Five years ago, a workgroup tasked with finding ways to reduce Colorado’s rate of drinking-related deaths — among the highest in the country — issued a simple recommendation: cut back on when and where people can buy alcohol.

Since then, however, the state has only expanded access to alcohol, and may do so again when the legislature reconvenes.

Coloradans voted in 2022 to allow grocery stores to sell wine, three years after they authorized full-strength beer on the shelves. Ahead of the 2024 session, the state’s Liquor Advisory Group recommended lawmakers extend the hours customers can drink at Colorado bars and restaurants by creating a “soft last call,” where final orders must be placed by 2 a.m., but people have until 4 a.m. to finish their drinks.

Colorado’s quiet killer

Alcohol-related deaths in Colorado spiked during the pandemic, and the state ranks as one of the worst for deaths due to drinking. In this four-part series, The Denver Post examines why so many Coloradans are dying, and ways to save lives that the state hasn’t pursued.

Click here to read more from this series.

Changing liquor laws is difficult, but with all of the major parts of the industry backing the soft last call concept, it could be successful in the legislature, said Rep. Marc Snyder, a Colorado Springs Democrat and chair of the committee that regulates alcohol. In 2022, Snyder introduced a bill to extend the hours when alcohol could be sold in the hope that bargoers would be less likely to get into fights if they could disperse more gradually, but it died in a different committee.

Colorado voters’ expansion of access to beer and wine came as the gradual rise in the state’s already high rate of alcohol deaths was accelerating, said Dr. Bill Burman, former director of the Public Health Institute at Denver Health.

The number of Coloradans killed by alcohol jumped more than 60% between 2018 and 2021, before dropping slightly in 2022. When researchers include people who died of chronic health conditions caused or worsened by drinking, alcohol killed more Coloradans than opioids.

“We have done things that probably made it worse, and nothing that has made it better,” Burman said.

The Denver Post is examining Colorado’s high rate of alcohol-related deaths and the state’s hesitation to take steps that could reduce fatalities. This is the third story in a four-part series, looking at how curtailing access to alcohol could limit deaths and what the areas of the state with the highest density of bars and liquor stores are doing to change their drinking cultures. The series also is reviewing barriers to treatment and how tax policy could reduce mortality.

As of August, Colorado had more than 18,000 licensed alcohol businesses, according to data from the state Department of Revenue. Coloradans have more than 12,000 places where they can walk in and buy alcohol, after removing duplicate licenses, out-of-state wineries that ship bottles, and businesses that aren’t public-facing, such as distribution warehouses.

The number of liquor licenses in the state has gradually increased in recent years, from 14,154 in 2017 to 16,057 in 2021. Full license data isn’t available from prior years, so it isn’t clear how many of those licenses were for new establishments, and how many went to existing businesses that got permission for new services, such as offering drinks for takeout or delivery.

Denver has the highest density of alcohol outlets in the state, with about 13 bars, liquor stores and restaurants licensed to serve alcohol and other alcohol retailers for every square mile as of 2020, according to the State Epidemiological Outcomes Workgroup. It also has a high rate of alcohol-related illnesses and injuries, with about one in seven hospitalizations at Denver Health from 2018 to 2022 related to alcohol consumption — more than twice the number of hospitalizations for opioid use.

With some exceptions, areas with more alcohol outlets tend to have higher all-cause mortality (a catch-all term meaning that residents die at a higher rate than would be expected based on the age of the population) as well as worse rates of specific outcomes like drunk-driving crashes and intimate partner violence, said Christopher Morrison, an assistant professor of epidemiology at Columbia University. When alcohol can be sold during more hours of the day, that also leads to worse health in surrounding communities, he said.

Having more outlets not only makes it more convenient to get alcohol, but also drives down prices through competition, making it easier for people to drink more, Morrison said.

Liquor store owners can have a positive effect on alcohol-related deaths because they can avoid selling bottles to people who are intoxicated or seem at risk of harming themselves or others, said Chris Fine, executive director of the Colorado Licensed Beverage Association, which represents non-chain liquor stores. The group opposed expanding beer and wine sales into grocery stores and allowing delivery by people who aren’t liquor store employees, because those changes would make it easier for teens to get alcohol, he said.

“Our members are part of the community,” Fine said.

The state isn’t likely to do anything to reduce the number of alcohol-related businesses, said Micki Hackenberger, executive director of the Wine and Spirits Wholesalers of Colorado. Local governments that are concerned about the amount of alcohol for sale in their communities can require a minimum distance between outlets and set up a process to determine the need for more liquor stores or bars, she said.

“Since the local governments are the ones that do zoning, I assume they would object to any state preemption,” Hackenberger said.

It isn’t fair to restrict how many outlets can serve drinks, said Colin Larson, director of government affairs for the Colorado Restaurant Association.

“We look forward to working with policymakers on implementing narrowly tailored measures that are proven to reduce alcohol-related accidents, while also taking steps to avoid unfairly punishing customers — and businesses — who are good actors,” he said in a statement.

