Article

Impact on alcohol-related mortality of a rapid rise in the density of private liquor outlets in British Columbia: A local area multi-level analysis

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  • Beijing center of diease control and prevention
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Abstract

To study relationships between rates of alcohol-related deaths and (i) the density of liquor outlets and (ii) the proportion of liquor stores owned privately in British Columbia (BC) during a period of rapid increase in private stores. Multi-level regression analyses assessed the relationship between population rates of private liquor stores and alcohol-related mortality after adjusting for potential confounding. The 89 local health areas of BC, Canada across a 6-year period from 2003 to 2008, for a longitudinal sample with n = 534. Population rates of liquor store density, alcohol-related death and socio-economic variables obtained from government sources. The total number of liquor stores per 1000 residents was associated significantly and positively with population rates of alcohol-related death (P < 0.01). A conservative estimate is that rates of alcohol-related death increased by 3.25% for each 20% increase in private store density. The percentage of liquor stores in private ownership was also associated independently with local rates of alcohol-related death after controlling for overall liquor store density (P < 0.05). Alternative models confirmed significant relationships between changes in private store density and mortality over time. The rapidly rising densities of private liquor stores in British Columbia from 2003 to 2008 was associated with a significant local-area increase in rates of alcohol-related death.

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... 11 Stockwell found that rates of alcohol-related death in British Columbia, Canada increased by 3.25% for each 20% increase in the density of private alcohol outlets. 12 Greater alcohol outlet density is associated with increased alcohol consumption and ensuing medical disease, injury, crime and violence. 13 There is a substantial body of research on neighbourhoods and health: neighbourhood disadvantage is associated with poor psychological and physical health. ...
... Stockwell showed that the density of private liquor stores is independently associated with local rates of alcohol-related death. 12 Alcohol impairs cognitive functioning, and, when combined with a higher propensity for risk-taking behaviours among males, increases their likelihood of intentional and unintentional injury and death. 9 10 In a study of hospitalisations for serious assault, we previously found that victimisation increased with alcohol sales, especially among young urban men. ...
... In Ontario, alcohol is completely regulated, 11 enabling us to account for all places where alcohol is sold, unlike in other Canadian provinces or US states, where private retail outlets exist. 12 51 52 Hence, in our study, where both retail in-store and on-premise alcohol sales were documented, it was possible to evaluate the general availability of alcohol within the population. ...
Article
Objective Alcohol overuse and poverty, each associated with premature death, often exist within disadvantaged neighbourhoods. Cheque cashing places (CCPs) may be opportunistically placed in disadvantaged neighbourhoods, where customers abound. We explored whether neighbourhood density of CCPs and alcohol outlets are each related to premature mortality among adults. Design Retrospective population-based study. Setting 140 neighbourhoods in Toronto, Ontario, 2005–2009. Participants Adults aged 20–59 years. Measures Our primary outcome was premature all-cause mortality among adults aged 20–59 years. Across neighbourhoods we explored neighbourhood density, in km2, of CCPs and alcohol outlets, and the relation of each to premature mortality. Poisson regression provided adjusted relative risks (aRRs) and 95% CIs, adjusting for material deprivation quintile (Q), crime Q and number of banks. Results Intentional self-harm, accidental poisoning and liver disease were among the top five causes of premature death among males aged 20–59 years. The overall premature mortality rate was 96.3/10 000 males and 55.9/10 000 females. Comparing the highest versus lowest CCP density Q, the aRR for death was 1.25 (95% CI 1.15 to 1.36) among males and 1.11 (95% CI 0.99 to 1.24) among females. The corresponding aRR comparing the highest Q versus lowest Q alcohol outlet density in relation to premature mortality was 1.36 (95% CI 1.25 to 1.48) for males and 1.11 (95% CI 1.00 to 1.24) for females. The pattern of the relation between either CCPs or alcohol outlet density and premature mortality was typically J shaped. Conclusions There is a J-shaped relation between CCP or alcohol outlet density and premature mortality, even on controlling for conventional measures of poverty. Formal banking and alcohol reduction strategies might be added to health promotion policies aimed at reducing premature mortality in highly affected neighbourhoods.
... 11 Stockwell found that rates of alcohol-related death in British Columbia, Canada increased by 3.25% for each 20% increase in the density of private alcohol outlets. 12 Greater alcohol outlet density is associated with increased alcohol consumption and ensuing medical disease, injury, crime and violence. 13 There is a substantial body of research on neighbourhoods and health: neighbourhood disadvantage is associated with poor psychological and physical health. ...
... Stockwell showed that the density of private liquor stores is independently associated with local rates of alcohol-related death. 12 Alcohol impairs cognitive functioning, and, when combined with a higher propensity for risk-taking behaviours among males, increases their likelihood of intentional and unintentional injury and death. 9 10 In a study of hospitalisations for serious assault, we previously found that victimisation increased with alcohol sales, especially among young urban men. ...
... In Ontario, alcohol is completely regulated, 11 enabling us to account for all places where alcohol is sold, unlike in other Canadian provinces or US states, where private retail outlets exist. 12 51 52 Hence, in our study, where both retail in-store and on-premise alcohol sales were documented, it was possible to evaluate the general availability of alcohol within the population. ...
Research
Objective: Alcohol overuse and poverty, each associated with premature death, often exist within disadvantaged neighbourhoods. Cheque cashing places (CCPs) may be opportunistically placed in disadvantaged neighbourhoods, where customers abound. We explored whether neighbourhood density of CCPs and alcohol outlets are each related to premature mortality among adults. Design: Retrospective population-based study. Setting: 140 neighbourhoods in Toronto, Ontario, 2005–2009. Participants: Adults aged 20–59 years. Measures: Our primary outcome was premature all cause mortality among adults aged 20–59 years. Across neighbourhoods we explored neighbourhood density, in km2, of CCPs and alcohol outlets, and the relation of each to premature mortality. Poisson regression provided adjusted relative risks (aRRs) and 95% CIs, adjusting for material deprivation quintile (Q), crime Q and number of banks. Results: Intentional self-harm, accidental poisoning and liver disease were among the top five causes of premature death among males aged 20–59 years. The overall premature mortality rate was 96.3/10 000 males and 55.9/10 000 females. Comparing the highest versus lowest CCP density Q, the aRR for death was 1.25 (95% CI 1.15 to 1.36) among males and 1.11 (95% CI 0.99 to 1.24) among females. The corresponding aRR comparing the highest Q versus lowest Q alcohol outlet density in relation to premature mortality was 1.36 (95% CI 1.25 to 1.48) for males and 1.11 (95% CI 1.00 to 1.24) for females. The pattern of the relation between either CCPs or alcohol outlet density and premature mortality was typically J shaped. Conclusions: There is a J-shaped relation between CCP or alcohol outlet density and premature mortality, even on controlling for conventional measures of poverty. Formal banking and alcohol reduction strategies might be added to health promotion policies aimed at reducing premature mortality in highly affected neighbourhoods.
... Previous research has found rates of alcohol consumption are far greater in rural and northern BC communities, which in turn also have high rates of per capita alcohol-related mortality and hospital morbidity (Centre for Addictions Research of British Columbia, 2012b). Within the context of these trends e and policy changes that further increase access to alcohol-products e there has been a growing need to improve our understanding of the geographic distribution of alcohol-related harms and need for substance use treatment services at the population level (Stockwell et al., 2011). ...
... The measures used in this project were selected in reference to other studies that have modeled geographic variations in alcoholrelated harm (Beshai, 1984;Dietze et al., 2000;Gregoire, 2002;McAuliffe, Woodworth, Zhang & Dunn, 2002;Sherman et al., 1996). The indicators selected for this project are highly correlated with alcohol dependency and alcohol-related diseases making them appropriate for estimating alcohol-related harm (Hahn et al., 2012;Norstr€ om, 2001;Rehm et al., 2003;Stockwell et al., 2009Stockwell et al., , 2011. Data analysis was completed at the Local Health Area (LHA) level because it is the smallest geographical scale available for most alcohol-related data that is collected in BC. ...
... Data on per capita liquor stores per 1000 by LHA (2012) were sourced from the Centre for Addictions Research of BC (CARBC) (CARBC, 2014b). Data were included in the model because previous research has found that an increase in the outlet density of liquor stores is associated with increased alcohol-related mortality (Popova, Giesbrecht, Bekmuradov, & Patra, 2009;Stockwell et al., 2011). ...
Article
The purpose of this project was to build a community index of alcohol-related harm to measure geographic variations in alcohol-related harm, and identify regions that have greater potential need for substance use treatment services in British Columbia (BC). Four categories of indicators were modeled that are indirect and direct measures of alcohol-related harm: alcohol consumption (N = 3); self-injury (N = 2) alcohol-related morbidity (N = 2), and alcohol-related mortality (N = 4). Data were analyzed using Principal Component Analysis (PCA) to identify relevant indicators of alcohol-related harm. Cronbach's alpha was used to determine the reliability of each of the components identified, and the PCA values were used to weight the indicators for the final index. The final index scores by Local Health Area (LHA) were then inputted into ArcGIS to examine spatial autocorrelation using Morans I and Getis-Ord-Gi. In the final PCA modl, there were nine alcohol-related harm indicators that accounted for 74.6% of the variance. The results of the index and spatial autocorrelation models showed significant geographic variations and clustering of high and low values of alcohol-related harms by LHA. The findings of this study show that there are significant geographic variations in alcohol-related harm throughout BC. The results of this study add to the growing body of research that has found that substance use related harms disproportionately negatively affect the health and wellbeing of less populated places.
... In neighboring British Columbia (BC), a rapid expansion of private liquor outlets from a low base was permitted between 2002 and 2006. As a result, by 2010 the number of private outlets increased from 543 to 1,045 while government outlets decreased from 212 to 197 (Stockwell et al., 2011). However, with the BC liquor distribution authority fixing wholesale prices only slightly below government liquor store prices (initially 10% lower, rising to 16%) and the imposition of minimum retail prices, private stores typically have sold alcohol at prices between 10% and 15% higher than in government stores-although on any given day, the cheapest alcohol is usually available from private stores (Stockwell et al., 2010). ...
... Socioeconomic and demographic data. Several socioeconomic and demographic variables were included in the analyses, being selected for their potential to confound the main relationships of interest Holder & Parker, 1992;Sloan et al., 1994;Stockwell et al., 2011). Time-invariant census variables available from the 2006 census for each LHA (Statistics Canada, 2006) included percentages of aboriginal people and mean family income. ...
... Although private liquor store density was positively associated with each category of crime examined, this relationship was only statistically significant for non-alcohol-involved traffic violations. We note that in other more powerful analyses with more time periods available, significant positive relationships were observed between the density of private liquor stores and both morbidity and mortality outcomes (Stockwell et al., 2011Zhao et al., 2013). The significant effect of minimum price on alcohol-related traffic violations but not on non-alcohol-related citations, along with the larger literature on alcohol pricing, consumption, and harm (Wagenaar et al., 2009a(Wagenaar et al., , 2010, is consistent with the interpretation that increases in minimum alcohol prices can cause reductions in alcohol-related traffic violations. ...
Article
Full-text available
The purpose of this study was to estimate the independent effects of increases in minimum alcohol prices and densities of private liquor stores on crime outcomes in British Columbia, Canada, during a partial privatization of off-premise liquor sales. A time-series cross-sectional panel study was conducted using mixed model regression analysis to explore associations between minimum alcohol prices, densities of liquor outlets, and crime outcomes across 89 local health areas of British Columbia between 2002 and 2010. Archival data on minimum alcohol prices, per capita alcohol outlet densities, and ecological demographic characteristics were related to measures of crimes against persons, alcohol-related traffic violations, and non-alcohol-related traffic violations. Analyses were adjusted for temporal and regional autocorrelation. A 10% increase in provincial minimum alcohol prices was associated with an 18.81% (95% CI: ±17.99%, p < .05) reduction in alcohol-related traffic violations, a 9.17% (95% CI: ±5.95%, p < .01) reduction in crimes against persons, and a 9.39% (95% CI: ±3.80%, p < .001) reduction in total rates of crime outcomes examined. There was no significant association between minimum alcohol prices and non-alcohol-related traffic violations (p > .05). Densities of private liquor stores were not significantly associated with alcohol-involved traffic violations or crimes against persons, though they were with non-alcohol-related traffic violations. Reductions in crime events associated with minimum-alcohol-price changes were more substantial and specific to alcohol-related events than the countervailing increases in densities of private liquor stores. The findings lend further support to the application of minimum alcohol prices for public health and safety objectives.
