Factor Surveillance System, 2000-2006. Cancer 10. Esser MB, Hedden SL, Kanny D, et al: Prev- Alcohol drinking and second primary cancer risk in 113:1131-1141, 2008 alence of alcohol dependence among US adult drinkers, patients with upper aerodigestive tract cancers: A 46. Warne D, Kaur J, Perdue D: American Indian/ 2009-2011. Prev Chronic Dis 11:E206-E206, 2014 systematic review and meta-analysis of observa- Alaska Native cancer policy: Systemic approaches to 11. Richter L, Pugh BS, Peters EA, et al: Underage tional studies. Cancer Epidemiol Biomarkers Prev 23: reducing cancer disparities. J Cancer Educ 27: drinking: Prevalence and correlates of risky drinking 324-331, 2014 S18-S23, 2012 measures among youth aged 12-20. Am J Drug Al- 30. Bagnardi V, Rota M, Botteri E, et al: Light al- 47. Shore JH, Beals J, Orton H, et al: Comorbidity cohol Abuse 42:385-394, 2016 cohol drinking and cancer: A meta-analysis. Ann of alcohol abuse and dependence with medical 12. Milam J, Slaughter R, Meeske K, et al: Sub- Oncol 24:301-308, 2013 conditions in 2 American Indian reservation com- stance use among adolescent and young adult cancer 31. World Cancer Research Fund: Diet, nutrition, munities. Alcohol Clin Exp Res 30:649-655, 2006 survivors. Psychooncology 25:1357–1362, 2015 physical activity and breast cancer. http://www.wcrf. 48. Collins SE: Associations between socioeco- 13. Hollen PJ, Hobbie WL, Donnangelo SF, et al: org/sites/default/files/CUP_BREAST_REPORT_2017_ nomic factors and alcohol outcomes. Alcohol Res 38: Substance use risk behaviors and decision-making WEB.pdf 83-94, 2016 skills among cancer-surviving adolescents. J Pediatr 32. Jarl J, Gerdtham UG: Time pattern of re- 49. Jones L, Bates G, McCoy E, et al: Re- Oncol Nurs 24:264-273, 2007 duction in risk of oesophageal cancer following al- lationship between alcohol-attributable disease 14. Morgan S, Davies S, Palmer S, et al: Sex, cohol cessation: A meta-analysis. Addiction 107: and socioeconomic status, and the role of alcohol drugs, and rock ‘n’ roll: Caring for adolescents and 1234-1243, 2012 consumption in this relationship: A systematic re- young adults with cancer. J Clin Oncol 28:4825-4830, 33. Rehm J, Patra J, Popova S: Alcohol drinking view and meta-analysis. BMC Public Health 15: 2010 cessation and its effect on esophageal and head and 400, 2015 15. Klosky JL, Howell CR, Li Z, et al: Risky health neck cancers: A pooled analysis. Int J Cancer 121: 50. Griggs, J, Maingi S, Blinder V, et al.: American behavior among adolescents in the childhood cancer 1132-1137, 2007 Society of Clinical Oncology position statement: survivor study cohort. J Pediatr Psychol 37:634-646, 34. Marron M, Boffetta P, Zhang ZF, et al: Ces- Strategies for reducing cancer health disparities 2012 sation of alcohol drinking, tobacco smoking and the among sexual and gender minority populations. J Clin 16. International Alliance for Responsible Drink- reversal of head and neck cancer risk. Int J Epidemiol Oncol 35:2203-2208, 2017 ing: Policy review: National drinking guidelines. http:// 39:182-196, 2010 51. Alvanzo AA, Storr CL, Mojtabai R, et al: www.iard.org/wp-content/uploads/2016/04/Policy- 35. Ahmad Kiadaliri A, Jarl J, Gavriilidis G, et al: Gender and race/ethnicity differences for initiation of Review-National-Drinking-Guidelines.pdf Alcohol drinking cessation and the risk of laryngeal alcohol-related service use among persons with al- 17. Kushi LH, Doyle C, McCullough M, et al: and pharyngeal cancers: A systematic review and cohol dependence. Drug Alcohol Depend 140:48-55, American Cancer Society guidelines on nutrition and meta-analysis. PLoS One 8:e58158, 2013 2014 physical activity for cancer prevention: Reducing the 36. Johansson E, Alho H, Kiiskinen U, et al: 52. Lehavot K, Browne KC, Simpson TL: Exam- risk of cancer with healthy food choices and physical Abstaining from alcohol and labour market under- ining sexual orientation disparities in alcohol misuse activity. CA Cancer J Clin 62:30-67, 2012 performance: Have we forgotten the ‘dry’ alcoholics? among women veterans. Am J Prev Med 47: 18. DeSalvo KB, Olson R, Casavale KO: Dietary Alcohol Alcohol 41:574-579, 2006 554-562, 2014 guidelines for Americans. JAMA 315:457-458, 2016 37. Hashibe M, Brennan P, Chuang SC, et al: In- 53. Hatzenbuehler ML, Corbin WR, Fromme K: 19. American Heart Association: Alcohol and heart teraction between tobacco and alcohol use and the Trajectories and determinants of alcohol use among health. http://www.heart.org/HEARTORG/HealthyLiving/ risk of head and neck cancer: Pooled analysis in the LGB young adults and their heterosexual peers: HealthyEating/Nutrition/Alcohol-and-Heart-Health_UCM_ International Head and Neck Cancer Epidemiology Results from a prospective study. Dev Psychol 44: 305173_Article.jsp# Consortium. Cancer Epidemiol Biomarkers Prev 18: 81-90, 2008 20. Dawson DA: Defining risk drinking. Alcohol 541-550, 2009 54. Hatzenbuehler L., McLaughlin KA, Xuan Z: Res Health 34:144-156, 2011 38. Taylor B, Rehm J: When risk factors combine: Social networks and sexual orientation disparities in 21. International Alliance for Responsible Drinking The interaction between alcohol and smoking for tobacco and alcohol use. J Stud Alcohol Drugs 76: Drinking guidelines: General population. http://www. aerodigestive cancer, coronary heart disease, and 117-126, 2015 iard.org/policy-tables/drinking-guidelines-general- trafficandfire injury. Addict Behav 31:1522-1535, 55. Li Y, Mao Y, Zhang Y, et al: Alcohol drinking population/ 2006 and upper aerodigestive tract cancer mortality: A 22. National Institute on Alcohol Abuse and Al- 39. Poschl¨ G, Seitz HK: Alcohol and cancer. Al- systematic review and meta-analysis. Oral Oncol 50: coholism: What is a standard drink? https://niaaa.nih. cohol Alcohol 39:155-165, 2004 269-275, 2014 gov/alcohol-health/overview-alcohol-consumption/ 40. Eriksson CP: Genetic–epidemiological evi- 56. Do KA, Johnson MM, Doherty DA, et al: what-standard-drink dence for the role of acetaldehyde in cancers related Second primary tumors in patients with upper aer- 23. van’t Veer P, Kampman E: Food, Nutrition, to alcohol drinking, in Vasiliou V, Zakhari S, Seitz H, odigestive tract cancers: Joint effects of smoking and Physical Activity, and the Prevention of Cancer: A et al (eds): Biological Basis of Alcohol-Induced Can- alcohol (United States). Cancer Causes Control 14: Global Perspective. Washington, DC, World Cancer cer. Advances in Experimental Medicine and Biology 131-138, 2003 Research Fund/American Institute for Cancer Re- (vol 815). Cham, Switzerland, Springer, 2015, p 41 57. Lowry SJ, Kapphahn K, Chlebowski R, et al: search, 2007 41. World Cancer Research Fund/American In- Alcohol use and breast cancer survival among par- 24. World Cancer Research Fund: Continuous stitute for Cancer Research: Food, Nutrition, Physical ticipants in the Women’s Health Initiative. Cancer update project report: Diet, nutrition, physical activity Activity, and the Prevention of Cancer: A Global Epidemiol Prev Biomarker 25:1268-1273, 2016 and liver cancer. wcrf.org/liver-cancer-2015 Perspective. Washington, DC, American Institute for 58. Weaver AM, McCann SE, Nie J, et al: Alcohol 25. IARC Working Group on the Evaluation of Cancer Research, 2007 intake over the life course and breast cancer survival Carcinogenic Risks to Humans: Personal habits and 42. National Institute on Alcohol Abuse and Al- in western New York exposures and breast cancer indoor combustions, in A Review of Human Carcin- coholism: Strategic plan to address health disparities. (WEB) study: Quantity and intensity of intake. Breast ogens. Lyon, France, 2009 https://niaaa.nih.gov/sites/default/files/publications/ Cancer Res Treat 139:245-253, 2013 26. World Cancer Research Fund: Continuous 20092013HealthDisparitiesStrategicPlan.pdf 59. Vrieling A, Buck K, Heinz J, et al: Pre-diagnostic update project report: Diet, nutrition, physical activity 43. Zemore S.E., Murphy RD, Mulia N, et al: A alcohol consumption and postmenopausal breast and stomach cancer. http://wcrf.org/stomach-cancer- moderating role for gender in racial/ethnic disparities cancer survival: A prospective patient cohort study. 2016 in alcohol services utilization: Results from the 2000 Breast Cancer Res Treat 136:195-207, 2012

