International Health Policy Program -Thailand Panatapon Chongprasertying,Kannapon Phakdeesettakun Center for Alcohol Studies, International Health Policy Program, Ministry of Public Health Thailand The density of liquor outlets: Case Study of The British Columbia, Canada.

International Health Policy Program -Thailand Aim : 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/ /8. Design : 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. 2

International Health Policy Program -Thailand Statistical analyses : 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. Setting: Liquor outlets in 89 local health areas of British Columbia,Canada. -Interior - Northern - Vancouver Coastal - Vancouver Island - Fraser 3

International Health Policy Program -Thailand 4 Variable name Dependent : Monthly per capita litres of absolute alcohol from…… - Beers - Coolers - Spirits - Wines - beer, cooler, spirit and wine otherwise known as ‘alcopops’—mixed alcohol and soft drinks with the strength of between 5% and 10% alcohol by volume

International Health Policy Program -Thailand Independent : 1.Monthly number of..…per population aged restaurants - government stores - bars - private stores Fixed effect 2.Season : - January–March - April–June - July–September - October–December 5

International Health Policy Program -Thailand 3. Calendar year as continuous variable : 2003–2008 Ex : -2003/4 mean:1 April 2003 to 31 March /8 mean:1 April 2007 to 31 March local health areas:89local health - Interior - Northern - Vancouver Coastal - Vancouver Island - Fraser 5. % of population aged 20–29 to population aged <14 % % - >18 % 6

International Health Policy Program -Thailand 7 6.Sex ratio : % of male versus female aged low income : % of low income versus all families 8. Population density (residents/km 2 ) – – < ≥ 37.00

International Health Policy Program -Thailand Per capita alcohol sales increased from 8.04 litres in 2003/04 to 8.63 litres in 2007/08 The number of outlets of all kinds per 10,000 population increased from in 2003/04 to in 2007/08 Per Capita Alcohol Sales and Density of Liquor Outlets by Region and Time. 8

International Health Policy Program -Thailand Per Capita Alcohol Sales and Density of Liquor Outlets by Region and Time Restaurants and private stores increase Government liquor stores decreased Bars remained unchanged 9

International Health Policy Program -Thailand Multi-level regression analysis Relationships between alcohol sales and outlet density 10 Per capita sales of alcohol were associated significantly and positively with changes in monthly number of each kind of liquor outlet per 10,000 residents. The direction of the relationship for government liquor stores was negative when adjustments were made for other independent variables. All types of density measures were associated significantly with changes in per capita alcohol sales : - Restaurants, bars and private stores were associated significantly and positively. - Government stores was associated significantly and negatively. The density of private stores was associated positively and significantly with per capita sales of beer, coolers, spirits and wine, while the density of government stores were related significantly negatively to per capita sales of beer, coolers or spirits, but not wine. The density of restaurants per head of population was associated most strongly positively with all varieties of alcoholic beverage sales.

International Health Policy Program -Thailand A 10% increase in the density of restaurants results in a 2.33% increase in per capita alcohol sales. A similar increase in the density of private stores results in only a 0.28% increase in alcohol sales. The estimated effect sizes are converted to an estimate of percentage change in per capita alcohol sales for all premises for a 10% increase in the population density of each type of outlet, for example: Multi-level regression analysis Relationships between alcohol sales and outlet density 11

International Health Policy Program -Thailand Multi-level regression analysis Proportion of private versus government stores and alcohol sales 12

International Health Policy Program -Thailand The proportion of stores in private hands was associated significantly with total alcohol sales (P < 0.01) Other independent variables which were related positively and significantly to per capita alcohol sales in this model were: - Financial year, the percentage of population aged 20–29 years in the local population aged 15 years and older (P = 0.05) and all annual quarters other than January to March (P < in each case). - The proportion of low-income families in a local area was associated negatively with per capita alcohol sales (P < 0.001). The multi-level regression analysis shown in Table 6 controlling or socio-economic and demographic variables found: 13 Multi-level regression analysis Proportion of private versus government stores and alcohol sales

International Health Policy Program -Thailand Between the financial years 2003/04 and 2007/08 the number of private liquor stores rose by 33.4%, while the number of government liquor stores fell by 9.9%. Overall, conclude that there is strong evidence for a connection between the number of liquor outlets overall per population and per capita alcohol sales: - hypothesis 1 was supported for most varieties of liquor outlet and beverage types. - hypothesis 2 was supported that private liquor outlets are somehow intrinsically more risky than government liquor stores, both for total alcohol sales and for sales of beer, wine and spirits, although not coolers. This suggests some support for the observation that private stores enable some differentiation of the alcohol market, putting further upward pressure on alcohol sales. Discussion 14

International Health Policy Program -Thailand The fully adjusted multi-level regression models found significant and positive associations for the number of restaurants, bars and private stores with total per capita sales of alcohol and also separately for sales of most beverages. By contrast, the population density of government stores was associated significantly and negatively with total alcohol sales, as well as sales of beer, coolers and spirits, but not wine and the numbers of restaurants per residents aged 15 and over was associated the most closely with changes in per capita sales of alcohol. A 10% increase in numbers of different liquor outlets per adult residents was associated with: - A 2.33% increase in per capita sales of alcohol for restaurants. - A 0.50% increase for bars. - A 0.28% increase for private stores. - A 0.22% decrease for government stores. These changes appear modest, it is important to bear in mind that they are changes in total per capita alcohol sales, not simply changes in sales for that particular type of liquor outlet. Discussion 15

International Health Policy Program -Thailand Conclude that there was a stimulating effect on alcohol sales introduced by increasing proportions of private stores over and above the increase in total number of liquor outlets that occurred during the study period. It is important to note that population density of liquor stores was less associated with total alcohol sales than was population density of on premise outlets (bars and restaurants). This is a counter- intuitive finding, as liquor stores contribute a substantially larger proportion of all alcohol sales than to bars and restaurants. This is also consistent with the finding that densities of private alcohol stores are associated significantly positively with changes in per capita alcohol sales, while densities of government alcohol stores are associated significantly and negatively with per capita alcohol sales. Private outlets, both on- and off-premise, have typically more freedom of economic response than government monopolies. Discussion 16

International Health Policy Program -Thailand Overall, findings support strongly a relationship between population density of liquor outlets and alcohol consumption. One impact of the policy that has led to gradually increasing partial privatization of liquor stores has been an increase in the overall number of outlets in many areas. This, in itself, has been associated clearly with increased per capita alcohol sales The analyses presented here show that there was substantial variation across different regions of British Columbia, both in density of liquor outlets and the population rate of alcohol sales. Further, these analyses indicate that local variation in population density of liquor outlets is associated strongly with changes in per capita alcohol sales—and that increasing privatization of liquor stores has further stimulated alcohol sales and consumption. Discussion 17

International Health Policy Program -Thailand As would be expected from international research, any increase in population density of outlets will put upward pressure on per capita alcohol consumption which will, in turn, usually increase a wide range of serious alcohol-related harms. Main finding is that when controlling for liquor outlet density plus spatial, temporal, economic and demographic characteristics across 89 local health areas, increasing privatization of liquor stores in British Columbia in recent years has been associated significantly with increasing alcohol sales per head of population with probable adverse effects on public health. Thus, a fully privatized system might be expected to increase total alcohol consumption still further, along with adverse alcohol-related consequences. Discussion 18

International Health Policy Program -Thailand Reference Tim Stockwell and other. “Changes in per capita alcohol sales during the partial privatization of British Columbia’s retail alcohol monopoly 2003–2008: a multi-level local area analysis”. Addiction, 104, 1827–

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