... It was estimated that doubling the number of restaurants would lead to a 23% increase in per capita consumption, doubling of bars in a 5% increase, while doubling the number of private stores would result in only a 3% increase. Using the same analytical period, alcohol-related mortality and morbidity were analysed in three papers with slightly differing models and control variables [75][76][77]. Despite being the strongest predictor of alcohol sales [74], restaurant density was not significantly associated with alcohol-related mortality [75][76][77], and private liquor stores, despite having a small estimated effect on sales [74], had the strongest positive association [75][76][77]. ...
... Using the same analytical period, alcohol-related mortality and morbidity were analysed in three papers with slightly differing models and control variables [75][76][77]. Despite being the strongest predictor of alcohol sales [74], restaurant density was not significantly associated with alcohol-related mortality [75][76][77], and private liquor stores, despite having a small estimated effect on sales [74], had the strongest positive association [75][76][77]. Governmental stores, with the largest share of sales [74], were negatively associated with alcohol-related mortality in two studies [75,77], and bars positively in one study [75]. ...
... Using the same analytical period, alcohol-related mortality and morbidity were analysed in three papers with slightly differing models and control variables [75][76][77]. Despite being the strongest predictor of alcohol sales [74], restaurant density was not significantly associated with alcohol-related mortality [75][76][77], and private liquor stores, despite having a small estimated effect on sales [74], had the strongest positive association [75][76][77]. Governmental stores, with the largest share of sales [74], were negatively associated with alcohol-related mortality in two studies [75,77], and bars positively in one study [75]. The studies in BC did not take into account that alcohol per capita data increased already before the policy change and also did not use other provinces or territories in Canada as control areas. ...
Article
There have been reviews on the association between density of alcohol outlets and harm including studies published up to December 2008. Since then the number of publications has increased dramatically. The study reviews the more recent studies with regard to their utility to inform policy. A systematic review found more than 160 relevant studies (published between January 2009 and October 2014). The review focused on: (i) outlet density and assaultive or intimate partner violence; (ii) studies including individual level data; or (iii) 'natural experiments'. Despite overall evidence for an association between density and harm, there is little evidence on causal direction (i.e. whether demand leads to more supply or increased availability increases alcohol use and harm). When outlet types (e.g. bars, supermarkets) are analysed separately, studies are too methodologically diverse and partly contradictory to permit firm conclusions besides those pertaining to high outlet densities in areas such as entertainment districts. Outlet density commonly had little effect on individual-level alcohol use, and the few 'natural experiments' on restricting densities showed little or no effects. Although outlet densities are likely to be positively related to alcohol use and harm, few policy recommendations can be given as effects vary across study areas, outlet types and outlet cluster size. Future studies should examine in detail outlet types, compare different outcomes associated with different strengths of association with alcohol, analyse non-linear effects and compare different methodologies. Purely aggregate-level studies examining total outlet density only should be abandoned. [Gmel G, Holmes J, Studer J. Are alcohol outlet densities strongly associated with alcohol-related outcomes? A critical review of recent evidence. Drug Alcohol Rev 2015]. © 2015 Australasian Professional Society on Alcohol and other Drugs.
... 1,2 In the past two years, several Canadian provinces, such as New Brunswick, Ontario and British Columbia, have expanded the distribution of alcohol to allow the sale of wine and/ or beer in private agency and grocery stores that are not owned or operated by the provincial liquor corporation. [3][4][5][6] Greater alcohol availability has been identified as a significant public health concern because of the increased consumption and associated alcohol-related harms that result from expanding the places where liquor can be sold in the community. 7 Previous research has found a strong relationship between liquor outlet proximity, alcohol availability, and higher rates of consumption and alcohol-related harms, such as premature mortality and risk of injury, among youth and adults. ...
... Existing research has consistently found that greater access to alcohol leads to increased levels of alcohol consumption and alcohol-related harms, such as interpersonal violence, injury, and the development of alcohol-related physical and mental health problems. 5,[37][38][39][40] Research focusing on the introduction of alcohol retail into grocery stores has found increased levels of consumption of the liquor products stocked within the grocery store setting. 41 Other studies support these findings, adding that not only does selling alcohol within grocery stores increase alcohol consumption but that the highest increases can occur in female and rural populations. ...
... 42 Research from other Canadian provinces, such as British Columbia, has identified increases in alcohol-related risk outcomes and alcohol-attributable mortality following the expansion of alcohol retail outlets. 5,6 Communities with greater access to alcohol have also been shown to generally have higher rates of violent crime and growth in the number of hospital visits for stress, anxiety and depression. [43][44][45][46] Neighbourhood socio-economic status ...
Article
p> OBJECTIVES: The purpose of this project was to evaluate how changes to the sale of alcohol in New Brunswick would be distributed across urban and rural communities, and low- and high-income neighbourhoods. The study objectives were to 1) estimate the population living close to alcohol outlets before and after liquor distribution reforms, 2) identify communities or regions that would be more or less affected, and 3) determine whether expanding access to alcohol products would reduce school proximity to retailers. METHODS: Data from Statistics Canada, Desktop Mapping Technologies Inc. (DMTI), and geocoded publicly available information were spatially linked and analyzed using descriptive statistics. The populations living within 499 m, 500–999 m and 1–5 km of an outlet were estimated, and the distances from schools to stores were examined by geographic characteristics and neighbourhood socio-economic status. RESULTS: Permitting the sale of alcohol in all grocery stores throughout the province would increase the number of liquor outlets from 153 to 282 and would increase the population residing within 499 m of an outlet by 97.49%, from 19 886 to 39 273 residents. The sale of alcohol in grocery stores would result in an additional 35 liquor sales outlets being located within 499 m of schools. Low-income neighbourhoods would have the highest number and proportion of stores within 499 m of schools. CONCLUSION: The findings of this study demonstrate the importance of considering social, economic and health inequities in the context of alcohol policy reforms that will disproportionately affect low-income neighbourhoods and youth living within these areas.</p
... A total of 1142 citations were identified from the database searches. After removal of duplicates, we reviewed 601 unique records by title and abstract, of which 18 longitudinal studies [23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] and one review article 41 of studies investigating a change in outlet density met the broad inclusion criteria. ...
... We found a further 18 papers 23-40 that investigated associations between change in outlet density and a limited range of outcomes, namely alcohol consumption, [24][25][26][27] violence, 23,[28][29][30][31][32][33]36,37 STIs, 34,35 suicide 38 and other causes of death. 39,40 Of these, seven 23,[24][25][26]33,39,40 were published after this study [change in alcohol outlet density and alcohol-related harm to population health (CHALICE)] was funded. ...
... We found a further 18 papers 23-40 that investigated associations between change in outlet density and a limited range of outcomes, namely alcohol consumption, [24][25][26][27] violence, 23,[28][29][30][31][32][33]36,37 STIs, 34,35 suicide 38 and other causes of death. 39,40 Of these, seven 23,[24][25][26]33,39,40 were published after this study [change in alcohol outlet density and alcohol-related harm to population health (CHALICE)] was funded. ...
Article
Full-text available
Excess alcohol consumption has serious adverse effects on health and results in violence-related harm. Objective This study investigated the impact of change in community alcohol availability on alcohol consumption and alcohol-related harms to health, assessing the effect of population migration and small-area deprivation. Design A natural experiment of change in alcohol outlet density between 2006 and 2011 measured at census Lower Layer Super Output Area level using observational record-linked data. Setting Wales, UK; population of 2.5 million aged ≥ 16 years. Outcome measures Alcohol consumption, alcohol-related hospital admissions, accident and emergency (A&E) department attendances from midnight to 06.00 and violent crime against the person. Data sources Licensing Act 2003 [Great Britain. Licensing Act 2003 . London: The Stationery Office; 2003. URL: www.legislation.gov.uk/ukpga/2003/17/contents (accessed 8 June 2015)] data on alcohol outlets held by the 22 local authorities in Wales, alcohol consumption data from annual Welsh Health Surveys 2008–12, hospital admission data 2006–11 from the Patient Episode Database for Wales (PEDW) and A&E attendance data 2009–11 were anonymously record linked to the Welsh Demographic Service age–sex register within the Secure Anonymised Information Linkage Databank. A final data source was recorded crime 2008–11 from the four police forces in Wales. Methods Outlet density was estimated (1) as the number of outlets per capita for the 2006 static population and the per quarterly updated population to assess the impact of population migration and (2) using new methods of network analysis of distances between each household and alcohol outlets within 10 minutes of walking and driving. Alcohol availability was measured by three variables: (1) the previous quarterly value; (2) positive and negative change over the preceding five quarters; and (3) volatility, a measure of absolute quarterly changes during the preceding five quarters. Longitudinal statistical analysis used multilevel Poisson models of consumption and Geographically Weighted Regression (GWR) spatial models of binge drinking, Cox regression models of hospital admissions and A&E attendance and GWR models of violent crime against the person, each as a function of alcohol availability adjusting for confounding variables. The impact on health inequalities was investigated by stratifying models within quintiles of the Welsh Index of Multiple Deprivation. Results The main finding was that change in walking outlet density was associated with alcohol-related harms: consumption, hospital admissions and violent crime against the person each tracked the quarterly changes in outlet density. Alcohol-related A&E attendances were not clinically coded and the association was less conclusive. In general, social deprivation was strongly associated with the outcome measures but did not substantially modify the associations between the outcomes and alcohol availability. We found no evidence for an important effect of population migration. Limitations Limitations included the absence of any standardised methods of alcohol outlet data collation, processing and validation, and incomplete data on on-sales and off-sales. We were dependent on the quality of clinical coding and administrative records and could not identify alcohol-related attendances in the A&E data set. Conclusion This complex interdisciplinary study found that important alcohol-related harms were associated with change in alcohol outlet density. Future work recommendations include defining a research standard for recording outlet data and classification of outlet type, the methodological development of residence-based density measures and a health economic analysis of model-predicted harms. Funding The National Institute for Health Research Public Health Research programme. Additional technical and computing support was provided by the Farr Institute at Swansea University, made possible by the following grant: Centre for the Improvement of Population Health through E-records Research (CIPHER) and Farr Institute capital enhancement. CIPHER and the Farr Institute are funded by Arthritis Research UK, the British Heart Foundation, Cancer Research UK, the Chief Scientist Office (Scottish Government Health Directorates), the Economic and Social Research Council, the Engineering and Physical Sciences Research Council, the Medical Research Council, the National Institute for Health Research, the National Institute for Social Care and Health Research (Welsh Government) and the Wellcome Trust (grant reference MR/K006525/1).
... Flam-Zalcman and Mann [21] observed that successive stages of privatisation of the alcohol retailing system in Alberta between 1985 and 1994 coincided with significant increases in male and female suicide mortality rates. Stockwell et al. [22][23][24] and Zhao et al. [25] concluded that increases in private alcohol retail outlets in British Columbia contributed to increases in alcohol-related deaths, hospital admissions and crime. Recent research by Myran et al. [26,27] assessed the Ontario experience, focusing on before and after periods when selected grocery supermarkets were permitted to sell alcohol, starting in December 2015. ...
... Myran et al [27] also indicate that this change was related to an increase in alcohol-related emergency department admissions after December 2015. Stockwell et al. [22][23][24], focusing on British Columbia during their period of partial privatisation and expansion of outlet density, found an increase in alcohol-related harm. Based on this research and the international evidence [e.g. ...