60. Kwan ML, Kushi LH, Weltzien E, et al: Alcohol Medicare enrollees with prostate cancer. J Geriatr 95. Naimi TS, Brown DW, Brewer RD, et al: consumption and breast cancer recurrence and sur- Oncol 7:444-452, 2016 Cardiovascular risk factors and confounders among vival among women with early-stage breast cancer: 76. O’Shea R, Byrne H, Tuckett J, et al: Impact of nondrinking and moderate-drinking US adults. Am J The life after cancer epidemiology study. J Clin Oncol current smoking and alcohol consumption on gastro- Prev Med 28:369-373, 2005 28:4410-4416, 2010 stomy duration in patients with head and neck cancer 96. Wellard L, Corsini N, Hughes C: Discussing 61. Holm M, Olsen A, Christensen J, et al: Pre- undergoing definitive chemoradiotherapy. JAMA alcohol and cancer with patients: Knowledge and diagnostic alcohol consumption and breast cancer Otolaryngol Head Neck Surg 141:463-469, 2015 practices of general practitioners in New South recurrence and mortality: Results from a prospective 77. Green A, Hauge J, Iachina M, et al: The Wales and South Australia. Aust Fam Physician 45: cohort with a wide range of variation in alcohol intake. mortality after surgery in primary lung cancer: Results 588-593, 2016 Int J Cancer 132:686-694, 2013 from the Danish Lung Cancer Registry. Eur J Car- 97. Tanriover O, Hidiroglu S, Save D, et al: 62. Li CI, Daling JR, Porter PL, et al: Relationship diothorac Surg 49:589-594, 2016 Knowledge of oral cancer, preventive attitudes, and between potentially modifiable lifestyle factors and 78. Tønnesen H, Petersen KR, Højgaard L, et al: behaviors of primary care physicians in Turkey. Eur J risk of second primary contralateral breast cancer Postoperative morbidity among symptom-free alco- Cancer Prev 23:464-468, 2014 among women diagnosed with estrogen receptor- hol misusers. Lancet 340:334-337, 1992 98. Freiser E., Desai DD, Azcarate PM, et al: Ed- positive invasive breast cancer. J Clin Oncol 27: 79. van Rooijen S, Carli F, Dalton SO, et al: Pre- ucational value of a medical student-led head and 5312-5318, 2009 operative modifiable risk factors in colorectal surgery: neck cancer screening event. Otolaryngol Head Neck 63. Knight JA, Bernstein L, Largent J, et al: Alcohol An observational cohort study identifying the possi- Surg 154:638-644, 2016 intake and cigarette smoking and risk of a contralat- ble value of prehabilitation. Acta Oncol 56:329-334, 99. Patton LL, Ashe TE, Elter JR, et al: Adequacy eral breast cancer: The Women’s Environmental 2017 of training in oral cancer prevention and screening as Cancer and Radiation Epidemiology Study. Am J 80. Sørensen LT, Jørgensen T, Kirkeby LT, et al: self-assessed by physicians, nurse practitioners, and Epidemiol 169:962-968, 2009 Smoking and alcohol abuse are major risk factors for dental health professionals. Oral Surg Oral Med Oral 64. Trentham-Dietz A, Newcomb PA, Nichols HB, anastomotic leakage in colorectal surgery. Br J Surg Pathol Oral Radiol Endod 102:758-764, 2006 100. et al: Breast cancer risk factors and second primary 86:927-931, 1999 Bleich SN, Bennett WL, Gudzune KA, et al: malignancies among women with breast cancer. 81. Danker H, Keszte J, Singer S, et al: Alcohol Impact of physician BMI on obesity care and beliefs. Breast Cancer Res Treat 105:195-207, 2007 consumption after laryngectomy. Clin Otolaryngol Obesity (Silver Spring) 20:999-1005, 2012 65. 101. Walter V, Jansen L, Ulrich A, et al: Alcohol 36:336-344, 2011 Pedersen AF, Sørensen JK, Bruun NH, et al: consumption and survival of colorectal cancer pa- 82. Sehlen S, Hollenhorst H, Lenk M, et al: Only Risky alcohol use in Danish physicians: Associated tients: Population-based study from Germany. Am J sociodemographic variables predict quality of life with alexithymia and burnout? Drug Alcohol Depend Clin Nutr 103:1497-1506, 2016 after radiography in patients with head-and-neck 160:119-126, 2016 66. 102. Phipps AI, Baron J, Newcomb PA: Pre- cancer. Int J Radiat Oncol Biol Phys 52:779-783, 2002 Baldisseri MR: Impaired healthcare pro- diagnostic smoking history, alcohol consumption, and fessional. Crit Care Med 35:S106-S116, 2007 83. Gloria´ L, Cravo M, Camilo ME, et al: Nutritional colorectal cancer survival: The Seattle Colon Cancer 103. Domino KB, Hornbein TF, Polissar NL, et al: deficiencies in chronic alcoholics: Relation to dietary Family Registry. Cancer 117:4948-4957, 2011 Risk factors for relapse in health care professionals intake and alcohol consumption. Am J Gastroenterol 67. Phipps AI, Robinson JR, Campbell PT, et al: with substance use disorders. JAMA 293: 92:485-489, 1997 Prediagnostic alcohol consumption and colorectal 1453-1460, 2005 84. Szabo G, Mandrekar P: A recent perspective cancer survival: The Colon Cancer Family Registry. 104. Jackson ER, Shanafelt TD, Hasan O, et al: on alcohol, immunity, and host defense. Alcohol Clin Cancer 123:1035-1043, 2016 Burnout and alcohol abuse/dependence among US Exp Res 33:220-232, 2009 68. Schwedhelm C, Boeing H, Hoffmann G, et al: medical students. Acad Med 91:1251-1256, 2016 85. Mostofsky E, Chahal HS, Mukamal KJ, et al: Effect of diet on mortality and cancer recurrence 105. Rath, KS, Huffman LB, Phillips GS, et al: Alcohol and immediate risk of cardiovascular events: among cancer survivors: A systematic review and Burnout and associated factors among members of A systematic review and dose-response meta-analysis. meta-analysis of cohort studies. Nutr Rev 74: the Society of Gynecologic Oncology. Am J Obstet Circulation 133:979-987, 2016 737-748, 2016 Gynecol 213:824.e1-824.e9, 2015 86. Allison PJ: Alcohol consumption is associated 69. Miller PM, Day TA, Ravenel MC: Clinical im- 106. Granek L, Ariad S, Nakash O, et al: Mixed- with improved health-related quality of life in head plications of continued alcohol consumption after methods study of the impact of chronic patient death and neck cancer patients. Oral Oncol 38:81-86, 2002 diagnosis of upper aerodigestive tract cancer. Alco- on oncologists’ personal and professional lives. 87. “ hol Alcohol 41:140-142, 2006 Ma C, Jatoi A: Wine for appetite loss: How do J Oncol Pract 13:e1-e10, 2017 ” 70. Chronopoulos A, Zarra T, Troltzsch¨ M, et al: you know? J Clin Oncol 25:1285-1287, 2007 107. Shanafelt T, Dyrbye L: Oncologist burnout: 88. Osteoradionecrosis of the mandible: A ten-year Rose AK, Hardman CA, Christiansen P: The Causes, consequences, and responses. J Clin Oncol single-center retrospective study. J Craniomaxillofac effects of a priming dose of alcohol and drinking 30:1235-1241, 2012 Surg 43:837-846, 2015 environment on snack food intake. Appetite 95: 108. Candelaria NR, Weldon R, Muthusamy S, et al: 71. Oh HK, Chambers MS, Martin JW, et al: 341-348, 2015 Alcohol regulates genes that are associated with 89. “ Osteoradionecrosis of the mandible: Treatment Jatoi A, Qin R, Satele D, et al: Enjoy glass of response to endocrine therapy and attenuates the ” outcomes and factors influencing the progress of wine before eating: A randomized trial to test the actions of tamoxifen in breast cancer cells. PLoS One osteoradionecrosis. J Oral Maxillofac Surg 67: orexigenic effects of this advice in advanced cancer 10:e0145061, 2015 1378-1386, 2009 patients. Support Care Cancer 24:3739-3746, 2016 109. World Health Organization: Global strategy to 72. Owosho AA, Tsai CJ, Lee RS, et al: The 90. Stockwell T, Zhao J: Alcohol’s contribution to reduce the harmful use of alcohol. Geneva, Switzerland, prevalence and risk factors associated with osteo- cancer is underestimated for exactly the same rea- World Health Organization, 2010 radionecrosis of the jaw in oral and oropharyngeal son that its contribution to cardioprotection is over- 110. The Community Guide: Alcohol: Excessive cancer patients treated with intensity-modulated ra- estimated. Addiction 112:230-232, 2017 consumption—Regulstion of alcohol outlet density. diation therapy (IMRT): The Memorial Sloan Kettering 91. Stockwell T, Zhao J, Panwar S, et al: Do https://www.thecommunityguide.org/findings/alcohol- Cancer Center experience. Oral Oncol 64:44-51, “moderate” drinkers have reduced mortality risk? A excessive-consumption-regulation-alcohol-outlet-density 2017 systematic review and meta-analysis of alcohol 111. Association of European Cancer Leagues: Alco- 73. Raguse JD, Hosamo J, Tinhofer I, et al: Patient consumption and all-cause mortality. J Stud Alcohol hol and cancer. http://www.europeancancerleagues. and treatment-related risk factors for osteoradionec- Drugs 77:185-198, 2016 org/cancer-prevention/alcohol-and-cancer.html rosis of the jaw in patients with head and neck cancer. 92. Goulden, R: Moderate alcohol consumption is 112. Eurocare: EU alcohol strategy. http://eur- Oral Surg Oral Med Oral Pathol Oral Radiol 121: not associated with reduced all-cause mortality. Am J lex.europa.eu/legal-content/EN/TXT/?uri=CELEX: 215-221, 2016 Med 129:180-186.e4, 2016 52006DC0625 74. Genther DJ, Gourin CG: The effect of alcohol 93. Holmes MV, Dale CE, Zuccolo L, et al: As- 113. University of Stirling: Health first: An evidence- abuse and alcohol withdrawal on short-term out- sociation between alcohol and cardiovascular dis- based alcohol strategy for the UK. http://www.stir.ac.uk/ comes and cost of care after head and neck cancer ease: Mendelian randomisation analysis based on media/schools/management/documents/Alcoholstrategy- surgery. Laryngoscope 122:1739-1747, 2012 individual participant data. BMJ 349:g4164, 2014 updated.pdf 75. Jayadevappa R, Chhatre S: Association be- 94. Friedmann PD: Clinical practice: Alcohol use in 114. Irish Cancer Society News: Irish drinkers tween age, substance use, and outcomes in adults. N Engl J Med 368:365-373, 2013 consume 700 times recommended alcohol exposure

threshold. https://www.cancer.ie/content/irish-drinkers- 126. American Academy of Family Physicians: vaccination of 11- to 12-year-olds. Pediatrics 130: consume-700-times-recommended-amount-alcohol- Alcohol advertising and youth (position paper). http:// 798-805, 2012 needed-prevent-cancer#sthash.Z3OaKWGS.dpbs www.aafp.org/about/policies/all/alcohol-advertising.html 139. Anderson P, Chisholm D, Fuhr DC: Effec- 115. Cancer Council Australia: Position statement: 127. American Public Health Association: A call for tiveness and cost-effectiveness of policies and pro- Alcohol pricing and taxation. http://wiki.cancer.org. a framework convention on alcohol control. https:// grammes to reduce the harm caused by alcohol. au/policy/Position_statement_-_Alcohol_pricing_and_ apha.org/policies-and-advocacy/public-health-policy- Lancet 373:2234-2246, 2009 taxation#_ga=1.53344168.1834557876.1490795867 statements/policy-database/2014/07/07/11/50/a-call- 140. Middleton JC, Hahn RA, Kuzara JL, et al: Ef- 116. Cancer Council Australia: Position statement: for-a-framework-convention-on-alcohol-control fectiveness of policies maintaining or restricting days Consumer information and labeling of alcohol. http:// 128. American Public Health Association: Reducing of alcohol sales on excessive alcohol consumption wiki.cancer.org.au/policy/Position_statement_-_ underage alcohol consumption. https://apha.org/policies- and related harms. Am J Prev Med 39:575-589, 2010 Consumer_information_and_labelling_of_alcohol#_ and-advocacy/public-health-policy-statements/policy- 141. Popova S, Giesbrecht N, Bekmuradov D, et al: ga=1.10942132.1834557876.1490795867 database/2014/07/02/15/13/reducing-underage-alcohol- Hours and days of sale and density of alcohol outlets: 117. Cancer Council Australia: Position statement: consumption impacts on alcohol consumption and damage: A Marketing and promotion of alcohol. http://wiki.cancer. 129. European Public Health Alliance: Three steps systematic review. Alcohol Alcohol 44:500-516, 2009 org.au/policy/Position_statement_-_Marketing_and_ toward healthier marketing. https://epha.org/3-steps- 142. Hingson RW, Heeren T, Winter MR: Age at promotion_of_alcohol#_ga=1.112038916.1834557876. towards-healthier-marketing-improve-the-avmsd/ drinking onset and alcohol dependence: Age at on- 1490795867 130. Centers for Disease Control and Prevention: set, duration, and severity. Arch Pediatr Adolesc Med 118. Alcohol Policy Coalition: Partners. http://www. Policies and practices for cancer prevention: Preventing 160:739-746, 2006 alcoholpolicycoalition.org.au/about/partners cancer by reducing excessive alcohol use. https://www. 143. Snyder LB, Milici FF, Slater M, et al: Effects of 119. Cancer Coalition Victoria: Alcohol Policy Co- cdc.gov/cancer/dcpc/pdf/reducingexcessalcoholuse.pdf alcohol advertising exposure on drinking among alition supports protecting kids from alcohol ads. 131. Task Force on Community Preventive Ser- youth. Arch Pediatr Adolesc Med 160:18-24, 2006 http://www.cancervic.org.au/about/media-releases/ vices: Recommendations for reducing excessive al- 144. Smith LA, Foxcroft DR: The effect of alcohol 2014-media-releases/september-2014/apc-supports- cohol consumption and alcohol-related harms by advertising, marketing and portrayal on drinking be- protecting-kids-from-alcohol-ads.html limiting alcohol outlet density. Am J Prev Med 37: haviour in young people: Systematic review of pro- 120. Cancer Association of South Africa: Fact sheet 570-571, 2009 spective cohort studies. BMC Public Health 9:51, 2009 and position statement on alcohol consumption and 132. Campbell CA, Hahn RA, Elder R, et al: The 145. Distilled Spirits Council of the United States: cancer risk. http://www.cansa.org.za/files/2017/03/ effectiveness of limiting alcohol outlet density as Code of responsible practices for beverage alcohol ad- Fact-Sheet-Position-Statement-on-Alcohol-Consumption- a means of reducing excessive alcohol consumption vertising and marketing. http://www.discus.org/assets/ Cancer-Risk-February-2017.pdf and alcohol-related harms. Am J Prev Med 37: 1/7/May_26_2011_DISCUS_Code_Word_Version1.pdf 121. World Cancer Research Fund: Alcoholic 556-569, 2009 146. The Beer Institute: Advertising and market- drinks. http://www.wcrf.org/int/research-we-fund/ 133. Livingston M, Chikritzhs T, Room R: Changing ing code. http://www.beerinstitute.org/responsibility/ cancer-prevention-recommendations/alcoholic-drinks the density of alcohol outlets to reduce alcohol- advertising-marketing-code/ 122. European Chronic Disease Alliance: Don’t related problems. Drug Alcohol Rev 26:557-566, 147. Wine Institute: Advertising code. http://www. bottle out: Why the EU needs a comprehensive al- 2007 wineinstitute.org/initiatives/issuesandpolicy/adcode/ cohol strategy. http://www.alliancechronicdiseases. 134. Kuntsche E, Kuendig H, Gmel G: Alcohol outlet details org/fileadmin/user_upload/policy_papers/ECDA_ density, perceived availability and adolescent alcohol 148. Ross C, Sims J, Jernigan D:, Alcohol Adver- position_paper_on_alcohol_-_March_2015.pdf use: A multilevel structural equation model. tising Compliance on Cable Television. Baltimore, 123. ESMO: Handbook of cancer prevention. 2007 J Epidemiol Community Health 62:811-816, 2008 MD, Johns Hopkins Bloomberg School of Public http://oncologypro.esmo.org/Publications/Handbooks/ 135. Elder RW, Lawrence B, Ferguson A, et al: The Health, 2016 Cancer-Prevention effectiveness of tax policy interventions for reducing 149. Hahn RA, Middleton JC, Elder R, et al: Effects 124. American Medical Association: Alcohol and excessive alcohol consumption and related harms. of alcohol retail privatization on excessive alcohol youth: D-170.998. https://policysearch.ama-assn.org/ Am J Prev Med 38:217-229, 2010 consumption and related harms: A community guide policyfinder/detail/D-170.998?uri=%2FAMADoc% 136. Chaloupka FH, Grossman M, Saffer H: The systematic review. Am J Prev Med 42:418-427, 2012 2Fdirectives.xml-0-401.xml effects of price on alcohol consumption and alcohol- 150. Henley SJ, Kanny D, Roland KB, et al: Alcohol 125. American Medical Association: Prevention of related problems. Alcohol Res Health 26:22-34, 2002 control efforts in comprehensive cancer control plans underage drinking: A call to stop alcoholic bever- 137. Xu X, Chaloupka FH: The effects of prices on and alcohol use among adults in the USA. Alcohol ages with special appeal to youths—D-60.973. alcohol use and its consequences. Alcohol Res Alcohol 49:661-667, 2014 https://policysearch.ama-assn.org/policyfinder/detail/ Health 34:236-245, 2011 151. World Health Organization: Global Status Re- D-60.973?uri=%2FAMADoc%2Fdirectives.xml-0- 138. Bednarczyk RA, Davis R, Ault K, et al: Sexual port on Alcohol and Health, 2014. Geneva, Switzerland, 1785.xml activity-related outcomes after human papillomavirus World Health Organization, 2014

