Baltimore City's landmark alcohol and tobacco billboard ban: an implementation case study.

INTRODUCTION Alcohol is the leading cause of death and disability globally among males aged 15–24 in all regions except the Eastern Mediterranean and females aged 15–24 in the wealthy nations and the Americas; much of this burden is from injury. Excessive alcohol use is the leading drug problem among young people in the USA, and the leading causes of alcohol-related deaths among young people in the USA are injury: MVCs, homicide, suicide, poisoning (not alcohol), child maltreatment and drowning comprise 95% of the approximately 4173 deaths caused by alcohol among persons under 21 annually. Exposure to alcohol advertising increases the likelihood that young people will hold positive beliefs about alcohol, intend to drink and consume alcohol. Longitudinal studies have consistently found that youth exposure to alcohol advertising in various settings—including broadcast, print, outdoor, point-of-purchase and at sporting events—correlates with earlier onset of drinking among non-drinkers and increased levels of drinking among youth already drinking. 8 Adolescents who report exposure to and liking of ads in early adolescence (7th grade) are more likely later (10th grade) to report negative alcohol-related consequences, including getting into fights. Outdoor advertisements target pedestrian and motor vehicle traffic and appear in a wide array of formats and sizes. In the early 1990s, tobacco companies were the most prominent outdoor advertisers: in 1992, the tobacco industry spent $123 million on outdoor advertising and by 1996 six of the top ten outdoor advertisers were tobacco companies. Following the Master Settlement Agreement in 1998, outdoor advertising for tobacco fell precipitously, and expenditures on outdoor advertising for alcohol surpassed spending on tobacco ads. By 2002, the Anheuser-Busch Company was the largest outdoor advertiser in the USA, spending just under $50 million annually on outdoor advertisements. Saffer and Dave assessed the impact of alcohol advertising restrictions in 20 countries over 26 years and estimated that each incremental restriction reduced population-level alcohol consumption by 5–8%. The same authors used advertising expenditure data to estimate that a 28% reduction in youth exposure to alcohol advertising, including outdoor advertising, would correlate with reductions of monthly adolescent binge drinking from 12% to between 11 and 8%. However, to the best of our knowledge, no studies have specifically examined the effects of bans on outdoor alcohol advertising on youth alcohol consumption. Historically, states and the federal government have relied on alcohol industry self-regulation as the primary protection against youth exposure to alcohol advertising. However, industry failure to uphold its own standards of regulation— particularly in more vulnerable lowerincome, urban communities—resulted in grassroots activism and groundbreaking legislation to regulate alcohol advertising. Significant changes occurred in local regulation of outdoor advertising for alcohol throughout the country, but while the legal aspects underpinning this movement have been documented in peerreviewed literature, to our knowledge no one has documented the process that led to these changes or their implementation and enforcement. This paper seeks to fill that gap by reviewing the history of outdoor alcohol advertising regulation in Baltimore City, which passed the first municipal ordinance banning alcohol and tobacco advertising in the USA in 1994, from the ordinance’s conception through legal hurdles and into implementation and enforcement, with a particular focus on the critical role that community organising and mobilisation played throughout the campaign. To produce this case study, the authors reviewed newspaper coverage of the events in Baltimore, as well as relevant Baltimore City and Court documents, including written opinions of the Baltimore City Circuit Court and United States Fourth Circuit Court of Appeals. The first author supplemented these with interviews of a range of key informants, including community activists, policymakers and city zoning officials; the first author also conducted an informal survey of Baltimore neighbourhoods to assess current implementation of the ordinance.