Article
Introduction Policy changes may contribute to increased alcohol‐related risks to populations. These include privatisation of alcohol retailing, which influences density of alcohol outlets, location of outlets, hours of sale and prevention of alcohol sales to minors or intoxicated customers. Meta‐analyses, reviews and original research indicate enhanced access to alcohol is associated with elevated risk of and actual harm. We assess the 10 Canadian provinces on two alcohol policy domains—type of alcohol control system and physical availability of alcohol—in order to track changes over time, and document shifting changes in alcohol policy. Methods Our information was based on government documents and websites, archival statistics and key informant interviews. Policy domains were selected and weighted for their degree of effectiveness and population reach based on systematic reviews and epidemiological evidence. Government representatives were asked to validate all the information for their jurisdiction. Results The province‐specific reports based on the 2012 results showed that 9 of 10 provinces had mixed retail systems—a combination of government‐run and privately owned alcohol outlets. Recommendations in each provincial report were to not increase privatisation. However, by 2017 the percentage of off‐premise private outlets had increased in four of these nine provinces, with new private outlet systems introduced in several. Discussion and Conclusions Decision‐making protocols are oriented to commercial interests and perceived consumer convenience. If public health and safety considerations are not meaningfully included in decision‐making protocols on alcohol policy, then it will be challenging to curtail or reduce harms.
... Today, 17 US states control sales of spirits and/or wine at the wholesale level and 13 of these also at the retail level [1]. Retail "monopolies" for all alcohol beverages remain in twelve of Canada's thirteen regional jurisdictions [2], though, increasingly, sales of alcohol are also being allowed in private stores and even grocery stores in some provinces [3]. In the Nordic countries, Iceland, Norway, Sweden and Finland have state alcohol retail monopolies for higher strength beers, wine and spirits. ...
... The median increase in per capita sales of privatised beverages was 44.4% over all studies, ranging from 0 to 305%. More recently, studies of the partial privatization of alcohol in British Columbia, Canada over a period of a few years, indicated that an increasing proportion of liquor stores in private ownership assessed across 89 regions was associated with increased alcohol consumption [13,14], alcohol attributable mortality [3] and morbidity [15]. In the latter study, the relationship held after controlling for changes in alcohol pricing policies. ...
Article
Full-text available
Background Government alcohol monopolies were created in North America and Scandinavia to limit health and social problems. The Swedish monopoly, Systembolaget, reports to a health ministry and controls the sale of all alcoholic beverages with > 3.5% alcohol/volume for off-premise consumption, within a public health mandate. Elsewhere, alcohol monopolies are being dismantled with evidence of increased consumption and harms. We describe innovative modelling techniques to estimate health outcomes in scenarios involving Systembolaget being replaced by 1) privately owned liquor stores, or 2) alcohol sales in grocery stores. The methods employed can be applied in other jurisdictions and for other policy changes. Methods Impacts of the privatisation scenarios on pricing, outlet density, trading hours, advertising and marketing were estimated based on Swedish expert opinion and published evidence. Systematic reviews were conducted to estimate impacts on alcohol consumption in each scenario. Two methods were applied to estimate harm impacts: (i) alcohol attributable morbidity and mortality were estimated utilising the International Model of Alcohol Harms and Policies (InterMAHP); (ii) ARIMA methods to estimate the relationship between per capita alcohol consumption and specific types of alcohol-related mortality and crime. Results Replacing government stores with private liquor stores (Scenario 1) led to a 20.0% (95% CI, 15.3–24.7) increase in per capita consumption. Replacement with grocery stores (Scenario 2) led to a 31.2% (25.1–37.3%) increase. With InterMAHP there were 763 or + 47% (35–59%) and 1234 or + 76% (60–92%) more deaths per year, for Scenarios 1 and 2 respectively. With ARIMA, there were 850 (334–1444) more deaths per year in Scenario 1 and 1418 more in Scenario 2 (543–2505). InterMAHP also estimated 10,859 or + 29% (22–34%) and 16,118 or + 42% (35–49%) additional hospital stays per year respectively. Conclusions There would be substantial adverse consequences for public health and safety were Systembolaget to be privatised. We demonstrate a new combined approach for estimating the impact of alcohol policies on consumption and, using two alternative methods, alcohol-attributable harm. This approach could be readily adapted to other policies and settings. We note the limitation that some significant sources of uncertainty in the estimates of harm impacts were not modelled.
... Ramstedt 20 estimated that for every litre increase in alcohol consumption at the population level in Canada, suicide mortality rates increased 4% overall, and by 3.8% for men and 6.6% for women. Stockwell et al 21 examined the impact of a rapid rise in the density of private liquor outlets in British Columbia on alcohol-related mortality, and estimated that alcohol-related deaths increased by 3.25% for each 20% increase in private liquor store density. They also estimated that 612 suicide deaths were attributable to alcohol use in British Columbia between 2003 and 2008 during the period of increased density of outlets. ...
... In contrast, the ecological studies and papers on attributable fractions tended to be conducted by policy or public health researchers, and were more likely to make policy suggestions with a goal of minimising or mitigating the harmful contribution of alcohol and drugs to suicide. 21 Research based on NVDRS in the USA has been positioned to inform suicide prevention at multiple levels, particularly from a policy perspective. 54 on-premise alcohol outlet density demonstrated that higher offpremise alcohol outlet density is associated with a greater share of alcohol-involved suicide for men. ...
Article
Full-text available
The use of alcohol and other drugs has been identified as a significant factor related to suicide through multiple pathways. This paper highlights current understanding of their contributions to suicide in Canada and identifies opportunities for enhancing monitoring and prevention initiatives. Publications from 1998 to 2018 about suicide in Canada and that referred to alcohol or other drugs were identified using PubMed and Google Scholar. A second literature search restricted to articles including results of toxicology testing was conducted by a librarian. We summarised the literature identified on ecological analyses, attributable fractions and deaths, and research including the results of toxicological analyses. Our literature search yielded 5230 publications, and 164 documents were identified for full-text screening. We summarised the findings from 30 articles. Ecological analyses support the association between alcohol sales, annual per capita alcohol consumption and suicide rates. Based on published estimates, approximately a quarter of suicide deaths in Canada are alcohol-attributable, while the estimated attributable fraction for illegal drugs is more variable. Finally, there is a dearth of literature examining the role of acute alcohol and/or drug consumption prior to suicide based on toxicological findings. The proportion of suicide decedents with drugs or alcohol present at the time of death varies widely. While there is evidence on the role of alcohol and drugs in suicide deaths, there is not a large body of research about the acute use of these substances at the time of death among suicide decedents in Canada. Our understanding of the role of alcohol and other drugs in suicide deaths could be enhanced through systematic documentation, which in turn could provide much needed guidance for clinical practice, prevention strategies and policy initiatives.
... Still, consumption did increase in geographic areas with proportionately more private stores (Stockwell et al., 2009). Further analyses of this privatization showed that the density of private stores increased alcohol-related deaths by 3.25% for each 20% increase in density for an area (Stockwell et al., 2011). Both of these cases suggest that increased availability may have a larger effect than increased prices, and that spirits and alcohol sales will most likely rise in Washington. ...
Article
Objective: In November 2011, voters in Washington State approved Initiative 1183 (I-1183), which ended the government monopoly on distilled-spirits sales. The current study examined the relationship between demographics, spirits use, and voting outcomes, as well as how these variables related to wanting to change one's vote. Method: The sample consisted of 1,202 adults recruited through random-digit-dial methods and reached via telephone between January and April 2014. Bivariate tests and multivariable regressions were used for statistical analyses. Results: Most notably, those who voted Yes on I-1183 had almost eight times the odds of wanting to change their votes compared with those who voted No. Older age, higher education, and being a spirits buyer/drinker were significantly associated with voting (vs. not voting). Among nonvoters, a larger proportion of those who reported that I-1183 was a success (vs. not) were spirits drinkers/nonbuyers. Those who reported that I-1183 was not a success were more likely to report that the number of liquor stores should be decreased. Opinions on taxes were not related to wanting to change one's vote or thinking that I-1183 had been a success. Conclusions: The result of the I-1183 election likely would have been different if voters could know their future opinions of the actual situation resulting from privatization. This finding is particularly important for states considering privatization. Results also indicate that spirits drinkers/buyers may be more invested in privatization than nonbuyers and that the increased availability of spirits may affect opinions regarding privatization.
... In another study, Zalcman and Mann (2007) evaluated the effects of the three stages of privatization of retail sale of alcohol in Alberta, Canada between 1985 and 1995, and their interrupted time series models showed significant increases in male and female suicide mortality rates in each of the three stages of privatization except for female suicide following the 1994 event. Another Canada-based study found the rapid rise in private liquor outlet density in British Columbia was associated with increase in alcohol-related mortality including suicide ( Stockwell et al., 2011). ...
Article
Both intoxication and chronic heavy alcohol use are associated with suicide. There is extensive population-level evidence linking per capita alcohol consumption with suicide. While alcohol policies can reduce excessive alcohol consumption, the relationship between alcohol policies and suicide warrants a critical review of the literature. This review summarizes the associations between various types of alcohol policies and suicide, both in the United States and internationally, as presented in English-language literature published between 1999 and 2014. Study designs, methodological challenges, and limitations in ascertaining the associations are discussed. Because of the substantial between-states variation in alcohol policies, U.S.-based studies contributed substantially to the literature. Repeated cross-sectional designs at both the ecological level and decedent level were common among U.S.-based studies. Non-U.S. studies often used time series data to evaluate pre-post comparisons of a hybrid set of policy changes. Although inconsistency remained, the published literature in general supported the protective effect of restrictive alcohol policies on reducing suicide as well as the decreased level of alcohol involvement among suicide decedents. Common limitations included measurement and selection bias and a focus on effects of a limited number of alcohol policies without accounting for other alcohol policies. This review summarizes a number of studies that suggest restrictive alcohol policies may contribute to suicide prevention on a general population level and to a reduction of alcohol involvement among suicide deaths.
... Such research includes a study of sudden change in outlet density (see Gmel et al., 2016 for review). For instance, Stockwell et al. (2009Stockwell et al. ( , 2011 examined the impact of a dramatic increase in the density of private liquor stores in British Columbia, Canada. Their results demonstrated that private liquor stores were found to be significantly associated with alcohol sales and alcohol-related mortality. ...
Article
Full-text available
Background: This study examined the associations between distance from residence to the nearest alcohol outlet with alcohol consumption as well as with alcohol-related harm. Methods: Data on alcohol consumption, alcohol-related harm and sociodemographics were obtained from the 2011 Danish Drug and Alcohol Survey (n = 5133) with respondents aged 15-79 years. The information on distances from residence to the nearest alcohol outlets was obtained from Statistics Denmark. Multiple logistic and linear regressions were used to examine the association between distances to outlets and alcohol consumption whereas alcohol-related harm was analysed using negative binomial regression. Results: Among women it was found that those living closer to alcohol outlets were more likely to report alcohol-related harm (p < 0.05). This was not true for men. No association was found between distances to outlets and alcohol consumption (volume of drinking and risky single occasion drinking). Conclusions: This study found some support for an association between closer distances between place of residence and alcohol outlets and alcohol-related harm for women. Future studies in the Nordic region should continue to examine the association between physical alcohol availability (nearest distance to an outlet and outlet densities) and alcohol consumption as well as alcohol-related problems using different outlet types.
... Her et al. (1999) also note that losing the monopoly of sale can Increase alcohol consumption rates because the number of outlets and hours of sale will increase. In British Columbia, several authors concluded that the rise of densities of private liquor stores between 2003 and 2008 led to an increase in alcohol-related deaths (Stockwell et al. 2011). A unique trend for BC was that there was a declining rate of consumption until the start of partial privatization, after which that trend reversed. ...
Technical Report
The Ontario government is renewing its tobacco strategy and has the opportunity to address the problem of widespread availability of tobacco products in the retail environment. This paper analyzes and evaluates one option for reducing the number of tobacco retail outlets: moving from essentially a potentially unlimited number of retailers selling tobacco products to a system of designated tobacco retail outlets with the number standardized according to population or geographic measures. This policy analysis explores the advantages, expected impacts and possible unintended consequences of such an intervention while taking into account equity considerations. The paper reviews literature and evidence available on tobacco and alcohol retail availability. The purpose of this paper is to help stimulate and inform the debate regarding a new tobacco retailing system in Ontario – one that aims to reduce the physical availability of tobacco products and thereby result in reduced tobacco consumption and ultimately improved health of Canadians.
... An analysis of prices paid for alcoholic beverages found a decline for beer especially due to a decline in the average quality purchased (Treno et al., 2013). Both alcohol consumption and alcohol-related deaths were found to increase with the density of private stores in an area (Stockwell et al., 2009(Stockwell et al., , 2011. Both of these cases suggest that increased availability has a larger effect than increased prices. ...