Affiliations Noelle K. LoConte, University of Wisconsin Madison, Madison, WI; Abenaa M. Brewster, MD Anderson Cancer Center, Houston, TX; Judith S. Kaur, Mayo Clinic, Jacksonville, FL; Janette K. Merrill, American Society of Clinical Oncology, Alexandria, VA; and Anthony J. Alberg, University of South Carolina, Columbia, SC. nnn

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Alcohol and Cancer: A Statement of the American Society of Clinical Oncology The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conﬂict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc. Noelle K. LoConte Janette K. Merrill Consulting or Advisory Role: Celgene No relationship to disclose Abenaa M. Bewster Anthony J. Alberg No relationship to disclose No relationship to disclose Judith S. Kaur Honoraria: Lilly Travel, Accommodations, Expenses: Lilly

Acknowledgment

We appreciate the contributions of Donald Zeigler and of the members of the ASCO Cancer Prevention Committee.

PROJECT EXTRA MILE 2019 Legislative Bill Tracking

Bill # Sponsor(s) Description Bill Status Additional Information Permits City and County to enter into an interlocal Blood Provide for interlocal agreements regarding Approved by LB11 agreement for joint and cooperative action within Urban Affairs nuisances Gov. 3/12/19 extraterritorial zoning jurisdiction to prevent nuisances. Hilkemann Change provisions relating to occupant Transportation and protection system enforcement and change Requires all passengers of a vehicle to utilize a seatbelt; LB39 Telecommunications Hearing 3/4/19 certain violations from secondary to primary infraction results in a primary offense and a fine of $25. McDonnell name enforcement added Permits the Nebraska Liquor Control Commission (LCC) to Change special designated licensure deliver a special designated license (SDL) to the licensee Lowe Approved by LB56 provisions under the Nebraska Liquor Control electronically. Reduces the number of days prior to the General Affairs Gov. 3/12/19 Act event from 21 to 12 if the local governing body has established an expedited process for SDL applications.  Permits a court to defer sentencing of a defendant pending upon successful completion of probation.  The defendant’s charge may be dismissed without judgment upon successful completion of probation and payment or waiver of all administrative & programming fees.  A defendant is not eligible for deferred judgement if: o Have previously been convicted of a felony o Have been granted deferred judgement 2 or more Wayne Provide for deferred judgments by courts as times LB91 Hearing 3/20/19 Judiciary prescribed o Had been granted deferment within the past 5 years for a felony o Are not eligible for probation o The defendant is a business entity  Court must first determine if deferred judgement will provide maximum opportunity for rehabilitation and protect the community from further offenses by the defendant  Upon judgement, the court must specify, in writing, reasons and supporting facts for decision Prepared by Project Extra Mile Last updated: 3/12/2019

 Probation limits are: o For a felony, not less than 2 years or more than 5 years o For a misdemeanor, not less than 1 year or more than 2 years o The term may be extended for up to 1 year o The term may be reduced if the purpose of probation has been fulfilled and fees paid Wishart LB110 Judiciary Adopt the Medical Cannabis Act Hearing 1/25/19 AM21 pending *Wishart priority Requires at least one hour of behavioral and mental health training for nurses, teachers, counselors, LB120 Crawford Require teacher and school staff to receive psychologists, administrators, social workers, etc. during Hearing 3/4/19 Support Education training on behavioral and mental health contract hours. New training topics include trauma- informed care, early detection of behavioral and mental health problems, effective responses for educators, etc. Quick; Albrecht, Increases legal age of use of vapor products to 21; Bolz, Cavanaugh, Violation will result in a Class V misdemeanor. Hilkemann, Howard, Misrepresenting one’s age in order to purchase vapor LB149 McDonnell, Pansing Change provisions relating to vapor products Hearing 3/4/19 products shall be guilty of a Class V misdemeanor. Brooks, Vargas, Sale to an individual under 21 will result in a Class III Walz, Wishart misdemeanor. General Affairs Requires Nebraska State Patrol to research how to Brewer; Gragert, increase state criminal justice protective and investigative Pansing Brooks resources for reporting and identifying Native American Judiciary Authorize a study to improve reporting and women and children in Nebraska by working with the LB154 Approved by Cavanaugh, DeBoer, investigation of missing Native American Commission on Indian Affairs and the Department of Support Gov. 3/12/19 Slama, Erdman, women Justice. Results and recommendations must be provided Hunt, McCollister to the Legislature by 6/1/2020. name added AM36 adopted

Prepared by Project Extra Mile Last updated: 3/12/2019

Appropriates $1.525M/fiscal year to the Nebraska Commission on Law Enforcement and Criminal Justice for the Office of Violence Prevention to be used for Bolz; Hilkemann State intent relating to appropriations for the increasing grant awards, developing an annual statewide LB174 Appropriations Hearing 3/6/19 Office of Violence Prevention strategic plan, increase administrative capacity, and Wayne name added develop a technical assistance partnership with the University of Nebraska. This appropriation does not sunset. Prohibits the Department of Health and Human Services from denying a license application or renewal of a facility Change provisions relating to licensure under due to the use of locked doors for civil protective custody Wishart the Health Care Facility Licensure Act of Pres. to Gov. services, as long as they are only used while the LB200 Health & Human alcoholism centers providing civil protective 3/7/19 individual is a danger to themselves or others. Services custody of intoxicated persons AM90 adopted ER20 adopted Restricts the ability of a person to petition to set aside an infraction, misdemeanor or felony to those sentenced to one year or less of imprisonment. A petition shall be denied if filed: 1) By any person with a criminal charge pending in any court in the United States or other country; 2) During any period in which the person is required to McCollister Provide for setting aside certain infraction, LB213 Hearing 1/25/19 register under the Sex Offender Registration Act; Judiciary misdemeanor, and felony convictions 3) For any misdemeanor or felony motor vehicle offense under 28-306 (motor vehicle homicide) or the Nebraska Rules of the Road, including reckless and willful reckless driving, driving under the influence of alcohol or drugs, or driving under a revocation period or; 4) Within 2 years after a previous petition denial. Crawford Expands the limited exception for home brewers to Change provisions relating to making and LB235** General Affairs Pres. to Gov. participate in brew competitions to include exhibitions, serving alcoholic liquor by nonlicensed Oppose Blood, Hunt name 3/7/19 festivals and tastings, including those for nonprofit persons as prescribed added fundraisers.

Prepared by Project Extra Mile Last updated: 3/12/2019

Provide property tax relief by eliminating certain sales tax exemptions and increasing other sales and excise taxes such as those levied on alcohol and cigarettes. Taxes on all alcoholic beverages increases to the equivalent of $0.10 per standard drink.  Tax on beer increases from $0.31 to $1.38/gallon Briese; Friesen  Tax on wine increases from $0.95 to $3.51/gallon Revenue Adopt the Remote Seller Sales Tax Collection  Tax on farm wine increases from $0.06 to $2.62/gallon LB314** Brandt, Pansing Act and change revenue and taxation Hearing 2/14/19  Tax on spirits increases from $3.75 to $12.28/gallon Support Brooks, Halloran provisions  Increased revenue from alcohol taxes is diverted to name added the Property Tax Credit Cash Fund  Tax on cigarettes increases from $0.64 to $2.14/pack  Expands taxable services  Expands taxable food to include candy, soft drinks, and bottled water  Defines vaping products as tobacco products for tax purposes. Permits youth ages 15 to 17 to assist law enforcement or private contractors hired by a licensee in conducting tobacco compliance checks. Requires written parental consent, that the youth not consume the tobacco product, written notice from the contractor of the Crawford; Blood Change provisions relating to enforcement of General File LB322 compliance check on the outcome of the check to a Judiciary certain tobacco restriction provisions 2/26/19 licensee that refused the sale, and that prevention coalitions shall not subject a business to more than one check every 30 days.

AM271 pending  Finds that alternatives to incarceration should be considered in order to reduce the cost to taxpayers, successfully rehabilitate offenders and ensure public Authorize a 24/7 sobriety program permit for LB335* Hansen, M safety. operating a motor vehicle as a condition of Hearing 2/13/19 Support Judiciary  Establishes a 24/7 sobriety program that requires bail abstinence from alcohol and other drugs for a specified period of time during which the individual is tested at least twice per day.