Communities look to change culture

Communities could take other steps, like capping the number of licenses they issue, to reduce alcohol consumption and deaths, according to the State Epidemiological Outcomes Workgroup.

So far, Colorado cities and counties with above-average concentrations of alcohol businesses haven’t done that, though health-focused groups in those areas are trying other approaches to mitigate the impact of drinking.

Teens in resort communities see alcohol all around them, which skews their view of how important drinking is to socializing, said Michelle Stecher, executive director of Mountain Youth in Edwards. The 81657 zip code, which includes much of Vail and Avon, has the second-highest ratio of licensed alcohol businesses to population in the state, behind only the Winter Park area, with about 24 sellers per 1,000 people.

With the exception of one in Huerfano County, all of Colorado’s top 10 zip codes by alcohol density are mountain communities catering to tourists, and most are home to ski resorts. (The Denver Post only compared zip codes with at least 1,000 residents, to reduce skewing based on small populations.)

While tourists are a significant source of revenue for alcohol businesses, locals feel the effects of being surrounded by drinking, Stecher said. Alcohol makers sponsor almost all festivals in the area, and adults can inadvertently model drinking as an important part of Colorado life, leading youth to start drinking earlier than in other parts of the state, she said.

Only 2% of Coloradans who died from alcohol-related causes were under 20, but starting to drink earlier in life increases the odds of excessive drinking — and all the health harm that comes with it — as an adult.

“Many of the resort communities like ours really celebrate the party lifestyle,” Stecher said. “The message that sends to young people is either, ‘That’s OK,’ or, ‘To have fun, the bike ride has to end with that cooler of beer.’”

To try to counter that message, Mountain Youth offers substance-free activities and works with teens to craft education campaigns reminding them that most of their peers aren’t actually getting drunk every Saturday, which is a common misconception, Stecher said. They also hold educational events for parents on how to build positive relationships with their teens, which is an important factor in protecting kids from early substance use, she said.

“The challenges change as kids grow up,” she said.

Gunnison County has taken a similar approach, focusing on intoxicated driving and youth use. The 81224 zip code, which serves Crested Butte, has the sixth-highest rate of alcohol businesses in the state.

Youth see adults letting loose on vacation and misinterpret it as the normal way to drink, said Kari Commerford, director of juvenile services for Gunnison County. Also, young people don’t have many places to gather where alcohol isn’t served, and parents often feel like the safest thing is just to let kids drink at their houses, she said.

“We’re highly saturated,” Commerford said.

The county’s substance use prevention group has been trying to inform parents that they could be ticketed if they allow minors to drink on their property, and that even if teens aren’t driving, allowing them to drink raises the risk of sexual assault, Commerford said. They’re also offering alternatives, like laser tag nights, and reminding parents that kids who drink heavily tend to be less mentally healthy than those who don’t, she said.

“We often hear concerns from parents that if they don’t let their kids go to the party, they’re going to be socially isolated,” she said.

Not every area with a high rate of alcohol-related businesses considers drinking a major health problem.

Pitkin County’s community health needs assessment noted that its residents were more likely than Coloradans in general to report binge drinking, but that a smaller percentage of the county’s fatal crashes involved someone whose blood alcohol was above the legal limit. Excessive alcohol use didn’t make it into the county’s community health improvement plan, which focused on access to health care and the health effects of climate change. Two zip codes in the Aspen area were in the state’s top 10 for alcohol outlets compared to population.

Over the last decade, however, the percentage of deaths linked to alcohol in Pitkin County was roughly the same as the state as a whole, when using a narrow definition that includes deaths from withdrawal and a few types of organ damage.

“Stigma” around not drinking

Alcohol long has held a special status as a socially acceptable drug, allowed in places and defended by people who would never do the same for opioids, marijuana or even tobacco.

The Denver Museum of Nature and Science promotes adults-only events like “Buzzed with Bugs.” A group of memory care facilities urged the public to “Raise a Pint for Alzheimer’s” by attending a dinner fundraiser to benefit the Alzheimer’s Association, even though excessive alcohol use is a risk factor for dementia. The Archdiocese of Denver, in a recently published anti-drug message, said its position that drug use is sinful doesn’t include alcohol, because people use it for health benefits or to appreciate the taste.

The long cultural history of alcohol, with Christian and Jewish rituals that include wine, gives it a kind of legitimacy that other drugs don’t have for white Americans who have generally made the laws, said David Jernigan, a Boston University professor who studies alcohol marketing. However, some of the role of alcohol in American life is a recent development based on deliberate marketing, such as the link between sports and beer. Until the 1970s, alcohol brands rarely sponsored sporting events, and while people might drink while watching a game, the two weren’t linked in the public imagination, he said.