Article
Full-text available
In June, 2012 the state of Washington ended a wholesale and retail monopoly on liquor sales resulting in about five times as many stores selling liquor. Three-tier restrictions were also removed on liquor, while beer and wine availability did not increase. Substantial taxes at both the wholesale and retail levels were implemented and it was expected that prices would rise. To evaluate price changes after privatization we developed an index of about 68 brands that were popular in Washington during early 2012. Data on final liquor prices (including all taxes) in Washington were obtained through store visits and on-line sources between November 2013 and March of 2014. Primary analyses were conducted on five or six brand indexes to allow the inclusion of most stores. Washington liquor prices rose by an average of 15.5% for the 750 ml size and by 4.7% for the 1.75 l size, while only small changes were seen in the bordering states of Oregon and Idaho. Prices were found to vary greatly by store type. Liquor Superstores had generally the lowest prices while drugstore, grocery and especially smaller Liquor Store prices were found to be substantially higher. Our findings indicate that liquor prices in Washington increased substantially after privatization and as compared to price changes in bordering states, with a much larger increase seen for the 750 ml size and with wide variation across store types. However, persistent drinkers looking for low prices will be able to find them in certain stores. © The Author 2015. Medical Council on Alcohol and Oxford University Press. All rights reserved.
... The authors introduce an example that helps make this point. Stockwell et al. [5][6][7][8] conducted a series of rigorously designed longitudinal studies in British Columbia, Canada, assessing the impacts of privatisation of alcohol sales on health outcomes (e.g. mortality, hospital admissions, per capita alcohol sales). ...
... The LRADG help Canadians moderate their alcohol consumption and reduce their immediate and long-term alcohol-related harm. Research has shown that increasing the availability of alcohol is related to increased consumption and alcohol-attributable morbidity and mortality[17][18][19][20]. Further, alcohol-related harms have repercussions that can affect others in the community[21]. ...
Article
Full-text available
Objectives Alcohol-related morbidity and mortality are significant public health issues. The purpose of this study was to describe the prevalence and trends over time of alcohol consumption and alcohol-related morbidity and mortality; and public attitudes of alcohol use impacts on families and the community in Ottawa, Canada. Methods Prevalence (2013–2014) and trends (2000–2001 to 2013–2014) of alcohol use were obtained from the Canadian Community Health Survey. Data on paramedic responses (2015), emergency department (ED) visits (2013–2015), hospitalizations (2013–2015) and deaths (2007–2011) were used to quantify the acute and chronic health effects of alcohol in Ottawa. Qualitative data were obtained from the “Have Your Say” alcohol survey, an online survey of public attitudes on alcohol conducted in 2016. Results In 2013–2014, an estimated 595,300 (83%) Ottawa adults 19 years and older drank alcohol, 42% reported binge drinking in the past year. Heavy drinking increased from 15% in 2000–2001 to 20% in 2013–2014. In 2015, the Ottawa Paramedic Service responded to 2,060 calls directly attributable to alcohol. Between 2013 and 2015, there were an average of 6,100 ED visits and 1,270 hospitalizations per year due to alcohol. Annually, alcohol use results in at least 140 deaths in Ottawa. Men have higher rates of alcohol-attributable paramedic responses, ED visits, hospitalizations and deaths than women, and young adults have higher rates of alcohol-attributable paramedic responses. Qualitative data of public attitudes indicate that alcohol misuse has greater repercussions not only on those who drink, but also on the family and community. Conclusions Results highlight the need for healthy public policy intended to encourage a culture of drinking in moderation in Ottawa to support lower risk alcohol use, particularly among men and young adults.
... Finally, both location and density of alcohol outlets also are associated with physical health consequences. Studies have shown that living within 1,000 meters of an alcohol outlet increases alcohol-related mortality for both men and women (Spoerri et al., 2013), and an increase in AOD significantly increased alcohol-related death in communities (Stockwell et al., 2011). Higher community AOD is associated with higher rates of consumption (Popova, 2009), which is associated with increased alcohol morbidity, such as liver disease (Jiang et al., 2014). ...
Article
Full-text available
This research investigated the relationship between alcohol outlet density (AOD) and life expectancy, as mediated by community violence and community disadvantage. We used linear regression models to assess bivariate and multivariate relationships. There was a negative bivariate association between liquor store density and average life expectancy (β = −7.3370, p < 0.001). This relationship was partially attenuated when controlling for community disadvantage and fully attenuated when controlling for community violence. Bars/taverns (i.e., on‐premise) were not associated with average life expectancy (β = −0.589, p = 0.220). Liquor store density is associated with higher levels of community disadvantage and higher rates of violence, both of which are associated with lower life expectancies. Future research, potential intervention, and current related policies are discussed.
... Research also shows an association between AOD, morbidity, and mortality. Mortality from alcohol-related harm is higher in areas of highest density compared to areas of low density, with evidence from the United Kingdom (Richardson et al. 2015), Canada (Stockwell et al. 2011), and Switzerland (Spoerri et al. 2013). Morbidity, including hospitalizations, emergency department visits, and injuries has also been found to be higher in areas of highest AOD (Cunradi et al. 2012;Richardson et al. 2015;Morrison et al. 2016). ...
Article
Alcohol and alcohol-related harm are key public health challenges. Research has shown that individual-level factors, such as age and sex, are important predictors of alcohol consumption, but such factors provide only a partial account of the drivers of consumption. In this article, we argue that individual-level factors interact with features of the risk environment to increase the vulnerability of individuals to such environments. Features of the alcohol risk environment include the density of alcohol premises in a neighborhood. Previous research has shown that neighborhoods with a higher density of alcohol outlets have higher levels of both alcohol consumption and alcohol-related harm. There has, however, been a distinct lack of attention paid to the differential ways in which particular sociodemographic groups might be more vulnerable to such risk environments. In this article, we address the risk environment through a primary focus on the local supply and availability of alcohol products (captured using a measure of outlet density) and the relationship with the harmful use of alcohol. Using responses to the Scottish Health Survey (2008–2011), we explore vulnerability through the interaction between individual-level socioeconomic position, measured using household income, and environmental risk to assess differential social vulnerability to such environments. We report findings showing that those in the lowest income groups might be disproportionately affected by outlet density. This evidence suggests that risk environments might not affect us all equally and that there could be socially differentiated vulnerability to such environments.
... Most of the alcohol in British Columbia (around 80%) is sold in privatised and governmental liquor stores and not in bars or even restaurants. For alcohol-related mortality, the results across outlet types showed different patterns of variation [9]. An increase of one private liquor store (per 1000 residents) was associated with a 27.5% increase in the rate of alcohol-related mortality, increase of one bar with an increase of 20.3% and increase of one governmental liquor store with a 56.8% decrease in alcohol-related mortality. ...
... A substantial body of research suggests that reducing alcohol availability-by, for example, increasing the price of alcoholic beverages, usually achieved through increasing taxes on alcohol-can reduce alcohol consumption (Chaloupka, Grossman, & Saffer, 1998;O'Mara et al., 2009;Skog, 2000;Wagenaar, Salois, & Komro, 2009). Conversely, expanded access to, or availability of, alcoholin the form of, for example, lower minimum legal purchase age, reduced alcohol prices, drink specials, increased hours and days of sale, or proximity to dense concentration of alcohol outlets-has been associated with higher likelihood of alcohol use and/or alcohol use disorder (Kypri, Bell, Hay, & Baxter, 2008;Popova, Giesbrecht, Bekmuradov, & Patra, 2009), increases in alcohol-related mortality (Stockwell et al., 2011), and acute alcohol intoxication hospitalizations (Bloomfield, Rossow, & Norstrom, 2009). Alcohol control policies that limit the general availability of alcohol, the geospatial concentration of alcohol outlets, and easy access to large quantities of alcohol may offer promise in the effort to reduce levels of interpersonal violence. ...
... A substantial body of research suggests that reducing alcohol availability-by, for example, increasing the price of alcoholic beverages, usually achieved through increasing taxes on alcohol-can reduce alcohol consumption (Chaloupka, Grossman, & Saffer, 1998;Skog, 2000;Wagenaar, Salois, & Komro, 2009). Conversely, expanded access to, or availability of, alcohol-in the form of, for example, lower minimum legal purchase age, reduced alcohol prices, drink specials, increased hours and days of sale, or proximity to dense concentration of alcohol outlets-has been associated with higher likelihood of alcohol use and/or alcohol use disorder (Kypri, Bell, Hay, & Baxter, 2008;Popova, Giesbrecht, Bekmuradov, & Patra, 2009), increases in alcohol-related mortality (Stockwell et al., 2011), and acute alcohol intoxication hospitalizations (Bloomfield, Rossow, & Norstrom, 2009). Although more research can help illuminate the extent to which alcohol availability constitutes a community-level risk factor for SV perpetration (DeGue et al., 2012), there is some reason to think that alcohol control policies that limit the number of alcohol outlets in close proximity to college campuses, access to high volumes of alcohol, and the availability of alcohol to underage drinkers may offer some promise in the effort to reduce campus SV (see Scribner et al., 2010;Xu et al., 2012). ...
... For instance, alcohol outlets are often disproportionately located in Black neighborhoods [39]. At the individual level, younger age has been associated with higher problem drinking and risk-taking [40], and the ecological argument that a higher proportion of younger-aged individuals in an area is associated with higher alcohol and drug problems appear to have some validity based on prior ecological studies [41,42]. A higher proportion of vacant buildings presents higher opportunities for illicit drug and alcohol use behavior [43] and higher visibility of activity that includes making police calls to report narcotics use or sales [44]. ...
Article
Alcohol outlet density has well-documented associations with social and health indicators such as crime and injury. However, significantly less is known about the relationships among alcohol-related complaints. Bayesian hierarchical Poisson regression with spatial autocorrelation was used to model the association between on- and off-premises alcohol outlet density and area-level prevalence of current drinkers and heavy drinking, and graffiti density—an indicator of physical disorder—in association with calls from civilians reporting illegal use, alcohol sales, and other alcohol-related activities (hereafter alcohol-related complaints). Complaints were separated into two groups based on whether they occurred at (a) clubs/bars/restaurants or (b) elsewhere. Alcohol-related complaints and graffiti were collected from NYC Open Data. Alcohol density data are from ESRI Business Analyst and information on the prevalence of drinking from the New York City Community Health Survey. The unit of analysis consisted of ZIP codes in New York City (n = 167), and the design was a cross-sectional analysis of aggregated data between 2009 and 2015. In multivariable models, a one-unit increase in off-premises alcohol outlet density was associated with a 47% higher risk of alcohol-related complaints at clubs, bars, and restaurants [rate ratio (RR = 1.46, 95% CI = 1.21, 1.77)]. Area-level prevalence of heavy drinking was associated with a 59% higher risk of alcohol-related complaints at the club, bars, and restaurants (RR = 1.59, 95% CI = 1.34, 1.86) and a 40% higher risk of complaints elsewhere (RR = 1.40, 95% CI = 1.20, 1.63). In New York City, area-level heavy drinking prevalence is a strong independent mechanism that links alcohol outlet density to alcohol-related complaints. Area-level heavy drinking should be investigated as a predictor of other public health problems such as drug overdose mortality.
... While the association between alcohol outlet density and alcohol use and problems has been extensively studied, there is limited evidence on the association between changing alcohol outlet policies and alcohol-related harm within a particular geographic location (5). An example of a policy change is the gradual privatization of alcohol retail sales in British Columbia, which resulted in increased alcohol outlet density; these changes have been associated with a higher risk of alcohol misuse and alcohol-related problems and deaths (12)(13)(14)(15). Reductions of alcohol outlet density, on the other hand, resulted from the implementation of legal changes to the alcohol policy of New Orleans, Louisiana, in 1997 (e.g., higher license fees, bans on selling alcohol through windows). ...