Prepared by Project Extra Mile Last updated: 3/12/2019

 Participation in the program is voluntary by each County Sheriff or his/her designee.  A test in violation of the 24/7 sobriety program will result in:  1st sanction – continuous 12-hour sanction (jail or detoxification center) & release back into program  2nd sanction – 24 hours in jail with release back into the program  3rd to 5th sanction – 48 hours served in jail and participant’s bond reset by the court  6th sanction – removal from the 24/7 sobriety program and participant shall be ineligible for further participation in the program for that case.  Participants may opt for a continuous alcohol monitoring device and be responsible for the cost of said device.  Reasonable fees not to exceed $3 per day shall be established by the sheriff or designated agency to cover costs incurred but may be waived by court if participant has demonstrated inability to pay.  If program participant is arrested for a DUI while in the program, the participant may petition the court to remain if he/she is able to demonstrate 30 consecutive days without sanctions being imposed. Hansen, B; Albrecht, Brewer, Clements, Dorn, Erdman, Friesen, Gragert, Provides an exemption for those 21 years and older to Groene, Halloran, LB378 Change helmet provisions for autocycles, not be required to wear a helmet while on an autocycle, Lowe, Murman, Hearing 2/12/19 Oppose motorcycles, and mopeds motorcycle, or moped. Requires eye protection for Slama, Wishart operators of autocycles, motorcycles and mopeds. Transportation & Telecommunications Linehan, Morfeld name added

Prepared by Project Extra Mile Last updated: 3/12/2019

Wayne Change tax provisions for cigars, cheroots, Establishes the maximum tax on cigars, cheroots, or LB429 Revenue and stogies stogies as 50 cents for each cigar, cheroot, or stogie. McDonnell; Requires metropolitan cities to annually report on the Cavanaugh, DeBoer, collection and use of any occupation tax levied and Groene, Halloran, collected under the biennial budget. Hilkemann, Hunt, The report must include, but is not limited to: Kolowski, Lathrop, Require a city of the metropolitan class to  Purpose for imposing the tax Linehan, Murman, provide an annual budget report relating to General File  Amount of tax collected LB445 Slama, Vargas, use of any occupation tax levied and 3/4/19  Itemization of how tax was expended or budgeted to Walz, Wayne, collected be spent Wishart  Scheduled or projected termination of the tax Urban Affairs

Erdman, Brewer, AM520 pending Geist, Lowe name AM641 pending added Rebuild the Cash Reserve Fund by eliminating certain sales tax exemptions and increasing other sales and Friesen; Albrecht, excise taxes such as those levied on alcohol and Bostelman, Brandt, cigarettes. Brewer, Briese,  Tax on beer increases from $0.31 to $1.38/gallon Dorn, Erdman, Adopt the School District Property Tax  Tax on wine increases from $0.95 to $3.51/gallon LB497** Gragert, Halloran, Authority Act and change revenue and Hearing 2/14/19  Tax on farm wine increases from $0.06 to $2.62/gallon Support Hughes, Murman taxation provisions  Tax on spirits increases from $3.75 to $12.28/gallon Revenue  Alcohol tax revenue continues to be deposited into Kolterman name the General Fund added  Tax on cigarettes increases from $0.64 to $2.14/pack  Expands taxable services  Terminates grocery tax exemption on 1/1/2020 Prohibit participation in pretrial diversion Allows a person who has been arrested but not yet LB500 Morfeld programs for certain driving under the Hearing 2/13/19 convicted of a first-time, non-aggravated DUI to be Oppose Judiciary influence and driver's license offenses eligible for pretrial diversion. Authorize issuance of ignition interlock LB579 Quick permits to persons who caused serious General File AM345 pending Oppose Judiciary bodily injury while driving under the 2/26/19 influence

Prepared by Project Extra Mile Last updated: 3/12/2019

 Decreases Nebraska grown grape requirement from 75% to 60%  Increases the gallonage production requirement from 30,000 to 50,000 gallons for the requirement to use a licensed wholesaler  Establishes “craft wineries” by allowing the sale of wine at the farm winery and 4 (instead of 1) branch LB584** Hilgers Change farm winery provisions and provide outlets in reasonable amounts Hearing 2/11/19 Oppose General Affairs for a promotional special designated license  Permits the farm winery to sell beer or other alcoholic beverages so long as they hold the appropriate license  Establishes a promotional special designated license for craft breweries, microdistilleries, and farm wineries to be used once in a 12-month period for sale of product at festivals, bazaars, picnics, carnivals, and similar functions conducted outside the licensed premise. Establishes a fee of $250.  Defines alcohol impact zones as geographical areas that are adversely affected by chronic public inebriation or illegal activity associated with sales or consumption of alcoholic liquor.  Permits a city council, village board of trustees, or county board to apply to the Nebraska Liquor Control Commission for the creation of an alcohol impact zone. The application must include the following information regarding the request: Provide for alcohol impact zones and provide LB591 Briese 1. A description of the issue and geographical area; duties for the Nebraska Liquor Control Hearing 3/18/19 Support General Affairs 2. Evidence demonstrating the need for the zone and Commission how chronic public inebriation or illegal activity associated with liquor sales or consumption in the area: . How it contributes to the deterioration of general quality of life, . How it threatens the welfare, health, peace or safety of visitors and occupants of the area, . Demonstrates a pervasive pattern of public intoxication of public consumption of liquor

Prepared by Project Extra Mile Last updated: 3/12/2019

 Requires the city council, village board of trustees, or county board to submit a report to the Commission one year after the creation of the impact zone, and every 5 years thereafter, clearly demonstrating the effectiveness of the conditions or restrictions.  The impact zone shall remain in effect until the Commission repeals the creation of it. Allows the LCC, at its discretion, to require 2 days of Provide additional powers to the Nebraska mandatory closure (licensee may not elect to pay cash LB592 Briese Liquor Control Commission to suspend sales penalty) in addition to any days of suspension within the Support General Affairs of alcoholic liquor four-year lookback period for all violations of the Liquor Control Act. Provide property tax relief by eliminating certain sales tax exemptions and increasing other sales and excise taxes such as those levied on liquor and cigarettes. Crawford  Tax on spirits increases from $3.75 to $8.02/gallon LB614* Revenue Change revenue and taxation provisions Hearing 3/1/19  Tax on cigarettes increases from $0.64 to $2.14/pack Support Pansing Brooks  Expands taxable food to include candy, soft drinks, name added and bottled water

AM186 pending LB635** Hilkemann Change membership of the Nebraska Liquor Expands the number of Nebraska Liquor Control Hearing 2/11/19 Support General Affairs Control Commission Commissioners from three to five. Alters spirits taxes to be taxed by proof gallon, rather than by the gallon.

(Proof measures the alcohol content of spirits by LB682 Vargas multiplying the percent of alcohol by volume by two. Provide for taxing spirits as proof gallons Oppose General Affairs Converting U.S. gallons into proof gallons: 1. Multiply U.S. gallons by the percent of alcohol by volume 2. Multiply by two 3. Divide by 100.)

Prepared by Project Extra Mile Last updated: 3/12/2019

 Creates the Behavioral Health Provider Stabilization Fund to be used to leverage federal funds for Change provisions relating to tobacco behavioral health services provider rate Cavanaugh LB710 including sales, crimes, a tax increase, and Hearing 2/28/19 reimbursement. Revenue distribution of funds  Increases taxes on cigarettes from $0.64 to $2.14 and allocates the additional $1.50 to various public health and health care funds and programs. Decreases alcohol excise taxes as follows:  Tax on beer decreases from $0.31 to $0.25/gallon Vargas; Blood, Change taxes on manufacturers and LB723  Tax on wine decreases from $0.95 to $0.90/gallon Wayne wholesalers under the Nebraska Liquor Oppose  Tax on farm wine decreases from $0.06 to General Affairs Control Act $0.05/gallon  Tax on spirits decreases from $3.75 to $3.50/gallon Hunt Requires charter bus services to be licensed by the Liquor LB734** Provide for licensure of charter bus services General Affairs Hearing 3/4/19 Control Commission to be able to consume alcohol on Support under the Nebraska Liquor Control Act Briese name added board the bus. Establishes an annual license fee of $75. Beginning January 1, 2020:  Occupation tax or license fees may not be greater than $25 annually Murman; Halloran  Metropolitan cities may not impose an occupation tax Provide restrictions on occupation taxes, Government, or license fee on a profession or business that LB736 license fees, and regulation by counties and Hearing 2/28/19 Military and provides good or services unless the profession or municipalities Veterans Affairs business was subject to a tax or fee on January 1, 2020  No licensing requirement shall be imposed by a metropolitan city on any profession or business which is subject to state licensing requirements

* Testimony, including submission of written comments, provided by Project Extra Mile ** Oral testimony was provided for bills

Prepared by Project Extra Mile Last updated: 3/12/2019

NEWS RELEASE For more information, contact: Sergeant Jeremy Leifeld Ralston Police Department Cell: (402) 995-9060 Chris Wagner, Executive Director Work: (402) 963-9047 Cell: (402) 516-5765

For Immediate Release Mon., Mar. 4, 2019

31 Omaha Area Businesses Cited for Selling Alcohol to Minors

OMAHA, NEB - As a result of compliance checks conducted at on- and off-sale alcohol retailers, 31 businesses were cited for selling alcohol to a minor.

In an effort to crack down on the availability of alcohol to minors, Omaha metro area law enforcement officers conducted compliance checks on January 4th and March 1-2 resulting in 31 (10%) of the 320 retail outlets checked in Douglas and Sarpy Counties being cited for selling alcohol to a minor. The percentage of businesses cited doubled from 5% in November. A summary sheet of the compliance check results and a full list of businesses checked can be found by clicking here.

"We're very concerned that the percentage of businesses selling to minors in the Omaha area has doubled since November," said Sgt. Jeremy Leifeld with the Ralston Police Department. "Underage drinking has many negative consequences for our communities and retailers can do their part by instructing employees to check ID, verify age and never sell to youth presenting a vertical ID."

14 (45%) of those businesses have been cited for selling alcohol to minors in the past - - nine of those within the last four years, which the Nebraska Liquor Control Commission (LCC) looks at when considering enhanced penalties:

A.B.'s 66, 4926 Underwood Ave, Omaha (9/15); Asian Family Super-Market, 5916 Ames Ave, Omaha (4/17); Hy-Vee Drugstore, 8404 N 30 Street, Omaha (7/18); J C Mandarin, 843 N 98 Street, Omaha (7/15); Kicks 66, 2505 Abbott Dr Plaza, Omaha (4/17); Landing Zone, 7170 Bennington Rd, Omaha (6/15); Mega Saver, 7210 Harrison St, Ralston (5/17, 8/14, 5/09); Speedee Mart 2760, 100 W Centennial Rd, Omaha (1/16); Super T's Liquor & Mini Mart, 3805 Lake St, Omaha (9/17).

If found guilty by the LCC, these businesses could face mandatory days of closure (no alcohol sales would be allowed) and days of suspension that could be paid off at $100 per day according to the LCC's penalty guidelines.

Also concerning is that nearly half (8 of 18) of the businesses cited for the first time received their liquor licenses within the last two years. If found guilty, these 18 businesses could face a 10- to 20-day suspension that could be paid off as a fine at $50 per day.

44 officers from the Douglas County Sheriff's Office, La Vista Police Department, Nebraska State Patrol, Omaha Police Department, Ralston Police Department and Sarpy County Sheriff's Office participated in the three-day, enhanced underage drinking enforcement effort.

To assist in reporting underage drinking or adults providing alcohol to minors, call the statewide tip line at 1-866-Must-B-21 (687-8221). It's anonymous and it's the right call. Individuals are urged to call 911 to report an underage drinking party in progress.

Heightened enforcements are supported by the Nebraska Department of Transportation - Highway Safety Office and Grants #93.959 and #93.243 under the Substance Abuse Prevention & Treatment Block Grant and Strategic Prevention Framework-Partnership for Success Grant from the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention through the Nebraska Department of Health and Human Services and Region 6 Behavioral Healthcare. The Nebraska Department of Transportation - Highway Safety Office also funds the tip line. Project Extra Mile helped to coordinate the enforcement efforts.

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Mission: Advocating for evidence-based policies and practices to prevent and reduce alcohol-related harms.

Summary

Alcohol Compliance Checks for sales to minors

Conducted on January 4, March 1 & 2, 2019

Location: Douglas and Sarpy Counties in Nebraska

Participating Agencies: Douglas County Sheriff’s Office La Vista Police Department Nebraska State Patrol Omaha Police Department Ralston Police Department Sarpy County Sheriff’s Office

Results:

# of checks Not in Compliance (n/c) n/c: Did not Check ID n/c: Checked ID 320 31 (10%) 14 (45%) 17 (55%)

Compliance checks coordinated by Project Extra Mile. For additional information, call our office at 402-963-9047.