People who no longer drink can struggle to find ways to be social in Colorado and in much of the country, said Trevor Flick, who works at the fitness-focused sober community The Phoenix in Denver. The Phoenix offers alternatives, like an alcohol-free dance that was part of Pride celebrations in June, a “Sober Bowl” party for those who don’t feel comfortable being around beer during the big game and a Halloween event, he said.

The average person is accustomed to meeting for drinks on dates or with friends, and not everyone in recovery feels capable of being around others who are drinking, Flick said. He said he personally doesn’t have a problem ordering a soda when others drink, but sometimes people have invasive questions or push him to try alcohol again.

“I had to leave my old social circle behind,” he said. “At first, it didn’t seem like there was much else to do.”

Part of the reason sobriety can be so difficult in the beginning is that people who drink excessively often find their social relationships revolve around alcohol, said Heidi, a Boulder resident who spoke on the condition her last name not be published to protect her privacy.

“You have to change your whole life,” she said.

For people who have recently stopped drinking and are still making that adjustment, it can be particularly challenging to find alcohol in places they can’t avoid, like grocery stores, Heidi said. She said she personally doesn’t mind seeing wine on the shelves because she’s been sober for more than 20 years and lived in other states where alcohol was sold in grocery stores, but others in recovery have told her they were startled.

“I went to a (Alcoholics Anonymous) meeting and people were blown away, seeing alcohol in stores,” she said.

Social events that don’t revolve around drinking are particularly hard to find for young people, said Emily Lippmer, who is from Denver but attends college in New Jersey. She said she doesn’t mind if others drink and that most of her friends supported her decision to stop drinking at 17, but it can be awkward to explain at parties.

“When I started telling people I was sober, I started apologizing, like, ‘Sorry if I’m boring,’” she said. “(At a party) I was just holding an empty cup because it was easier than to explain it.”

Rebecca Hersley, who graduated from Chaparral High School in Parker earlier this year and is friends with Lippmer, agreed not drinking can come with a “stigma,” and that people her age don’t necessarily see drinking until they pass out as a problem.

For most people, having a drink is about loosening up and being social, but some drink alone even as teenagers, she said.

“I think people don’t know when to stop because it’s so normalized,” she said.

Environment nudges decisions

With the exception of Utah, states in the Mountain West have higher rates of alcohol consumption, as well as more drinking-related deaths and illnesses, than the country as a whole.

States’ drinking cultures are a product of many factors, including how they choose to regulate alcohol and residents’ demographics, said Bill Kerr, scientific director of the California-based Alcohol Research Group.

A teetotaler in Utah doesn’t automatically become a party animal if they move across the state line, but differences in environment nudge people’s choices in small ways that add up over time, Kerr said. In a community where people drink more, more restaurants will consider it worth the trouble to have liquor licenses, and people who wouldn’t have bothered to stop by a bar after dinner may have a cocktail while they eat. And if the bars are full of people, they’re more appealing to those who wouldn’t seek one out just to get drunk, he said.

“Absolutely, people are affected by the area they’re in,” Kerr said.

Also, different areas set different expectations for what could be considered heavy or problematic drinking, Kerr said. If everyone else stops at one drink, a person ordering four might feel uncomfortable — but if they see someone else is on their eighth drink, their own drinking feels healthy, he said.

“People measure their own drinking in terms of what other people do,” he said.

While people might assume that those who drink heavily will continue to do so regardless of convenience, studies have found that when alcohol is sold in more locations or available later into the night, hospitalizations and other bad outcomes increase, Kerr said. For example, a person may still drink heavily even with restrictive laws, but if the liquor stores already are closed when they run out of alcohol, that at least reduces their consumption for that night, he said.

“If it’s more convenient, if there’s more stores in the area, if it’s easier to get to, if you can bundle purchases like at grocery stores, there’s a marginal increase,” he said.

But no one knows whether regions could change their alcohol cultures because none have tried to in recent decades, Kerr said. Americans’ average consumption has been rising over time, but states have been reluctant to raise taxes and quick to expand access, he said.

The one major experiment in reducing alcohol access — Prohibition in the 1920s and early 1930s — may have reduced alcohol consumption by about 70% in its first year, though by the time it was repealed, consumption was down by only about 30%, according to a paper from the National Bureau of Economic Research. Of course, no one in power is discussing a return to Prohibition, which was marked by organized crime groups peddling sometimes unsafe forms of alcohol.

“We don’t see any cases of alcohol being sold in fewer stores over time,” Kerr said.

In the 1950s and ’60s, tobacco was at least as pervasive as alcohol is now, but that’s no longer the case because social norms changed, said Burman, the former director of the Public Health Institute at Denver Health. While many people won’t give up drinking entirely, the perception of what’s an unhealthy relationship with alcohol could shift, particularly now that more are reconsidering their drinking during the increasingly popular Dry January, he said.

“Can we get to a social norm that’s much healthier?” he asked. “I think the evidence is that we can.”

READ PART 4: Alcohol addiction treatment is available in Colorado, but people struggle to get the help they need

The Denver Post is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity and newsrooms in select states across the country.