Article
Increasing alcohol outlet density is well-documented to be associated with increased alcohol use and problems, leading to the policy recommendation that limiting outlet density will decrease alcohol problems. Yet few studies of decreasing problematic outlets and outlet density have been conducted. We estimated the association between closing alcohol outlets and alcohol use and alcohol-related violence, using an agent-based model of the adult population in New York City. The model was calibrated according to the empirical distribution of the parameters across the city's population, including the density of on- and off-premise alcohol outlets. Interventions capped the alcohol outlet distribution at the 90th up to the 50th percentiles of the New York City density, and closed 5% to the 25% of outlets with the highest levels of violence. Capping density led to a lower population of light drinkers (42.2% at baseline vs. 38.1% at the 50th percentile), while heavy drinking increased slightly (12.0% at baseline vs. 12.5% at the 50th percentile). Alcohol-related homicides and non-fatal violence remained unchanged. Closing violent outlets was not associated with changes in alcohol use or related problems. Results suggest that focusing solely on closing alcohol outlets may not be an effective strategy to reduce alcohol-related problems.
... Previous work has found that increasing alcohol outlet density is associated with more alcohol-related hospitalizations and deaths. (26) (27) Our finding adds further to this literature by suggesting that both increased hours of operation for alcohol outlets and physical availability independently contribute to alcohol-related harms. We also found significant associations between the socioeconomic status of geographic areas and rates of alcohol attributable ED visits. ...
Article
Background and Aims The availability of alcohol through retail outlets is associated with alcohol‐related harms, but few studies have demonstrated a causal relationship. We investigated the association between alcohol availability and alcohol‐attributable emergency department (ED) visits in the province of Ontario during a period of deregulation of controls on the number of alcohol outlets. Design Cross sectional and pre‐post design Setting and participants The study used data from two time periods: pre‐deregulation (2013‐2014) and post‐deregulation (2016‐2017), to compare rates of ED visits for 513 defined geographic regions in Ontario Canada, called Forward Sortation Areas (FSAs). Measurements The primary outcome was the age‐standardized rates of alcohol‐attributable ED visits. We compiled a list of all alcohol retail outlets in Ontario during 2014 and 2017 and matched them to their corresponding FSA. We fit mixed‐effects Poisson regression models to assess: (a) the cross‐sectional association between number of outlets and hours of operation and ED visits; (b) the impact of deregulation on ED visits using a difference‐in‐difference approach. Findings Alcohol‐attributed ED visits increased 17.8% over the study period; over twice the rate of increase for all ED visits. Increased hours of operation and numbers of alcohol outlets within a FSA were positively associated with higher rates of alcohol‐attributable ED visits. The increase in ED visits attributable to alcohol was 6% (IRR 1.06; 95% CI 1.04‐1.08) greater in FSAs that introduced alcohol sales in grocery stores following deregulation compared with FSAs that did not. Conclusions Deregulation of alcohol sales in Ontario, Canada in 2015 was associated with increased emergency department visits attributable to alcohol.
... Several socioeconomic and demographic data by site and time period were obtained to produce per capita alcohol consumption estimates and socioeconomic variables in order to examine and control for their potential confounding effects [49][50][51][52][53]. These data included population data in Yukon [54] and Northwest Territories [55], income and CPI data [56][57][58][59][60][61][62], and land data [63]. ...
Article
Background: Alcohol warning labels are a promising, well-targeted strategy to increase public awareness of alcohol-related health risks and support more informed and safer use. However, evidence of their effectiveness in real-world settings remains limited and inconclusive. Objective: This paper presents a protocol for a real-world study examining the population-level impact of enhanced alcohol warning labels with a cancer message; national drinking guidelines; and standard drink information on attention, processing, and alcohol-related behaviors among consumers in Canada. Postimplementation modifications to the original protocol due to interference by national alcohol industry representatives are also described. Methods: This quasi-experimental study involved partnering with local governments in two northern Canadian territories already applying alcohol warning labels on alcohol containers for sale in liquor stores. The study tested an 8-month intervention consisting of three new enhanced, rotating alcohol warning labels in an intervention site (Whitehorse, Yukon) relative to a comparison site (Yellowknife, Northwest Territories) where labelling practices would remain unchanged. Pre-post surveys were conducted at both sites to measure changes in awareness and processing of label messages, alcohol-related knowledge, and behaviors. Liquor store transaction data were collected from both sites to assess changes in population-level alcohol consumption. The intervention was successfully implemented for 1 month before it was halted due to complaints from the alcohol industry. The government of the intervention site allowed the study to proceed after a 2-month pause, on the condition that the cancer warning label was removed from rotation. Modifications to the protocol included applying the two remaining enhanced labels for the balance of the intervention and adding a third wave of surveys during the 2-month pause to capture any impact of the cancer label. Results: This study protocol describes a real-world quasi-experimental study that aimed to test the effectiveness of new enhanced alcohol warning labels as a tool to support consumers in making more informed and safer alcohol choices. Alcohol industry interference shortly after implementation compromised both the intervention and the original study design; however, the study design was modified to enable completion of three waves of surveys with cohort participants (n=2049) and meet the study aims. Conclusions: Findings from this study will directly inform alcohol labelling policies in Canada and internationally and provide further insight into the alcohol industry's attempts to disrupt research in this area. Additional unimpeded real-world evaluations of enhanced alcohol warning labels are recommended. International registered report identifier (irrid): RR1-10.2196/16320.
... We were provided with monthly retail alcohol sales data for the whole of Yukon to calculate monthly per capita al-Chart 1. Point-of-sale warning labels placed on alcohol containers in different alcohol monopoly liquor stores in Yukon and Northwest Territories (NWT) at different times between January 2015 and July 2018 cohol consumption for people age 15 and older (estimated as monthly SDs per adults age ≥ 15 years) with Whitehorse and the additional five surrounding areas each acting as comparison areas. Socioeconomic and demographic data by areas and times in Yukon were obtained to produce per capita alcohol consumption estimates and socioeconomic variables in order to examine and control for their potential confounding effects Holder & Parker, 1992;Sloan et al., 1994;Stockwell et al., 2011). The analysis included the estimated retail alcohol sales in NWT as an additional control. ...
Article
Objective: There is limited evidence that alcohol warning labels (AWLs) affect population alcohol consumption. New evidence-informed AWLs were introduced in the sole government-run liquor store in Whitehorse, Yukon, that included a cancer warning (Ca), low-risk drinking guidelines (LRDGs) and standard drink (SD) messages. These temporarily replaced previous pregnancy warning labels. We test if the intervention was associated with reduced alcohol consumption. Method: An interrupted time series study was designed to evaluate the effects of the AWLs on consumption for 28 months before and 14 months after starting the intervention. Neighboring regions of Yukon and Northwest Territories served as control sites. About 300,000 labels were applied to 98% of alcohol containers sold in Whitehorse during the intervention. Multilevel regression analyses of per capita alcohol sales data for people age 15 years and older were performed to examine consumption levels in the intervention and control sites before, during, and after the AWLs were introduced. Models were adjusted for demographic and economic characteristics over time and region. Results: Total per capita retail alcohol sales in Whitehorse decreased by 6.31% (t test p < .001) during the intervention. Per capita sales of labeled products decreased by 6.59% (t test p < .001), whereas sales of unlabeled products increased by 6.91% (t test p < .05). There was a still larger reduction occurring after the intervention when pregnancy warning labels were reintroduced (-9.97% and -10.29%, t test p < .001). Conclusions: Applying new AWLs was associated with reduced population alcohol consumption. The results are consistent with an accumulating impact of the addition of varying and highly visible labels with impactful messages.
... Alcohol misuse further leads to 2.5 billion years of potential life lost annually [2]. Previous research suggests that alcohol consumption is related to retail availability; observational studies have found that the density of off-premise outlets (establishments that sell alcohol to be consumed off the premises) is associated with rates of alcohol-attributable deaths and hospitalizations as well as ambulance attended accidental injuries [3][4][5][6][7][8]. ...
Article
Background and Aims In June 2012, Washington state (USA) implemented Initiative 1183, privatizing liquor sales. As a result, off‐premises outlets increased from 330 to over 1400 and trading hours lengthened. Increased availability of liquor may lead to increased consumption. This study examines the impact of Initiative 1183 on alcohol‐related adverse health outcomes, measured by inpatient hospitalizations for alcohol‐related disorders and accidental injuries. It further assesses heterogeneity by urbanicity, because outlets increased most in metropolitan‐urban areas. Design County‐by‐quarter difference‐in‐difference linear regression models, estimated statewide and within metropolitan/rural strata. Setting and Participants Data are from AHRQ Healthcare Cost and Utilization State Inpatient Database 2010–2014 and HHS Area Health Resource File 2010–2014. Changes in the rates of hospitalizations in the 2.5 years following Initiative 1183 in Washington (n = 39 counties) are compared with changes in Oregon (n = 36 counties). Measurements County rates of hospitalizations per 1000 residents, including all records with any‐listed ICD‐9 Clinical Classification Software code denoting an alcohol‐related disorder, and all records with any‐listed external cause of injury code denoting an accidental injury. Findings The increase in the rate of accidental injury hospitalizations in Washington's metropolitan‐urban counties was on average 0.289 hospitalizations per 1000 county residents per quarter greater than the simultaneous increase observed in Oregon (P = 0.017). This result was robust to alternative specifications using a propensity score matched sample and synthetic control methods with data from other comparison states. The evidence did not suggest that Initiative 1183 was associated with differential changes in the rate of hospitalizations for alcohol‐related disorders in metropolitan‐urban (P = 0.941), non‐metropolitan‐urban (P = 0.162), or rural counties (P = 0.876). Conclusions Implementing Washington's Initiative 1183 (privatizing liquor sales) appears to have been associated with a significant increase in the rate of accidental injury hospitalizations in urban counties in that state but does not appear to be significantly associated with changes in the rate of hospitalizations specifically for alcohol‐related disorders within 2.5 years.
... /signature-stores -and-product-consultants). Previous research of the BC situation has provided detailed descriptions of sales for different beverage types across 89 geographic jurisdictions (Macdonald, Zhao, Pakula, Stockwell, & Martens, 2009). Privatization of the liquor market in BC has increased per capita consumption of ethanol (Stockwell et al., 2009) and had adverse effects on alcohol related mortality (Stockwell et al., 2011). A preliminary assessment of the expanded private store system in BC suggests that privatization would result in higher prices, longer trading hours, and increased accessibility of beverages (Consumers' Association of Canada, 2003). ...
Article
British Columbia (BC), Canada, has unique regulations for sales of alcohol in off-premise establishments where both government (n = 199) and privately controlled stores (n = 977) sell all types of off-premise alcoholic beverages. The purpose of this study is to compare the different marketing approaches of government and private stores and examine how their sales vary in relation to demographic characteristics within the regions that they operate. Data was collected for 89 geographic areas of BC from the following sources: a survey of BC private stores, BC demographic statistics, and sales records for different types of alcoholic beverages from private and government stores. Private stores had higher average prices, longer hours of operation, and were more likely to refrigerate beverages than government stores. Also, types of beverage sold differed between government and private stores depending on the demographic characteristics of the regions being served.
Article
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Considerable resources are spent on research to establish what works to improve the nation’s health. If the findings from this research are used, better health outcomes can follow, but we know that these findings are not always used. In public health, evidence of what works may not ‘fit’ everywhere, making it difficult to know what to do locally. Research suggests that evidence use is a social and dynamic process, not a simple application of research findings. It is unclear whether it is easier to get evidence used via a legal contracting process or within unified organisational arrangements with shared responsibilities. Objective To work in cocreation with research participants to investigate how research is utilised and knowledge mobilised in the commissioning and planning of public health services to reduce alcohol-related harms. Design, setting and participants Two in-depth, largely qualitative, cross-comparison case studies were undertaken to compare real-time research utilisation in commissioning across a purchaser–provider split (England) and in joint planning under unified organisational arrangements (Scotland) to reduce alcohol-related harms. Using an overarching realist approach and working in cocreation, case study partners (stakeholders in the process) picked the topic and helped to interpret the findings. In Scotland, the topic picked was licensing; in England, it was reducing maternal alcohol consumption. Methods Sixty-nine interviews, two focus groups, 14 observations of decision-making meetings, two local feedback workshops ( n = 23 and n = 15) and one national workshop ( n = 10) were undertaken. A questionnaire ( n = 73) using a Behaviourally Anchored Rating Scale was issued to test the transferability of the 10 main findings. Given the small numbers, care must be taken in interpreting the findings. Findings Not all practitioners have the time, skills or interest to work in cocreation, but when there was collaboration, much was learned. Evidence included professional and tacit knowledge, and anecdotes, as well as findings from rigorous research designs. It was difficult to identify evidence in use and decisions were sometimes progressed in informal ways and in places we did not get to see. There are few formal evidence entry points. Evidence (prevalence and trends in public health issues) enters the process and is embedded in strategic documents to set priorities, but local data were collected in both sites to provide actionable messages (sometimes replicating the evidence base). Conclusions Two mid-range theories explain the findings. If evidence has saliency (relates to ‘here and now’ as opposed to ‘there and then’) and immediacy (short, presented verbally or visually and with emotional appeal) it is more likely to be used in both settings. A second mid-range theory explains how differing tensions pull and compete as feasible and acceptable local solutions are pursued across stakeholders. Answering what works depends on answering for whom and where simultaneously to find workable (if temporary) ‘blends’. Gaining this agreement across stakeholders appeared more difficult across the purchaser–provider split, because opportunities to interact were curtailed; however, more research is needed. Funding This study was funded by the Health Services and Delivery Research programme of the National Institute for Health Research.