Project Extra Mile – Alcohol Compliance Checks Conducted on January 4, March 1 & 2, 2019 320 Businesses Checked, 31 Cited for Selling Alcohol to a Minor (10%) The following businesses were non-compliant (cited for selling alcohol to a minor):

License # Class Business Location City Zip Non-Comp Check ID 59034 D A.B.'S 66 4926 UNDERWOOD AVE OMAHA 68132 X 100719 D ALDI 43 4801 N 30 STREET OMAHA 68111 X X 60240 D AMES AVENUE CONVENIENCE STORE 4145 AMES AVENUE OMAHA 68111 X X 116320 D ASIAN FAMILY SUPER-MARKET 5916 AMES AVE OMAHA 68104 X 82199 C BEYOND GOLF 12040 MCDERMOTT PLZ LA VISTA 68128 X 121104 D BIG JIMS PLUS 3024 AMES STREET OMAHA 68111 X 122492 D BILLS BBQ & CONVENIENCE STORE 4414 NORTH 24TH ST OMAHA 68110 X 112986 D BLONDO CONVENIENT FOOD MART 6606 BLONDO ST OMAHA 68104 X 113960 I BLUE & FLY ASIAN KITCHEN 721 SOUTH 72 STREET OMAHA 68114 X X 100697 CK BUSHWACKERS DANCE HALL & SALOON 7401 MAIN STREET RALSTON 68127 X X 121858 D CASEY'S GENERAL STORE 2886 1202 S 13TH STREET OMAHA 68108 X 30262 C CUBBY'S 601 S 13 STREET OMAHA 68102 X X 122622 D FAIRFIELD INN & SUITES 1501 NICHOLAS STREET OMAHA 68102 X X 98093 C FAMILY FARE 785 3003 N 108 STREET OMAHA 68164 X X 97285 D HUSKER FOOD STORE 4201 S 24 STREET OMAHA 68107 X 79663 C HY-VEE DRUGSTORE 8404 N 30 STREET OMAHA 68112 X X 101654 I J C MANDARIN 843 N 98 STREET OMAHA 68114 X 58261 D KICKS 66 2505 ABBOTT DR PLAZA OMAHA 68110 X 119785 I KOREAGARDEN 5352 S 72ND STREET RALSTON 68127 X X 82134 D LA ECONOMICA 5520 S 36 STREET OMAHA 68107 X 80915 IK LA VISTA EMBASSY SUITES 12520 WESTPORT PRKWY LA VISTA 68128 X 93944 D LANDING ZONE 7170 BENNINGTON RD OMAHA 68152 X 79789 D MEGA SAVER 7210 HARRISON ST RALSTON 68128 X X 107558 B MIDTOWN GAS & GROCERY 1349 PARK AVENUE OMAHA 68108 X X 106717 I OFF THE WALL INDOOR SOCCER 6950 S 110 STREET LA VISTA 68128 X X 122801 I PUDGY'S PIZZERIA 16919 AUDREY STREET OMAHA 68136 X X 111551 B SPEEDEE MART 2760 100 W CENTENNIAL RD PAPILLION 68046 X X 42848 D SUPER T'S LIQUOR & MINI MART 3805 LAKE ST OMAHA 68111 X 122611 D T & A EXPRESS 5825 N 30TH STREET OMAHA 68111 X X Project Extra Mile 3/19 www.projectextramile.org

121864 D VALERO 2604 S 13TH STREET OMAHA 68108 X X 122478 D WHITE OAK STATION #78 8242 MAPLE STREET OMAHA 68134 X X

Project Extra Mile 3/19 www.projectextramile.org

Project Extra Mile – Alcohol Compliance Checks Conducted January 4, March 1 & 2, 2019 320 Businesses Checked, 31 Cited for Selling Alcohol to a Minor (10%) The following businesses were compliant (did not sell alcohol to a minor): Checked Business Address City Zip Compliant ID ALAMO DRAFTHOUSE CINEMA 12750 WESTPORT PKWY LA VISTA 68128 X X ALDI 42 2502 S 133RD PLAZA OMAHA 68144 X X ALDI 46 17240 EVANS STREET OMAHA 68116 X X ALDI 48 885 S 72 STREET OMAHA 68106 X X ALDI 75 3433 N 90 STREET OMAHA 68134 X X ALL NATIONS GROCERY LIQUOR 715 S 24 STREET OMAHA 68102 X X TOBACCO AMERICAN LEGION POST 32 230 W LINCOLN ST PAPILLION 68046 X X ANDERSON CONVENIENCE MARKET 2630 S 140 STREET OMAHA 68144 X X ANDERSON CONVENIENCE MARKET 11955 PACIFIC ST OMAHA 68154 X X ANDERSON CONVENIENCE MARKET 123 N 114 STREET OMAHA 68154 X X ANDERSON CONVENIENCE MARKET 16727 "Q" STREET OMAHA 68135 X X ANDERSON CONVENIENCE MARKET 17915 ARBOR STREET OMAHA 68130 X X ANDERSON CONVENIENCE MARKET 15635 W DODGE RD OMAHA 68118 X X ANGUS BURGERS & SHAKES 10177 S 168TH AVE OMAHA 68136 X X ASIAN MARKET 321 N 76TH ST OMAHA 68114 X X AZTLAN 2 5170 S 72 STREET RALSTON 68127 X X B & T CONVENIENCE & LIQUOR STORE 2704 FLORENCE BLVD OMAHA 68110 X X B J'S 4122 AMES AVENUE OMAHA 68111 X X BAKER'S SUPERMARKET 301 4405 N 72ND ST OMAHA 68134 X X BAKER'S SUPERMARKET 311 5555 N 90TH ST OMAHA 68134 X X BAKER'S SUPERMARKET 315 13250 W MAPLE RD OMAHA 68164 X X BAKER'S SUPERMARKET 316 7312 N 30TH ST OMAHA 68112 X X 17370 LAKESIDE HILLS BAKER'S SUPERMARKET 320 OMAHA 68130 X X PLAZA BERRY AND RYE THE 1105 HOWARD STREET OMAHA 68102 X X BILLS CONVENIENT STORE 3928 MAPLE STREET OMAHA 68111 X X BLUE NILE CORNER STORE 2541 N 20TH STREET OMAHA 68110 X X BUCKY'S #24 2223 S 24TH STREET OMAHA 68108 X X BUCKY'S EXPRESS 12 10202 MAPLE ST OMAHA 68134 X X BUCKY'S EXPRESS 13 2765 S 13TH ST OMAHA 68108 X X BUCKY'S EXPRESS 14 11400 S 72ND ST PAPILLION 68046 X X BUCKY'S EXPRESS 20 2510 S 132ND ST OMAHA 68144 X X BUCKY'S EXPRESS 32 3909 N 132ND ST OMAHA 68164 X X BUCKY'S EXPRESS 38 13736 Q ST OMAHA 68137 X X BUCKY'S EXPRESS 42 3435 S 42ND ST OMAHA 68132 X X BUCKY'S EXPRESS 58 5718 NW RADIAL HWY OMAHA 68104 X X BUCKY'S EXPRESS 60 6003 CENTER ST OMAHA 68106 X X BUCKY'S EXPRESS 61 2605 S 160TH ST OMAHA 68130 X X BUCKY'S EXPRESS 70 3529 S 72ND ST OMAHA 68124 X X BUCKY'S EXPRESS 72 2901 N 72ND ST OMAHA 68134 X X BUCKY'S EXPRESS 73 7203 HARRISON ST LA VISTA 68128 X X

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BUCKY'S EXPRESS 76 7660 DODGE ST OMAHA 68114 X X BUCKY'S EXPRESS 831 4414 N 30TH ST OMAHA 68111 X X BUCKY'S EXPRESS 84 3052 S 84TH ST OMAHA 68124 X X 9226 MORMON BRIDGE CABIN BAR & GRILL, THE OMAHA 68152 X X ROAD CASEYS GENERAL STORE 2441 609 MAGNOLIA AVENUE PAPILLION 68046 X X CASEY'S GENERAL STORE 2985 5120 S 118 STREET OMAHA 68137 X X CASEY'S GENERAL STORE 2987 15275 WEIR PLAZA OMAHA 68137 X X CASEYS GENERAL STORE 3444 18174 EMILINE STREET OMAHA 68136 X X CHARLESTON'S 7540 DODGE STREET OMAHA 68114 X X CHEESECAKE FACTORY, THE 10120 CALIFORNIA ST OMAHA 68114 X X CHUBB FOODS 2905 N 16 STREET OMAHA 68110 X X CHUCK E CHEESE'S 225 N 76 STREET OMAHA 68114 X X CILANTROS MEXICAN BAR & GRILL 7515 PACIFIC ST OMAHA 68114 X X CONVENIENT WORLD 2302 S 20 STREET OMAHA 68108 X X 12560 WESTPORT COURTYARD MARRIOTT LA VISTA 68128 X X PARKWAY CRYSTAL BEVERAGE MART 4807 S 20 STREET OMAHA 68107 X X CUBBY'S 9220 MORMAN BRIDGE OMAHA 68152 X X CUBBY'S OMAHA REDMAN AVENUE 4232 REDMAN AVENUE OMAHA 68111 X X CVS/PHARMACY 2741 6901 S 84 STREET LA VISTA 68128 X X CVS/PHARMACY 2931 14303 "U" STREET OMAHA 68137 X X CVS/PHARMACY 3478 2609 S 132 STREET OMAHA 68144 X X CVS/PHARMACY 4929 10770 FORT STREET OMAHA 68134 X X CVS/PHARMACY 5634 8315 W CENTER ROAD OMAHA 68124 X X CVS/PHARMACY 5714 4840 DODGE STREET OMAHA 68132 X X CVS/PHARMACY 5863 14460 W MAPLE ROAD OMAHA 68116 X X CVS/PHARMACY 6733 1919 N 90 STREET OMAHA 68114 X X D J'S DUGOUT 1003 & 1009 CAPTIOL AVE OMAHA 68102 X X DOUBLETREE HOTEL OMAHA 1616 DODGE STREET OMAHA 68102 X X DOWNTOWN DOWNTOWN FOOD MART 318 S 16 STREET OMAHA 68102 X X DUAL STOP FOOD & FUEL 8307 PARK VIEW BLVD LA VISTA 68128 X X EASY DRIVE PACKAGE 5124 N 24 STREET OMAHA 68110 X X EL-BASHA 7503 PACIFIC STREET OMAHA 68114 X X EVEREST GASMART 5188 LEAVENWORTH ST OMAHA 68106 X X EZ MART 6818 S 13TH STREET OMAHA 68107 X X FAMILY FARE 776 5101 HARRISON STREET BELLEVUE 68157 X X FAMILY FARE 780 2650 N 90 STREET OMAHA 68134 X X FAMILY FARE 795 7402 N 30 STREET OMAHA 68112 X X FAMILY FARE 799 1230 N WASHINGTON ST PAPILLION 68046 X X FAMILY FARE 800 3026 S 24 STREET OMAHA 68108 X X FAMILY FARE 811 1221 S 203 STREET OMAHA 68130 X X FAREWAY STORES #043 17070 AUDREY STREET OMAHA 68136 X X FAREWAY STORES #049 1325 JERSEY STREET PAPILLION 68046 X X FAREWAY STORES #132 3070 N 90 STREET OMAHA 68134 X X FAREWAY STORES #165 8900 WEST CENTER RD OMAHA 68124 X X FAS MART 550 11919 FORT STREET OMAHA 68164 X X

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FLAGSHIP COMMONS 10000 CALIFORNIA ST OMAHA 68114 X X FLIXX 1019 S 10 STREET OMAHA 68108 X X FLORENCE FOOD MART AND GAS 9516 CALHOUN ROAD OMAHA 68112 X X FOOD & FUELS R US 6912 S 110TH STREET LA VISTA 68128 X X FOOD MART 8204 HARRISON STREET RALSTON 68128 X X FRESH THYME FARMERS MARKET 17550 GOLD PLAZA OMAHA 68130 X X FRESH THYME FARMERS MARKET 14949 EVANS RD OMAHA 68116 X X GOLDEN GROCERY STORE 6341 N 24TH STREET OMAHA 68110 X X GURUNG BROTHERS SUPERMARKET 9010 FORT STREET OMAHA 68134 X X HAMILTON CONVENIENT FOOD MART 4901 HAMILTON OMAHA 68132 X X HAMPTON INNS & SUITES LAVISTA 12331 SOUTHPORT PKWY LA VISTA 68128 X X HILTON GARDEN INN 17879 CHICAGO STREET OMAHA 68118 X X HILTON OMAHA 1001 CASS STREET OMAHA 68102 X X HIRO 88 1308 JACKSON ST OMAHA 68102 X X HOOK & LIME 735 NORTH 14 STREET OMAHA 68102 X X HUHOT MONGOLIAN GRILL 2101 N 120 STREET OMAHA 68164 X X HUTTI 2430 S 24TH STREET OMAHA 68108 X X HY-VEE FOOD STORE 17810 WELCH PLAZA OMAHA 68135 X X HY-VEE FOOD STORE 10808 FORT STREET OMAHA 68164 X X HY-VEE FOOD STORE 7910 CASS STREET OMAHA 68114 X X HY-VEE FOOD STORE 1000 S 178 STREET OMAHA 68118 X X HY-VEE FOOD STORE 3410 N 156 STREET OMAHA 68116 X X HY-VEE GAS 749 N 132 STREET OMAHA 68154 X X HY-VEE GAS 5102 CENTER STREET OMAHA 68106 X X HY-VEE GAS 17901 WELCH PLAZA OMAHA 68135 X X HY-VEE GAS 8829 W CENTER ROAD OMAHA 68124 X X HY-VEE GAS 7930 CASS STREET OMAHA 68114 X X HY-VEE GAS 3404 N 156 STREET OMAHA 68116 X X 14405 STONY BROOK HY-VEE GAS BOULEVARD OMAHA 68137 X X ICE HOUSE SPORTS BAR 10920 EMMET STREET OMAHA 68164 X X INKWELL 8716 PACIFIC STREET OMAHA 68114 X X JACK'S DISCOUNT TOBACCO & 721 N 120TH STREET OMAHA 68154 X X LIQUOR JAKE'S MINI MART 8320 BLONDO STREET OMAHA 68134 X X JAMS GRILL & BAR 1101 HARNEY STREET OMAHA 68102 X X JD'S LIQUOR LOCKER 8052 S 84TH STREET LA VISTA 68128 X X JUMP START 5920 SORENSEN PKWY OMAHA 68152 X X K N J EXPRESS 3009 PARKER ST OMAHA 68111 X X KB'S FOOD SHOP 304 S WASHINGTON ST PAPILLION 68046 X X KEITH'S AMOCO 1 5220 N 90 STREET OMAHA 68134 X X KELLY'S PACKAGE LIQUOR 3501 N 30TH ST OMAHA 68111 X X KICK'S 66 16808 AUDREY STREET OMAHA 68136 X X KUM & GO #360 10025 S 168 AVENUE OMAHA 68136 X X KUM & GO #368 4041 N 168 STREET OMAHA 68116 X X KUM & GO #369 11111 EMMET STREET OMAHA 68164 X X KUM & GO #371 13149 FORT STREET OMAHA 68164 X X

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KUM & GO #374 10764 VIRGINIA PLAZA PAPILLION 68046 X X KUM & GO 348 12011 BLONDO STREET OMAHA 68164 X X KUM & GO 352 1010 S 154 STREET OMAHA 68154 X X KUM & GO 361 1010 S 189 STREET OMAHA 68130 X X KUM & GO 363 1819 N 72ND STREET OMAHA 68114 X X KUM & GO 364 8990 BOYD STREET OMAHA 68134 X X KUM & GO 367 18908 "Q" STREET OMAHA 68135 X X KUM & GO 372 7152 PACIFIC STREET OMAHA 68106 X X KUM & GO 376 2627 S HWS CLEVELAND OMAHA 68130 X X KUM & GO 378 14353 "Q" STREET OMAHA 68137 X X KWIK SHOP 652 3222 Q ST OMAHA 68107 X X KWIK SHOP 653 5929 N 72ND ST OMAHA 68134 X X KWIK SHOP 657 7525 CASS ST OMAHA 68114 X X KWIK SHOP 664 6910 S 108TH ST LA VISTA 68128 X X KWIK SHOP 665 15556 BLONDO ST OMAHA 68116 X X KWIK SHOP 668 6845 S 167TH ST OMAHA 68135 X X KWIK SHOP 672 5208 S 72ND ST RALSTON 68127 X X KWIK SHOP 673 5306 N 103RD ST OMAHA 68134 X X KWIK SHOP 687 101 CEDAR DALE DR PAPILLION 68046 X X LA VISTA MART 9849 GILES ROAD LA VISTA 68128 X X LATINO LEGACY RESTAURANT 7755 "L" STREET RALSTON 68127 X X LEGENDS PATIO GRILL & BAR 6910 N 102 CIRCLE OMAHA 68122 X X LIGHTHOUSE BAR & GRILL 10215 S 168TH AVE OMAHA 68136 X X LING'S CUISINE 6909 SOUTH 157TH ST OMAHA 68136 X X LIQUOR & TOBACCO DEPOT 13822 P ST OMAHA 68137 X X LONGHORN STEAKHOUSE 5422 7425 DODGE ST OMAHA 68114 X X MANGIA ITALIANA 6516 IRVINGTON ROAD OMAHA 68122 X X MARCUS MAJESTIC 14304 W MAPLE ROAD OMAHA 68164 X X MARIA'S RESTAURANT 7630 BURLINGTON ST RALSTON 68127 X X MEGA SAVER 8928 MAPLE ST OMAHA 68134 X X MEGA SAVER 7205 LAWNDALE DR OMAHA 68134 X X MEGA SAVER 3223 N 108TH ST OMAHA 68134 X X MEGA SAVER 1910 N 144TH ST OMAHA 68154 X X MEGA SAVER 5444 CENTER ST OMAHA 68106 X X MEGA SAVER 6000 GROVER ST OMAHA 68106 X X MEGA SAVER 8540 BLONDO ST OMAHA 68134 X X MEGA SAVER 10707 BLONDO ST OMAHA 68134 X X MEGA SAVER 2014 L ST OMAHA 68107 X X MEGA SAVER 4420 S 24TH ST OMAHA 68107 X X MEGA SAVER 5101 S 24 ST OMAHA 68107 X X MEGA SAVER 1357 NW RADIAL HWY OMAHA 68132 X X MEGA SAVER 4725 S 77TH AVE RALSTON 68127 X X MEGA SAVER 7204 BLONDO ST OMAHA 68134 X X MIDTOWN GAS & GROCERY 2302 S 13 STREET OMAHA 68108 X X MIDTOWN GAS & GROCERY 1222 S 24TH STREET OMAHA 68108 X X MILLARD PARK FANTASY'S 15611 HARRISON ST OMAHA 68136 X X MOE & CURLY'S PUB 2946 N 108TH STREET OMAHA 68164 X X MURPHY EXPRESS #8774 9810 REDICK AVE OMAHA 68122 X X

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MURPHY EXPRESS #8811 4411 S 132ND STREET OMAHA 68137 X X MY PIE PIZZA 2085 N 120 STREET OMAHA 68164 X X N P MART 4219 N 60TH STREET OMAHA 68104 X X N PETRO 5203 NW RADIAL HWY OMAHA 68104 X X NATIONS MART 6620 S 36TH STREET OMAHA 68107 X X NBH GROCERY 1817 N 33RD STREET OMAHA 68111 X X NUESTRA FAMILIA SUPERMERCADO 1826 VINTON STREET OMAHA 68108 X X 775 OHIO FANTASY'S 2540 N 90 STREET OMAHA 68134 X X OLD CHICAGO 425 N 78 STREET OMAHA 68114 X X OLD CHICAGO 1109-11 HARNEY ST OMAHA 68102 X X OLD MARKET SPAGHETTI WORKS 502 S 11 STREET OMAHA 68102 X X OLD MATTRESS FACTORY BAR & 501 N 13 STREET OMAHA 68102 X X GRILL ON THE ROCKS LOUNGE 16919 AUDREY STREET OMAHA 68136 X X PANDA HOUSE 301 S 16 STREET OMAHA 68102 X X 6508 JOHN J PERSHING PETROMART OMAHA 68112 X X DRIVE PHILLIPS 66 7530 PACIFIC STREET OMAHA 68114 X X PITSTOP 4015 S 42 STREET OMAHA 68107 X PIZZERIA DAVLO 14220 FORT STREET OMAHA 68164 X X PLANK SEAFOOD PROVISIONS 1205 HOWARD STREET OMAHA 68102 X X QUIKTRIP 576 3201 L STREET OMAHA 68107 X X QUIKTRIP 579 1704 S 72ND STREET OMAHA 68124 X X QUIKTRIP 585 4720 HAMILTON STREET OMAHA 68132 X X QUIKTRIP 587 4404 N 72ND STREET OMAHA 68134 X X QUIKTRIP 589 5305 N 103RD STREET OMAHA 68134 X X QUIKTRIP 594 715 S SADDLECREEK RD OMAHA 68106 X X QUIKTRIP 596 5005 S 108TH STREET OMAHA 68137 X X QUIKTRIP 597 8727 MAPLE STREET OMAHA 68134 X X QUIKTRIP 599 13007 Q STREET OMAHA 68137 X X RALSTON KENO 5130 S 72ND STREET RALSTON 68127 X X RED LOBSTER 115 330 S 72 STREET OMAHA 68114 X X REGIS FOOD MART 2810 SO 108TH ST OMAHA 68144 X X REGIS FOOD MART 6828 S 143 PLAZA OMAHA 68137 X X RIDGEVIEW FANTASY'S 18280 WRIGHT STREET OMAHA 68130 X X RUSSELL SPEEDER'S CAR WASH 11212 WRIGHT CIRCLE OMAHA 68144 X X SCORZ SPORTS CENTER 7602 MAIN STREET RALSTON 68127 X X SELECT MART 2411 N 30TH STREET OMAHA 68111 X X SELECT MART 4741 GILES ROAD BELLEVUE 68157 X X SINCLAIR 5215 N 16TH ST OMAHA 68110 X X SMASHBURGER 1221 7204 JONES STREET OMAHA 68114 X X SMITTY'S GARAGE BURGERS & BEER 7610 DODGE ST OMAHA 68114 X X SOUTHPORT FANTASY'S 7828 S 123RD PLAZA LA VISTA 68128 X X SOUTHWEST FANTASY'S 14330 HILLSDALE AVE OMAHA 68137 X X SPEEDEE MART 2725 13235 GROVER STREET OMAHA 68144 X X SPEEDEE MART 2732 8724 N 30 STREET OMAHA 68112 X X SPEEDEE MART 2762 13820 MANDERSON CIR OMAHA 68164 X X