Article
The papers in this issue detail state-of-the science knowledge regarding the role of alcohol use in HIV/AIDS risk, as well as offer suggestions for ways forward for behavioral HIV prevention for at-risk alcohol-using populations. In light of recent evidence suggesting that the anticipated uptake of the newer biomedical HIV prevention approaches, prominently including pre-exposure prophylaxis, has been stalled owing to a host of barriers, it has become ever more clear that behavioral prevention avenues must continue to receive due consideration as a viable HIV/AIDS prevention approach. The papers collected here make a valuable contribution to "combination prevention" efforts to curb HIV spread.
Article
This article involves a comparison of the Nordic alcohol-monopoly countries with Canadian provinces that have a tradition of off-premise alcohol retail monopolies. The aim of the article is to shed light on recent developments in Canadian and Nordic alcohol-retailing systems, and to propose a way forward for alcohol-control policy that involves balancing alcohol trade and damage-reduction agendas. The article first considers developments over the past three decades in alcohol production, marketing, and retailing involving a concentration of production, and an expansion and increased sophistication of alcohol marketing and retailing, and the underlying international and national pressures. Next, it examines examples of recent alcohol policy making in Canada and the Nordic countries, noting the challenges of controlling total alcohol consumption and high-risk drinking in a market-oriented environment. Third, it offers several steps forward that will facilitate a better balance of alcohol trade and problem-prevention agendas in the context of off-premise alcohol-retail-control systems.
Article
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Aim This paper assesses alcohol policies and interventions in Finland and the Canadian province of Ontario, using the policy options and interventions recommended in WHO's Global strategy to reduce the harmful use of alcohol (2010). Data & Methods The information and data are based on archival sources, surveys, legislative and government documents, and published papers. The paper assesses both jurisdictions on 10 areas in the WHO document and their sub-topics: 1. leadership, 2. health services response, 3. community action, 4. drinking and driving policies and countermeasures, 5. availability of alcohol, 6. marketing of alcoholic beverages, 7. pricing policies, 8. reducing the negative consequences of drinking and alcohol intoxication, 9. reducing the public health impact of illicit alcohol and informally produced alcohol, and 10. monitoring and surveillance. Results Ontario had several recent noteworthy developments in line with WHO recommendations: health services response, controls of drinking and driving, pricing policies, reducing the negative consequences of drinking and intoxication, and monitoring and surveillance. Finland has emphasised pricing policies in recent years, and there have also been significant developments in community action, controls of drinking and driving, alcohol advertising, and monitoring and surveillance. Conclusions Challenges and opportunities for strengthening the policy responses are noted, as well as topics for future research.
Article
Alcohol use disorder is by far the most prevalent substance use disorder in the general population and is a major contributor to disease worldwide. Recovery from the disorder is a dynamic process of change, and individuals take many different routes to resolve their alcohol problems and seek to achieve a life worth living. Total abstention is not the only solution and robust recovery involves more than changing drinking practices. This volume brings together multidisciplinary research on recovery processes, contexts, and outcomes as well as new ideas about the multiple pathways involved. Experts chart the individual, social, contextual, community, economic, regulatory, policy, and structural influences that are vital to understanding alcohol use disorder and recovery. The book recommends new approaches to conceptualizing and assessing recovery alongside new avenues for research, community engagement, and policy that constitute a major shift in the practice and policy landscape.
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This chapter summarizes some of the issues that determine the content and direction of national policies on alcohol. It is argued that evidence-based policy may still be talked about more in hope than expectation. Policy frameworks may be partly based on evidence but also on political ideology, media campaigns and ensuring preservation of an alcohol industry. The emphasis of the chapter is on the process of policy formulation rather than a detailed review of the evidence for and against popular policy initiatives. Policy parameters are helpful when trying to understand the breadth of potential policies to structure the nature of these policies into different categories.
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Aims: Numerous policies have been shown to reduce the harm from alcohol; however, not all sub-populations respond similarly to policy interventions. This paper explores the specific effects of alcohol pricing policies and controls regarding physical availability on different types of harms from alcohol as well as on different sectors of the population, including impacts by gender, age, and drinking patterns. Design, Setting, Participants, and Measures: We focus on two dimensions. The first is alcohol pricing and taxation; the second is alcohol availability, comprising type of alcohol control system, outlet density, and hours/days of sale. We focused on peer-reviewed research and reviews published from 2005–2015, using several databases: PsycINFO, MEDLINE/PubMed, and Cochrane. Findings: Precautionary alcohol prices have substantial harm reduction potential, particularly among youth and high-risk drinkers. Restrictions on outlet densities and hours/days of sale impact the drinking patterns of underage youth, reduce high-risk drinking, and reduce alcohol-related harm. A reduction in prices or an increase in alcohol availability are associated with increase in high-risk drinking or alcohol-related harm. Conclusions: Future work should examine these policy measures in light of socioeconomic status and cultural factors, as well as impacts of policy interventions on evidence of harm to others from alcohol.
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Background Violence-related injury has been an important harmful consequence of drinking in the Latin American and Caribbean (LAC) region, but the risk at which drinking places the individual for violence-related injury or the burden this places on the population is unknown. Methods A probability sample of 969 emergency room (ER) patients reporting a violence-related injury and arriving within six hours was analysed from 12 ERs in 9 countries in the LAC region. Dose-response relative risk (RR) of violence-related injury based on volume of consumption prior to the event is examined using pair-matched case-crossover fractional polynomial analysis of mean volume and alcohol attributable fraction (AAF) calculated from the RR and prevalence of drinking prior to injury in each volume category. Results A dose-response relationship was observed with a six-fold increase in risk (RR = 5.88) for less than two drinks prior to injury, increasing to a nine-fold increase (RR = 9.06) for those reporting more than 30 drinks. Risk was similar for males and females up to ten drinks, but higher for females over ten drinks. Risk was higher for those 30 and older compared to those younger at all volume levels, reaching a three-fold increase for 30 or more drinks (RR = 4.78 vs. 14.99). Among all injuries related to violence, 33.56% were attributable to alcohol (population AAF), and among those who reported drinking prior to injury, alcohol was an attributable factor in 87% (exposed AAF). AAF did not vary by age but was nearly three times larger for males (38.66%) than for females (13.52%), although exposed AAF did not differ. Conclusions A dose-response relationship was found between the amount of alcohol consumed prior to the event and risk of violence-related injury, but risk was not uniform across gender or age. While females were at greater risk of injury than males at higher volume levels, lower prevalence of women drinking at higher levels contributed to overall lower AAF for women.
Chapter
Alcohol use disorder is by far the most prevalent substance use disorder in the general population and is a major contributor to disease worldwide. Recovery from the disorder is a dynamic process of change, and individuals take many different routes to resolve their alcohol problems and seek to achieve a life worth living. Total abstention is not the only solution and robust recovery involves more than changing drinking practices. This volume brings together multidisciplinary research on recovery processes, contexts, and outcomes as well as new ideas about the multiple pathways involved. Experts chart the individual, social, contextual, community, economic, regulatory, policy, and structural influences that are vital to understanding alcohol use disorder and recovery. The book recommends new approaches to conceptualizing and assessing recovery alongside new avenues for research, community engagement, and policy that constitute a major shift in the practice and policy landscape.
Chapter
Alcohol is greatly valued, deeply integrated into social and cultural contexts, used extensively, or its consumption is banned. This chapter begins by discussing the various use-values of alcohol, including for intoxication, socialization, meal enhancement, and others. Then, it explains the range of alcohol-related problems, including harms not only to the drinker, but also to others who are victims of alcohol-related events, such as drinking and driving incidents, alcohol-related violence, or dealing with family members with chronic alcohol-related problems. The chapter also discusses emerging international attention to several issues, including alcohol as a carcinogen, and the association between alcohol use and social determinants of health. Next, the societal responses to alcohol use and problems are highlighted, which is followed by a discussion on the several challenges of how to promote a public health response in the context of easy access to alcohol and governmental interest in only modest controls.
Article
Background and aim: Previous research indicates that minimum alcohol pricing (MAP) is negatively associated with alcohol attributable (AA) hospitalizations. Modeling studies predict this association will be stronger for people on lower incomes. The objective of this study was to test whether the association between MAP and AA hospitalizations is greater in low income regions. Design: Cross-sectional versus time-series analysis using multivariate multilevel effect models. Setting: All 89 Local Health Areas in British Columbia (BC), Canada, 2002-2013 (48 quarters). Participants: BC population. Measurements: Quarterly rates of AA hospital admissions, mean consumer price index-adjusted minimum dollars per standard alcoholic drink and socio-demographic covariates. Findings: Family income was inversely related to the effect of minimum prices on rates of some types of AA morbidity. A 1% price increase was associated with reductions of 3.55% (95% CI: -5.72, -1.38; p<0.01) in low family income regions and 1.64% (95% CI: -2.765, -0.519; p<0.01) across all income regions for 100% acute AA hospital admissions. Delayed (lagged) effects on chronic AA morbidity were found 2 to 3 years after minimum price increases for low income regions and all regions combined. A 1% increase in minimum price was associated with reductions of 2.05% (95% CI: -3.87, -0.22; p<0.05) for 100% chronic AA and 1.80% (95% CI: (-3.240, -0.359; p<0.05) for partially chronic AA admissions for low income regions. Conclusion: In Canada, minimum price increases for alcohol are associated with reductions in alcohol attributable hospitalizations, especially for populations with lower income, both for immediate effects on acute hospitalizations and delayed effects on chronic hospitalizations.
Article
Background and aims: Alcohol taxation and availability restrictions are among the most effective methods for reducing alcohol use and problems, yet may affect demographic subgroups differently. Understanding who responds to specific policies can inform approaches for reducing disparities. We examined how state-level beverage-specific taxes and availability restrictions in the United States are associated with consumption and alcohol-related problems across subgroups defined by gender and race/ethnicity. Design, setting and participants: Data came from the 2000-15 National Alcohol Surveys (n = 28 251), computer-assisted telephone cross-sectional surveys of United States residents aged 18+. African Americans and Hispanics were oversampled. Measurements: Primary outcomes were beverage-specific (beer, wine, spirits and total) volume, DSM-IV alcohol dependence and alcohol-related consequences. Analyses entailed survey-weighted log-log and logistic regressions adjusting for state-level beer tax, spirits tax, government-controlled spirits sales and sales tax; respondent ZIP-code-level density of off-premise beer outlets, off-premise spirits outlets and on-premise bars; respondent individual-level age, marital status, education, employment and income; and fixed effects for wet/moderate/dry US region and year. Findings: Higher beer tax was significantly (P < 0.05) associated with lower odds of any drinking among white women [odds ratio (OR) = 0.98] and lower beer volume (price-elasticity = -0.40), total volume (price-elasticity = -0.50) and odds of alcohol-related consequences (OR = 0.84) among African American women. Higher spirits tax was significantly (P < 0.05) associated with both lower beer and total volume among Hispanic women (price-elasticities = -0.73 and - 1.04, respectively) and men (price-elasticities = -1.19 and - 0.92, respectively) and decreased wine volume among Hispanic women (price-elasticity = -0.62). Apparent protective effects of living in a state with government-controlled spirits sales or a neighborhood with lower bar density was greater among white men than other groups. Conclusions: The effects of beverage-specific taxes and alcohol availability policies may vary across subgroups, highlighting the importance of considering differential policy impacts in future research and intervention.