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SPEEDY GAS N SHOP 5822 MAPLE STREET OMAHA 68104 X X SPIRITS AND THINGS 2762 S 129 AVENUE OMAHA 68144 X X SPRING INN BAR 2703 S 10 STREET OMAHA 68108 X X SUGAR HILL PACKAGE 5627 AMES AVENUE OMAHA 68104 X X SUPER CARNICERIA EL PUEBLITO 5116 S 24TH STREET OMAHA 68107 X X TANNER'S BAR & GRILL 7340 HARRISON STREET RALSTON 68128 X X TARGET STORE 0530 4001 N 132 STREET OMAHA 68164 X X TARGET STORE 0532 718 N WASHINGTON ST PAPILLION 68046 X X TARGET STORE 1777 17810 W CENTER ROAD OMAHA 68130 X X TARGET STORE 2326 16959 EVANS PLAZA OMAHA 68116 X X TARGET STORE 2383 12500 "K" PLAZA OMAHA 68137 X X THAI HOUSE 2101 N 120TH STREET OMAHA 68164 X X TOBACCO & LIQUOR OUTLET 2938 N 108TH STREET OMAHA 68164 X X TOBACCO HUT 1 5826 MAPLE STREET OMAHA 68104 X X TOBACCO HUT 10 4865 CENTER STREET OMAHA 68106 X X TOBACCO HUT 15 5434 N 103RD STREET OMAHA 68134 X X 1414 S SADDLE CREEK TOBACCO ROAD DISCOUNTS OMAHA 68106 X X ROAD TRADER JOE'S 719 10305 PACIFIC ST OMAHA 68114 X X 9229 MORMON BRIDGE TUSSEY'S CASUAL GRILL OMAHA 68152 X X PLAZA TWISTED FORK 1014 HOWARD STREET OMAHA 68102 X X VERDICT BAR & GRILL, THE 1901 HARNEY STREET OMAHA 68102 X X VIETNAMESE ASIAN RESTAURANT 7212 JONES STREET OMAHA 68114 X X VILLAGE BAR 5700 S 77 STREET RALSTON 68127 X X VILLAGE POINTE FANTASY'S 250 N 168TH CIRCLE OMAHA 68118 X X VILLAGIO PIZZERIA 6922 N 102ND CIRCLE OMAHA 68122 X X VINTON STREET TOBACCO 1602 VINTON STREET OMAHA 68108 X X WALGREENS 10437 5225 N 90 STREET OMAHA 68134 X X WALGREENS 11203 17909 BURKE STREET OMAHA 68118 X X WALGREENS 11355 9512 S 71 PLAZA PAPILLION 68133 X X WALGREENS 13137 13510 "Q" STREET OMAHA 68137 X X WALGREENS 15237 2929 N 60TH STREET OMAHA 68104 X X WALGREENS 2472 18040 "R" PLAZA OMAHA 68135 X X WALGREENS 3186 3701 N 132 STREET OMAHA 68164 X X WALGREENS 3621 9001 BLONDO STREET OMAHA 68134 X X WALGREENS 4443 9001 W CENTER ROAD OMAHA 68124 X X WALGREENS 4974 5038 CENTER STREET OMAHA 68106 X X WALGREENS 5059 10725 FORT STREET OMAHA 68134 X X WALGREENS 5143 7151 CASS STREET OMAHA 68132 X X WALGREENS 5190 2323 "L" STREET OMAHA 68107 X X WALGREENS 5360 5062 S 155 STREET OMAHA 68137 X X WALGREENS 5966 2605 S 171 STREET OMAHA 68130 X X WALGREENS 6802 15525 SPAULDING PLAZA OMAHA 68116 X X WALGREENS 6962 3121 S 24 STREET OMAHA 68108 X X WALGREENS 7272 13155 W CENTER RD OMAHA 68144 X X WALGREENS 7563 8989 W DODGE ROAD OMAHA 68114 X X WALMART 1637 6304 N 99 STREET OMAHA 68134 X X

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WALMART 1671 8525 S 71 STREET PAPILLION 68133 X X WALMART 3151 5018 AMES AVENUE OMAHA 68104 X X WALMART 3267 18201 WRIGHT ST OMAHA 68130 X X WALMART 4358 1606 S 72 STREET OMAHA 68124 X X WALMART 5141 16960 W MAPLE ROAD OMAHA 68116 X X WALMART 5361 12850 "L" STREET OMAHA 68137 X X WALMART MARKET 3152 2451 N 90 STREET OMAHA 68134 X X WALMART MARKET 3153 6710 S 167 STREET OMAHA 68135 X X WALMART MARKET 3173 9460 GILES ROAD LA VISTA 68128 X X WALMART MARKET 4138 13105 BIRCH DRIVE OMAHA 68164 X X WATERFALL LOUNGE 10208 S 168TH AVE OMAHA 68136 X X WEST CORNHUSKER FANTASY'S 9911 S 71ST AVE PAPILLION 68133 X X WEST MAPLE FANTASY'S 3725 N 147TH STREET OMAHA 68116 X X WHISPERING RIDGE FANTASY'S 16960 EVANS PLAZA OMAHA 68116 X X WHITE OAK STATION #81 720 N 108TH COURT OMAHA 68154 X X WHOLE FOODS MARKET 10020 REGENCY CIRCLE OMAHA 68114 X X YAMATO SUSHI 7425 PACIFIC STREET OMAHA 68114 X X ZIO'S PIZZERIA 7834 W DODGE ROAD OMAHA 68114 X X ZIO'S PIZZERIA 1109 HOWARD STREET OMAHA 68102 X X ZOO MART 4023 S 13TH STREET OMAHA 68107 X X

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Lincoln Journal Star Wednesday, February 27, 2019

Local View: Nebraska due for alcohol tax hike

Written by Project Extra Mile Executive Director Chris Wagner

The Lincoln Journal Star published an editorial (“Tax reform mustn’t hit breweries this tough,” Feb. 20) urging lawmakers not to unfairly target alcohol producers to pay for property tax relief. The editorial offers arguments extolling the economic benefits of Nebraska’s 49 breweries but presents a one-sided argument that ignores the harms that alcohol causes in our state. With more than 20 percent of our population drinking excessively, we need evidence-based policies that only the Legislature can deliver. Nebraska is the fifth-worst binge and excessive drinking state in the nation, according to America’s Health Rankings in 2018. This led to an estimated 703 alcohol-attributable deaths in 2015 alone, according to the Nebraska Department of Health and Human Services, and 721 alcohol-related traffic fatalities between 2008-2017, according to the Nebraska Department of Transportation. There are also significant economic costs that outweigh the benefits noted in the editorial – in 2010 alone, Nebraska had $1.16 billion of costs. Of those costs, research in the Journal of American Preventative Medicine noted 72 percent ($835 million) were work productivity losses, with 42 percent ($491 million) paid by government. In other words, we’re expecting Nebraska businesses and taxpayers to pick up the alcohol industry’s tab. Broken down by drink, economic costs alone amounted to $1.61 per drink in our state. By contrast, the bills drafted by Albion Sen. Tom Briese and Henderson Sen. Curt Friesen seek to increase the excise tax paid per drink from 3 to 4 cents to 10 cents. In total, these bills would raise approximately $90 million or less than 8 percent of our economic costs. The World Health Organization recommends that policymakers focus on three areas to reduce alcohol-related harms: price, availability and advertising in order to reduce excessive drinking, which affects all Nebraskans -- and not just those engaging in that activity. Dozens of academic studies show that these policy strategies are effective because the industry passes these increases on to their customers. Yet you won’t hear the alcohol industry citing peer-reviewed studies. Their reaction is the same as every other industry facing increased taxes: doing so will result in jobs cuts and ruin businesses, but that statement couldn’t be further from the truth. Illinois (excise taxes) and Maryland (sales tax) both increased their alcohol taxes recently, yet the craft brewing industry continued to thrive with expanded sales and new breweries opening. Bureau of Labor Statistics data also demonstrated that following the 1991 federal alcohol tax increase, the alcohol industry actually added jobs, according to the Community Anti-Drug Coalitions of America. It’s also worth noting that these tax proposals affect the entire industry, and alcohol producers in our state are currently enjoying their lowest tax bill in decades due to the 2017 federal tax cut. We put our trust in our elected leaders to weigh all the evidence and make decisions that are best for our state, but how can they do that if the alcohol industry’s talking points are amplified by the media without fair coverage of both sides?

Project Extra Mile – News Clippings Page 1 of 2 Lincoln Journal Star Wednesday, February 27, 2019

Excessive drinking is killing our citizens, contributing to crime, spreading disease and costing us at least $1 billion each year. Increasing alcohol taxes isn’t a silver bullet, but it will go a long way towards addressing these problems.

Project Extra Mile – News Clippings Page 2 of 2 Lincoln Journal Star Tuesday, February 19, 2019

Editorial, 2/20: Tax reform mustn’t hit breweries this tough

Written by Journal Star editorial board

Nebraska’s need to reform property taxes while promoting business growth has come to a head. Separate bills by Albion Sen. Tom Briese and Henderson Sen. Curt Friesen propose sweeping changes to state tax laws, including provisions that would increase excise taxes paid by the state’s breweries, wineries and distilleries in 2020 several times over, threatening these burgeoning industries’ continued success. Rural Nebraska doesn't need a threat of this magnitude to an industry that’s demonstrated success at bringing people and tourism dollars to town. Any glance at maps plotting Nebraska’s beer, wine and spirits producers includes expected clusters in and around Lincoln and Omaha. But entrepreneurs have popped up in smaller communities across the state. Fairfield, Ohiowa and Taylor boast breweries. Brownville, Nenzel and Raymond have wineries. Moorefield, St. Paul and West Point are home to distilleries. Regardless of size, all produce tangible economic benefits. Steep increases in excise taxes – from 31 cents per gallon to $1.38 for beer (345 percent), 95 cents to $3.51 for wine (269 percent) and $3.75 to $12.28 on spirits (227 percent) – could very well jeopardize some of these success stories. If beer were taxed at that level, it would be the such highest rate in the nation and make the fruits of Nebraskans’ labor less competitive. And it’s not as if these products aren’t already being taxed fairly; Nebraska presently ranks 20th in the nation, and higher than all bordering states, on beer excise taxes. Although we may disagree with this portion of their proposals, Briese and Friesen are leading a worthy charge, generating bipartisan support for a difficult but vital conversation on tax policy. We applaud their thoughtful efforts to ensure adequate funding for K-12 schools and achieve meaningful property tax reform – two items inextricably linked. They’ve also championed legislation that reflects the reality that such an overhaul mustn’t drive the state deeper into a budget shortfall. Their bills also highlight the daunting challenge of striking an accord. Right now, property owners, especially in agriculture, bear a disproportionate burden by way of property taxes – but other groups will fight against additional taxation. Compromise will be difficult to obtain, but pursuing it is imperative. Tax reform that adequately funds education returned to our annual editorial board agenda. We called for “fairer evaluations of ag land” and “rebalancing the three-legged stool of sales, income and property taxes.” Though higher excise taxes would generate millions in new revenue, they don’t address the core structural problems. Sharply increasing taxes on a homegrown Nebraska industry, one that’s helped provide rural areas both jobs and tax base, fails to achieve our desired ends – and could endanger the existence of some small-town successes.

Project Extra Mile – News Clippings Page 1 of 1 Omaha World Herald Monday, February 25, 2019

Questions raised over appointment of former Budweiser distributor to Nebraska liquor board

Written by Paul Hammel

LINCOLN — Advocates for shutting down beer sales in the border town of Whiteclay, Nebraska, and a group that discourages binge drinking are raising concerns about the appointment of a former Budweiser distributor to the State Liquor Control Commission. Harry Hoch, who ran a Budweiser distributing business in Grand Island for three decades, was recently appointed to the three-member liquor board by Gov. Pete Ricketts. The governor, in a statement, said he trusts Hoch to be “impartial” in enforcing state liquor laws. But the appointment requires confirmation by the State Legislature, and it is raising some eyebrows. Hoch, who sold his distributing business in 2015 and moved to Omaha, was also a donor to Ricketts, giving $16,453 from 2014 through 2018. Anheuser-Busch, which produces Budweiser, gave Ricketts $22,500 during the same period. Frank LaMere, a Native American activist from South Sioux City, Nebraska, and Alan Jacobsen, a Lincoln businessman, both said it was wrongheaded to appoint someone who profited from alcohol sales for years to regulate others who do the same. Both expressed doubt that Hoch would have voted to close down the Whiteclay beer stores, as the Liquor Control Commission did unanimously in 2017. “This is like hiring a fox to watch the chicken coop,” Jacobsen said. “It is terrible public policy.” La Mere asked, “Am I the only one who thinks that this is a conflict of interest and flies in the face of logic?” Chris Wagner of Omaha-based Project Extra Mile said his organization’s opposition is more broadly based and focused on statistics like Nebraska’s high rates of adult binge drinking — the fourth-highest in the nation — and alcohol-impaired driving. “We need public health and safety at the table, not a person who spent their life in the industry,” Wagner said. Hoch would not be the first member of the Liquor Control Commission with a background in the industry. Bob Logsdon, who served from 1989 to 1995, was the former manager of an American Legion club in Lincoln. Current Commissioner Bruce Bailey of Lincoln also had a liquor license when he managed a sports arena in Kearney that opened in 2000. Commissioners, who are paid $12,000 a year, meet monthly to confirm or deny liquor licenses based on recommendations from cities and counties and a review of an applicant’s background. The board rules over all alcohol sales in the state, and, if a license holder violates rules or laws, it can issue fines or suspend or revoke a license. Besides shutting down the Whiteclay stores, the commission has dealt with other controversial issues in recent years, including a dispute between beer distributors and craft brewers and determining how flavored malt beverages, like “hard” lemonade, should be taxed.

Project Extra Mile – News Clippings Page 1 of 2 Omaha World Herald Monday, February 25, 2019

State law bans commissioners from having any financial interest “whatsoever” in the sale, manufacture or distribution of alcohol. Hoch, in an email, said he sold his distributing business in December 2015 and dissolved his corporation. He said he will faithfully enforce state liquor laws. “I will follow those guidelines and the Nebraska Liquor Control Act,” Hoch wrote. “The commission should be neutral and does not have the job of picking winners and losers.” Two key senators on liquor issues expressed differing opinions. State Sen. Tom Brewer of Gordon, who advocated for closing down the four beer stores in Whiteclay, said the appointment raises some concerns for him, but he doubted that Hoch or other future commissioners would approve a resumption of beer sales there because of the positive impacts of the closings. Before the Whiteclay stores closed, they sold the equivalent of 3.5 million cans of beer a year, mostly to residents of the officially dry Pine Ridge Indian Reservation just across the border in South Dakota. Beer sales in Whiteclay were blamed for many of the alcohol-related woes on the reservation and for the band of street people who openly drank and urinated on the town’s streets — street people who are now gone. The Legislature’s General Affairs Committee will hold a public hearing on March 4 on Hoch’s appointment, and the committee’s chairman, Sen. Tom Briese of Albion, said Hoch’s background and experience in the liquor industry would be an asset on the commission. “He’s an excellent candidate to put forth,” he said.

Project Extra Mile – News Clippings Page 2 of 2 NTV Thursday, February 14, 2019

Neb. senator amends tax relief proposal after pressure from brewers

Written by KHGI

LINCOLN, Neb. — Pressure from beer makers and the governor seems to have paid off for Nebraska breweries. State Senator Tom Briese said he'd like to amend his tax relief proposal. The amendment, announced Wednesday, would remove the per gallon excise tax on beer, wine, and liquor from LB 314. “After much discussion with craft brewers, vineyards, and local distilleries across the state and specifically within District 41, we decided that a tax directly on one of our fastest growing and most attractive businesses is not the answer to property tax relief that we are looking for. LB 314 will still provide substantial property tax relief to all of the hard working citizens of our state and will continue to protect and advance the ability of schools to prepare our young folks for the future.” Briese said the bill will still provide much needed property tax relief. “By increasing the excise tax on products produced in Nebraska, the bill would have led to an increased price on the shelves for consumers, as well as leading to cash flow problems for producers who could be put in a position of having to pay a higher tax on a product which they haven’t sold yet. A much lower increase of three percent, applied as a sales tax at the register, is a more transparent way for consumers to see where dollars are being collected, while keeping our local small businesses able to offer competitive prices on the shelves,” he said. “Agriculture is the backbone of the state of the Nebraska, and we cannot have economic growth in Nebraska without significant property tax relief. Additionally, small business is the lifeblood of many of our rural communities in Nebraska, and by working with our craft brewers, we are working to grow and improve these rural areas.” The amendment comes after Governor Pete Ricketts announced he’d back brewers on March 1, with a simultaneous events in Omaha, Lincoln and Grand Island. "Raise Glasses, Not Taxes" aims to raise awareness about Briese's bill, as well as State Senator Curt Friesen's LB 497. “We are urging the Legislature to oppose tax increases on craft brewers and other Nebraska goods and services,” said Governor Ricketts. “In urban and rural areas across our state, these tax hikes will kill job opportunities for Nebraska families and inhibit continued growth in tourism and economic development.” Friesen said revenue needs to be raised. "I'm a fan of the craft brew too and we'll work with them, but I think, again, we all know how this is going to play out. So, we kind of know everybody is taking their spots, but again, if we don't raise some revenue from somewheres and we're hoping to look anywhere; and between Senator Briese's bill and my bill we've got numerous options. It's just where we go with it. And, if we do not want to raise any revenue than we're not going to have property tax relief," said Friesen.

Project Extra Mile – News Clippings Page 1 of 1 Lincoln Journal Star Wednesday, February 20, 2019

Revenue Committee chairwoman foresees a tax reform package, not one bill

Written by Don Walton

Another journey down the long and winding road begins next week. Three major property tax reform proposals have received public hearings in the Legislature, and its Revenue Committee is ready now to begin to tackle the task of corralling majority support for a plan to send to the floor. Sen. Lou Ann Linehan of Elkhorn will be leading the way as committee chair and she sees the likelihood of "one package, not one bill." "Components," Linehan said Tuesday during an interview in her first-floor Capitol office. "Pieces of the puzzle." "What can we do right now? What next year and what finally later?" Linehan is planning for the committee discussion to begin next week; first will come an executive session Thursday to get online sales tax collection legislation out of committee and onto the floor for legislative action. And then, she said, it would help "if three guys come to some kind of agreement" about how to proceed with their competing tax reform bills that focus on property tax reduction. "They're all going in the same direction," Linehan said. Those senators are Tom Briese of Albion, Curt Friesen of Henderson and Mike Groene of North Platte. All three are members of the committee and will be fully engaged in the discussions aimed at negotiating a settlement or a compromise, or at least a package, to take to the floor. "But the whole committee will be involved," Linehan said. "There are parts of all of the bills that I like," she said. "We need some big-picture understanding now." Linehan does not plan to involve Gov. Pete Ricketts in the discussion at this point. "Not until I have something," she said, and that might be sometime in April. Ricketts has his own property tax reduction plan, which consists of a $51 million increase in the state's property tax credit relief fund and a proposed constitutional amendment that would establish a 3 percent cap on the growth rate of local property taxes. Friesen's bill (LB497) has the support of the Nebraska Farm Bureau; Briese's bill (LB314) has backing from the Nebraska State Education Association. Only one senator from Omaha or Lincoln signed onto any of the three bills and that was Sen. Patty Pansing Brooks of Lincoln, who co-signed Briese's proposal. The Briese plan envisions $650 million in property tax relief by fiscal 2020-21 funded by generating new state revenue through a one-half percent increase in the state sales tax rate,

Project Extra Mile – News Clippings Page 1 of 2 Lincoln Journal Star Wednesday, February 20, 2019 imposing an income surtax on high-income Nebraskans, increasing taxes on cigarettes and alcoholic beverages, and repealing a number of sales tax exemptions. Friesen's proposal would generate an estimated $518 million in additional state revenue to fund 50 percent state support for every school by repealing a number of sales tax exemptions, increasing taxes on alcohol and cigarettes, and repealing the state's personal property tax exemption. The Groene plan (LB677) would reduce the maximum property tax levy for school districts, coupled with a corresponding increase in state funding triggered by the state aid formula. That increase was estimated at $91 million in fiscal 2020-21.

Project Extra Mile – News Clippings Page 2 of 2 The Grand Island Independent Tuesday, March 5, 2019

Raising alcohol taxes will improve public health, safety

Written by Project Extra Mile Executive Director Chris Wagner

On March 1, the Grand Island Independent published an editorial “Raise a toast in support of our craft brewers,” urging support for brewers in order to send a strong message to lawmakers to not unfairly target alcohol producers to pay for property tax relief. Much like the Lincoln Journal Star editorial that preceded it, the Independent’s editorial board presents a one-sided picture of the impact alcohol has on our communities and our state. The editorial portrays the push for increased alcohol taxes as farmers seeking to ride a wave of alcohol taxes to provide property tax relief and ignores the fact that alcohol causes great harm in our communities. The truth is over 20 percent of our population drinks excessively (CDC, 2017) and causes these problems. Senators Briese and Friesen are simply asking that the entire alcohol industry — not just the craft brewers — pass on these increases to consumers so that the state can simultaneously prevent excessive drinking and its harms while addressing the property tax dilemma. Alcohol tax increases have been recommended as a highly effective way to reduce excessive alcohol consumption and related harms by the American Medical Association; American Public Health Association; American Society of Clinical Oncology; Community Preventive Services Task Force; National Academies of Sciences, Engineering, and Medicine; Non-Communicable Diseases Alliance; and the World Health Organization. Nebraska is the fifth-worst binge and excessive drinking state in the nation (CDC, 2017; America’s Health Rankings, 2018), which led to an estimated 703 alcohol-attributable deaths in 2015 alone, 2,403 hospitalizations in 2014 (NE DHHS, 2017), and 721 alcohol-related traffic fatalities between 2008-2017 (NDOT-HSO, 2018). There are also significant economic costs that outweigh the benefits noted in the editorial — in 2010 alone, Nebraska had $1.16 billion of costs. 72 percent of those costs ($835 million) were work productivity losses and 42 percent ($491 million) were paid by taxpayers (Sacks et al., 2015). These costs are much greater than the indicated $465 million that the Nebraska craft brewery industry generates. The costs break down to $1.61 per drink in the state, by contrast, the bills mentioned seek to increase the excise tax paid per drink from 3-4 cents to 10 cents. In total, these bills would raise approximately $90 million, or less than 8 percent of our economic costs. The editorial and the industry have also ignored the fact that an amendment is being drafted to LB314 to substitute a 3 percent sales tax on alcohol for the proposed excise tax increases. It was intended to be a compromise for craft breweries, but the breweries are uninterested in that good faith effort. Instead, their reaction is the same as every other industry facing increased taxes: doing so will result in jobs cuts and ruin businesses, but that statement couldn’t be further from the truth. Illinois (excise taxes) and Maryland (sales tax) both increased their alcohol taxes recently, yet the craft brewing industry continued to thrive with expanded sales and the number of new breweries nearly tripling. Bureau of Labor Statistics data also demonstrated that following the 1991 federal alcohol tax increase, the alcohol industry actually added jobs.

Project Extra Mile – News Clippings Page 1 of 2 The Grand Island Independent Tuesday, March 5, 2019

It’s also worth noting that these tax proposals affect the entire industry, and alcohol producers in our state are currently enjoying their lowest tax bill in decades due to the 2017 federal tax cut, and they already receive tax credits for using Nebraska agricultural products in their brews. The goal of this proposal is not just to provide property tax relief, which is much needed across the state, but also to improve public health and safety. Excessive drinking is killing our citizens, contributing to crime, spreading disease and costing us at least $1 billion each year. Increasing alcohol taxes will save lives and force excessive drinkers to pay for a majority of the increase. Chris Wagner of Omaha is executive director of Project Extra Mile in Nebraska

Project Extra Mile – News Clippings Page 2 of 2

RESEARCH SUMMARY Date Compiled: March 2019

Key Takeaways from Included Research  A study of a national cohort of 10th graders - led by researchers from multiple National Institutes of Health - found that higher state beer excise taxes were linked to less risk of escalation of binge drinking among young people. Stronger overall alcohol policies were also found to reduce binge escalation risk.  Problem on-premise alcohol outlets not only negatively impact community public health and public safety, but also disproportionately drain public services and resources. There are a number of policy interventions which can help alleviate these problems, but they require communities to commit to adequate funding and enforcement.

 An analysis of data from 2006-2010 from the Centers for Disease Control and Prevention’s Alcohol- Related Disease Impact (ARDI) software application found that age played a large part in deaths by alcohol consumption. Their findings suggest that many studies which find a beneficial effect of light- to-moderate alcohol consumption length of life may be flawed in that they overrepresent older people. Accordingly, any modest health benefits from light-to-moderate alcohol consumption may not apply at all to younger (under 50) people.

 An analysis from a large, nationally (U.S.) representative population-based survey showed a significant association between moderate alcohol consumption (7-14 drinks per week) and prevalence of hypertension – compared with never drinkers.

 Given the risks to health posed by youth alcohol use, and substantial evidence of an association between youth exposure and alcohol marketing and youth alcohol use, governments at all levels should consider restricting and reducing alcohol marketing to protect young people. While legal protections for commercial speech limit the feasibility of advertising and marketing restrictions in the U.S., there are numerous steps that states could be taking to reduce youth exposure to such marketing.

Project Extra Mile 1 March 2019