Article
Objectives In 2015, the Liquor Control Board of Ontario (LCBO) authorized sale of alcohol in some Ontario grocery stores. This research evaluates the impact of the new policy on alcohol use patterns of youth in a quasi-experimental setting with two control groups.Methods The sample consists of 2267 grade 9 students attending 60 secondary schools across Ontario (n = 56) and Alberta (n = 4), who provided 4-year linked longitudinal data (2013–2014 to 2016–2017) in the COMPASS study. The study used the frequency of drinking and the frequency of binge drinking to characterize alcohol use behaviours.ResultsLatent transition analysis found four statuses of alcohol use: abstainer, periodic drinker, low-risk drinker, and high-risk regular drinker. The new policy had no negative impact among periodic and low-risk drinkers, but the risk of transitioning from the abstainer (lowest risk status) to high-risk regular drinker (highest risk status) among the exposed cohort was 1.71 times greater post-policy than pre-policy change, compared with those of Ontario-unexposed (0.50) and Alberta-unexposed cohorts (1.00). The probability of sustaining high-risk drinking among the exposed cohort increased by a factor of 1.76, compared with 1.13-fold and 0.89-fold among the Ontario-unexposed and Alberta-unexposed cohorts, respectively.Conclusion Youth are more likely to transition from abstinence to high-risk regular drinking, and high-risk regular drinkers are more likely to maintain their behaviours in the jurisdictions exposed to the latest change in LCBO policy authorizing grocery stores to sell alcohol. When formulating policy interventions, youth access to alcohol should be considered in order to reduce their harmful alcohol consumption.
Article
In the United States, some racial/ethnic minorities suffer from higher rates of chronic alcohol problems, and alcohol-related morbidity and mortality than Whites. Furthermore, state-level alcohol policies may affect racial/ethnic subgroups differentially. We investigate effects of beverage-specific taxes and government control of spirits retail on alcohol-related mortality among non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic American Indians/Alaska Natives (AI/AN) and Hispanics using death certificate and state-level alcohol policy data for 1999–2016. Outcomes were analyzed as mortality rates (per 10,000) from 100% alcohol-attributable chronic conditions (“100% chronic AAD”). Statistical models regressed racial/ethnic-specific logged mortality rates on state-level, one-year lagged and logged beer tax, one-year lagged and logged spirits tax, and one-year lagged government-controlled spirits sales, adjusted for mortality trends, fixed effects for state, and clustering of standard errors. Government control was significantly (P < 0.05) related to 3% reductions in Overall and non-Hispanic White mortality rates, and 4% reductions in Hispanic mortality rates from 100% chronic AAD. Tax associations were not robust. Results support that government control of spirits retail is associated with significantly lower 100% AAD from chronic causes Overall and among non-Hispanic Whites and Hispanics. Government control of spirits retail may reduce both population-level 100% chronic AAD as well as racial/ethnic disparities in 100% chronic AAD.
Article
Alcohol use is well established globally as one of the major risk factors for burden of disease and mortality. Although it is not yet clear how the COVID-19 pandemic has impacted the overall level of alcohol use in Canada, we do know that various levels of government have promoted its use - either by designating it essential or by increasing its availability. Such actions may have both an immediate and sustained impact on alcohol-related harm in Canada. We encourage all levels of government to support and prioritize the development and implementation of an evidence-informed framework for both alcohol policy and service delivery to reduce alcohol-related harms during the current pandemic and beyond.
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Background Availability of alcohol is a major policy issue for governments, and one of the availability factors is the density of alcohol outlets within geographic areas. Objective The aim of this study is to investigate the association between alcohol outlet density and hospital admissions for alcohol-related conditions in a national (English) small area level ecological study. Methods This project will employ ecological correlation and cross-sectional time series study designs to examine spatial and temporal relationships between alcohol outlet density and hospital admissions. Census units to be used in the analysis will include all Lower and Middle Super-Output Areas (LSOAs and MSOAs) in England (53 million total population; 32,482 LSOAs and 6781 MSOAs). LSOAs (approximately 1500 people per LSOA) will support investigation at a fine spatial resolution. Spatio-temporal associations will be investigated using MSOAs (approximately 7500 people per MSOA). The project will use comprehensive coverage data on alcohol outlets in England (from 2003, 2007, 2010, and 2013) from a commercial source, which has estimated that the database includes 98% of all alcohol outlets in England. Alcohol outlets may be classified into two broad groups: on-trade outlets, comprising outlets from which alcohol can be purchased and consumed on the premises (eg, pubs); and off-trade outlets, in which alcohol can be purchased but not consumed on the premises (eg, off-licenses). In the 2010 dataset, there are 132,989 on-trade and 51,975 off-trade outlets. The longitudinal data series will allow us to examine associations between changes in outlet density and changes in hospital admission rates. The project will use anonymized data on alcohol-related hospital admissions in England from 2003 to 2013 and investigate associations with acute (eg, admissions for injuries) and chronic (eg, admissions for alcoholic liver disease) harms. The investigation will include the examination of conditions that are wholly and partially attributable to alcohol, using internationally standardized alcohol-attributable fractions. Results The project is currently in progress. Results are expected in 2017. Conclusions The results of this study will provide a national evidence base to inform policy decisions regarding the licensing of alcohol sales outlets.
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Introduction to the Logistic Regression Model Multiple Logistic Regression Interpretation of the Fitted Logistic Regression Model Model-Building Strategies and Methods for Logistic Regression Assessing the Fit of the Model Application of Logistic Regression with Different Sampling Models Logistic Regression for Matched Case-Control Studies Special Topics References Index.
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A subsample (n = 2,550) of the 2005 US National Alcohol Survey of adults was used to estimate prevalence and correlates of six externalities from alcohol abuse--family problems, assaults, accompanying intoxicated driver, vehicular accident, financial problems and vandalized property--all from another's drinking. On a lifetime basis, 60% reported externalities, with a lower 12-month rate (9%). Women reported more family/marital and financial impacts and men more assaults, accompanying drunk drivers, and accidents. Being unmarried, older, white and ever having monthly heavy drinking or alcohol problems was associated with more alcohol externalities. Publicizing external costs of drinking could elevate political will for effective alcohol controls.
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Alcohol: No Ordinary Commodity - Research and Public Policy Second Edition is a collaborative effort by an international group of addiction scientists to improve the linkages between addiction science and alcohol policy. It presents the accumulated scientific knowledge on alcohol research that has a direct relevance to the development of alcohol policy on local, national, and international levels. It provides an objective analytical basis on which to build relevant policies globally, and informs policy makers who have direct responsibility for public health and social welfare. By locating alcohol policy primarily within the realm of public health, this book draws attention to the growing tendency for governments, both national and local, to consider alcohol misuse as a major determinant of ill health, and to organize societal responses accordingly. The scope of the book is comprehensive and international. The authors describe the conceptual basis for a rational alcohol policy and present new epidemiological data on the global dimensions of alcohol misuse. The core of the book is a critical review of the cumulative scientific evidence in seven general areas of alcohol policy: pricing and taxation; regulating the physical availability of alcohol; modifying the environment in which drinking occurs; drink-driving countermeasures; marketing restrictions; primary prevention programs in schools and other settings; and treatment and early intervention services. The final chapters discuss the current state of alcohol policy in different parts of the world and describe the need for a new approach to alcohol policy that is evidence-based, realistic, and coordinated.
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What drug provides Americans with the greatest pleasure and the greatest pain? The answer, hands down, is alcohol. The pain comes not only from drunk driving and lost lives but also addiction, family strife, crime, violence, poor health, and squandered human potential. Young and old, drinkers and abstainers alike, all are affected. Every American is paying for alcohol abuse. Paying the Tab , the first comprehensive analysis of this complex policy issue, calls for broadening our approach to curbing destructive drinking. Over the last few decades, efforts to reduce the societal costs--curbing youth drinking and cracking down on drunk driving--have been somewhat effective, but woefully incomplete. In fact, American policymakers have ignored the influence of the supply side of the equation. Beer and liquor are far cheaper and more readily available today than in the 1950s and 1960s. Philip Cook's well-researched and engaging account chronicles the history of our attempts to "legislate morality," the overlooked lessons from Prohibition, and the rise of Alcoholics Anonymous. He provides a thorough account of the scientific evidence that has accumulated over the last twenty-five years of economic and public-health research, which demonstrates that higher alcohol excise taxes and other supply restrictions are effective and underutilized policy tools that can cut abuse while preserving the pleasures of moderate consumption. Paying the Tab makes a powerful case for a policy course correction. Alcohol is too cheap, and it's costing all of us.
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To assess whether government monopoly outlets comply better with minimum legal age for purchase of alcohol compared to other off-premise outlets for alcohol sales. Under-age-appearing 18-year-olds attempted to purchase alcohol in off-premise outlets applying identical procedures in Finland (n = 290) and Norway (n = 170). Outcomes were measured as whether or not the buyers were asked to present an identity (ID) card and whether or not they succeeded in purchasing alcohol. RESULTS The buyers were asked to present an ID card in slightly more than half the attempts, and they succeeded in purchasing alcohol in 48% of the cases. The buyers were more likely to be requested to present an ID card and less likely to succeed in purchasing alcohol in monopoly outlets compared to other types of outlets, and also when other outcome predictors, such as age and gender of salesperson and crowdedness in the outlet, were taken into account. Monopoly outlets may facilitate compliance with minimum legal age for purchase of alcohol.
Article
This is a practical introduction to multilevel analysis suitable for all those doing research. Most books on multilevel analysis are written by statisticians, and they focus on the mathematical background. These books are difficult for non-mathematical researchers. In contrast, this volume provides an accessible account on the application of multilevel analysis in research. It addresses the practical issues that confront those undertaking research and wanting to find the correct answers to research questions. This book is written for non-mathematical researchers and it explains when and how to use multilevel analysis. Many worked examples, with computer output, are given to illustrate and explain this subject. Datasets of the examples are available on the internet, so the reader can reanalyse the data. This approach will help to bridge the conceptual and communication gap that exists between those undertaking research and statisticians.
Chapter
In this chapter, we introduce statistical methods for the analysis of spatial data that arise as point events in space (e.g., the locations of disease “cases”). We compare and contrast the ideas of “clustered”, “random”, and “regular” spatial patterns and provide introductory descriptions of the first- and second-order statistical properties of a spatial point pattern. The heterogeneous Poisson process is introduced to allow us to assess spatial patterns in disease events after accounting for spatial variations in population density. We recommend Monte Carlo simulation as a flexible tool for hypothesis testing and illustrate its utility in several “data breaks” that provide examples of how our hypotheses can be sequentially refined to answer a variety of practical questions about the nature of the spatial patterns we observe.
Book
Introduction.- Data management and software.- Advice for teachers.- Exploration.- Linear regression.- Generalised linear modelling.- Additive and generalised additive modelling.- Introduction to mixed modelling.- Univariate tree models.- Measures of association.- Ordination--first encounter.- Principal component analysis and redundancy analysis.- Correspondence analysis and canonical correspondence analysis.- Introduction to discriminant analysis.- Principal coordinate analysis and non-metric multidimensional scaling.- Time series analysis--Introduction.- Common trends and sudden changes.- Analysis and modelling lattice data.- Spatially continuous data analysis and modelling.- Univariate methods to analyse abundance of decapod larvae.- Analysing presence and absence data for flatfish distribution in the Tagus estuary, Portugual.- Crop pollination by honeybees in an Argentinean pampas system using additive mixed modelling.- Investigating the effects of rice farming on aquatic birds with mixed modelling.- Classification trees and radar detection of birds for North Sea wind farms.- Fish stock identification through neural network analysis of parasite fauna.- Monitoring for change: using generalised least squares, nonmetric multidimensional scaling, and the Mantel test on western Montana grasslands.- Univariate and multivariate analysis applied on a Dutch sandy beach community.- Multivariate analyses of South-American zoobenthic species--spoilt for choice.- Principal component analysis applied to harbour porpoise fatty acid data.- Multivariate analysis of morphometric turtle data--size and shape.- Redundancy analysis and additive modelling applied on savanna tree data.- Canonical correspondence analysis of lowland pasture vegetation in the humid tropics of Mexico.- Estimating common trends in Portuguese fisheries landings.- Common trends in demersal communities on the Newfoundland-Labrador Shelf.- Sea level change and salt marshes in the Wadden Sea: a time series analysis.- Time series analysis of Hawaiian waterbirds.- Spatial modelling of forest community features in the Volzhsko-Kamsky reserve.
Article
We investigated whether high-risk drinking patterns are restricted to a few high-volume drinkers or are evenly distributed across the population to inform discussion regarding the optimal mix of targeted versus universal prevention strategies. Drinking patterns reported in the 2004 Canadian Addiction Survey (CAS, n = 13,909) were assessed against various low-risk drinking guidelines. Under-reporting was assessed against known alcohol sales for 2004. Non-response bias due to the low response rate (47%) was investigated through comparisons with the 2002 Canadian Community Health Survey (CCHS). Self-reported alcohol consumption for the past week and past year accounted for between 31.9% and 37.0%, respectively of official alcohol sales data. Comparisons with the 2002 CCHS suggested only limited non-response bias. Many more respondents regularly placed themselves at risk of short-term harm (20.6%) than exceeded guidelines for avoiding long-term health problems (3.9%). Ten percent of respondents consumed more than 50% of total self-reported consumption. Most alcohol (73.4%) consumed by the sample in the previous week was drunk in excess of Canadian low-risk drinking guidelines – for 19 to 24 year olds this figure was 89.4%. These data provide support both for universal prevention strategies (e.g. reducing economic and physical availability of alcohol) as well as targeted interventions for risky drinkers (e.g. screening and brief interventions in primary health care settings).
Book
Panel data models have become increasingly popular among applied researchers due to their heightened capacity for capturing the complexity of human behavior as compared to cross-sectional or time series data models. As a consequence, richer panel data sets also have become increasingly available. This 2003 second edition is a substantial revision of the highly successful first edition of 1986. Advances in panel data research are presented in a rigorous and accessible manner and are carefully integrated with the older material. The thorough discussion of theory and the judicious use of empirical examples make this book useful to graduate students and advanced researchers in economics, business, sociology, political science, etc. Other specific revisions include the introduction of the notion of strict exogeneity with estimators presented in a generalized method of moments framework, the notion of incidental parameters, more intuitive explanations of pairwise trimming, and discussion of sample selection dynamic panel models.
Article
Trading hours of licensed premises have been progressively relaxed since World War II across much of the English-speaking world as part of a global trend towards liquor deregulation. This review was informed by a systematic search of studies published in the English language since 1965 which sought to evaluate the public health and safety impacts of changes to liquor trading hours for on premise consumption – namely ‘pubs’ and clubs in the United Kingdom, ‘hotels’ and ‘taverns’ in Australia and New Zealand and ‘bars’ in North America. The systematic search was supplemented by materials identified from the ‘grey literature’, mostly government reports. A total of 49 unique studies met the inclusion criteria of which only 14 included baseline and control measures and were peer-reviewed. Among these, 11 reported at least one significant outcome indicating adverse effects of increased hours or benefits from reduced hours. Controlled studies with fewer methodological problems were also most likely to report such effects. It is suggested that differences between findings from Australia and the United Kingdom following the Licensing Act 2003 are most likely due to differences in methodological approach. It is concluded that the balance of reliable evidence from the available international literature suggests that extended late-night trading hours lead to increased consumption and related harms. Further well-controlled studies are required to confirm this conclusion.
Article
This proposed study was to assess non-response bias in the 2004 Canadian Addictions Survey (CAS). Two approaches were used to assess non-response bias in the CAS which had a response rate of only 47%. First, the CAS sample characteristics were compared with the 2002 Canadian Community Health Survey (CCHS, response rate 77%) and the 2001 Canada Census data. Second, characteristics of early and late respondents were compared. People with lowest income and less than high-school education and those who never married were under-represented in the CAS compared with the Census, but similar to the CCHS. Substance use was more prevalent in the CAS than the CCHS sample, but most of the CAS and CCHS estimates did not exceed +/-3% points. Late respondents were also significantly more likely to be male, young adult, highly educated, used, have high income, live in different provinces and report substance use. Multivariate logistic regression found significant non-response bias for lifetime, past 12 months, chronic risky, acute risky and heavy monthly alcohol use, lifetime and past year cannabis use, lifetime hallucinogen use, any illicit drug uses of lifetime and past year. Adjustment for non-response bias substantially increased prevalence estimates. For example, the estimates for lifetime and past 12 month illicit drug use increased by 5.22% and 10.34%. It is concluded that non-response bias is a significant problem in substance use surveys with low response rates but that some adjustments can be made to compensate.
Article
To investigate the independent effects on liquor sales of an increase in (a) the density of liquor outlets and (b) the proportion of liquor stores in private rather than government ownership in British Columbia between 2003/4 and 2007/8. The British Columbia Liquor Distribution Branch provided data on litres of ethanol sold through different types of outlets in 89 local health areas of the province by beverage type. Multi-level regression models were used to examine the relationship between per capita alcohol sales and outlet densities for different types of liquor outlet after adjusting for potential confounding social, economic and demographic factors as well as spatial and temporal autocorrelation. Liquor outlets in 89 local health areas of British Columbia, Canada. The number of private stores per 10,000 residents was associated significantly and positively with per capita sales of ethanol in beer, coolers, spirits and wine, while the reverse held for government liquor stores. Significant positive effects were also identified for the number of bars and restaurants per head of population. The percentage of liquor stores in private versus government ownership was also associated significantly with per capita alcohol sales when controlling for density of liquor stores and of on-premise outlets (P < 0.01). The trend towards privatisation of liquor outlets between 2003/04 and 2007/08 in British Columbia has contributed to increased per capita sales of alcohol and hence possibly also to increased alcohol-related harm.
Article
The formal powers and resources of state alcohol beverage control agencies place them in a position to regulate access to alcoholic beverages through restrictions on retail distribution and sales. For example, monopoly states restrict access to spirits, and sometimes wine, by allowing retail sales only through state stores. On the other hand, license and monopoly states share in restricting sales through the use of price posting and fixing provisions. The degree to which these powers are realized in restrictions on alcohol outlets (e.g., licenses) and subsequent alcohol consumption (e.g., sales) was investigated in the current study. In a cross-sectional analysis of data available from 44 alcohol beverage control (ABC) jurisdictions in the United States, it was shown that states with greater restrictions on retail sales had greater resources for the conduct of ABC activities and lower densities of spirit outlets. These states, however, had greater densities of wine and beer outlets. States with greater marketplace restrictions had more resources for ABC enforcement activities and lower outlet densities across all beverage types. Further, supporting the suggestion that availability and demand may be simultaneously related, greater outlet densities were related to greater alcohol consumption (for beer) and greater levels of consumption were related to greater outlet densities (for wine).
Article
This paper examines a ‘natural experiment’ where sixty brands of low-priced domestic fortified wines were removed from stock (i.e., delisted). Ten communities where the brands were delisted were compared to a group of 18 where these brands continued to be available. Changes in consumption levels and beverage preference are examined for the ‘delisted’ and ‘available’ outlets in the two groups of communities in the northwestern region. There was little difference between the delisted and non-delisted group in the overall consumption level although the decline was slightly steeper in the former group. Purchasing of domestic red and rose wines, as well as domestic vodka and Liquor Board alcohol increased in the delisted group. In some instances these wines and spirits may have been used in combination to produce a fortified beverage. Geographic adaption to the restriction was a minor phenomenon in that the increase in consumption of the relevant brands in a non-listed community was a fraction of the reduction in the comparable sales in an adjacent delisted community.
Article
The influence of alcohol advertising on young people continues to be the subject of much debate. This paper presents a review of the literature showing that, while many econometric studies suggest little effect, more focused consumer studies, especially recent ones with sophisticated designs, do show clear links between advertising and behaviour. Furthermore, these effects have to be viewed in combination with the possible impact of other marketing activities such as price promotions, distribution, point of sale activity and new product development. Here, the evidence base is less well developed, but there are indications of effects. It must be acknowledged that categorical statements of cause and effect are always difficult in the social sciences; marketing is a complex phenomenon involving the active participation of consumers as well as marketers and more research is needed on its cumulative impact. Nonetheless, the literature presents an increasingly compelling picture that alcohol marketing is having an effect on young people's drinking.
Article
To evaluate the effects of the Living With Alcohol (LWA) program and the LWA Alcoholic Beverage Levy on alcohol-attributable deaths in the Northern Territory (NT) controlling for simultaneous trends in death rates from a control region and non-alcohol related death trends in the NT, between 1985 and 2002. The LWA program was introduced in 1992 with funding from a special NT tax (Levy) on beverages with greater than 3% alcohol content by volume. The Levy was removed in 1997 but the LWA program continued to be funded by the federal government until 2002. Trends in age standardised rates of acute and chronic alcohol-attributable deaths in the NT were examined before, during and after the combined implementation of the LWA program and Levy and before and during the full length of the LWA program. Auto-regressive integrated moving average (ARIMA) time series analyses included internal and external control series and adjustments for possible confounders. Separate estimates were made for Indigenous and non-Indigenous NT residents. When combined, the Levy and the LWA program were associated with significant declines in acute alcohol-attributable deaths in the NT as well as Indigenous deaths between 1992 and 1997. A significant but delayed decline in chronic deaths was evident towards the end of the study period between 1998 and 2002. The combined impact of the LWA program Levy and the programs and services funded by the Levy reduced the burden of alcohol-attributable injury to the NT in the short term and may have contributed to a reduction in chronic illness in the longer term. The results of this study present a strong argument for the effectiveness of combining alcohol taxes with comprehensive programs and services designed to reduce the harm from alcohol, and underline the need to distinguish between the acute and chronic effects of alcohol in population level studies.
Article
Although the published literature on alcohol beverage taxes, prices, sales, and related problems treats alcoholic beverages as a simple good, alcohol is a complex good composed of different beverage types (i.e., beer, wine, and spirits) and quality brands (e.g., high-, medium-, and low-quality beers). As a complex good, consumers may make substitutions between purchases of different beverage types and brands in response to price increases. For this reason, the availability of a broad range of beverage prices provides opportunities for consumers to mitigate the effects of average price increases through quality substitutions; a change in beverage choice in response to price increases to maintain consumption. Using Swedish price and sales data provided by Systembolaget for the years 1984 through 1994, this study assessed the relationships between alcohol beverage prices, beverage quality, and alcohol sales. The study examined price effects on alcohol consumption using seemingly unrelated regression equations to model the impacts of price increases within 9 empirically defined quality classes across beverage types. The models enabled statistical assessments of both own-price and cross-price effects between types and classes. The results of these analyses showed that consumers respond to price increases by altering their total consumption and by varying their brand choices. Significant reductions in sales were observed in response to price increases, but these effects were mitigated by significant substitutions between quality classes. The findings suggest that the net impacts of purposeful price policy to reduce consumption will depend on how such policies affect the range of prices across beverage brands.
Article
This paper investigates the impact of international migration on technical efficiency, resource allocation and income from agricultural production of family farming in Albania. The results suggest that migration is used by rural households as a pathway out of agriculture: migration is negatively associated with both labour and non-labour input allocation in agriculture, while no significant differences can be detected in terms of farm technical efficiency or agricultural income. Whether the rapid demographic changes in rural areas triggered by massive migration, possibly combined with propitious land and rural development policies, will ultimately produce the conditions for a more viable, high-return agriculture attracting larger investments remains to be seen.
Article
Using the result that under the null hypothesis of no misspecification an asymptotically efficient estimator must have zero asymptotic covariance with its difference from a consistent but asymptotically inefficient estimator, specification tests are devised for a number of model specifications in econometrics. Local power is calculated for small departures from the null hypothesis. An instrumental variable test as well as tests for a time series cross section model and the simultaneous equation model are presented. An empirical model provides evidence that unobserved individual factors are present which are not orthogonal to the included right-hand-side variable in a common econometric specification of an individual wage equation.
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