1. International Health Policy Program -Thailand 1 Literature of density of alcohol outlets effects on alcohol consumption and alcohol-related problems Weranuch Wongwatanakul International Health Policy Program (IHPP) Health Promotion Journal Club 19 December 2009

2. International Health Policy Program -Thailand 2 Outline of Presentation Introduction Overview of alcohol outlet density literature Alcohol outlet density and theory Gaps in literature The implication for harm reduction

3. International Health Policy Program -Thailand 3 Introduction This presentation reviews the paper “Changing the density of alcohol outlet to reduce alcohol-related problems” by Michael Livingston, Tanya Chikritzhs, and Robin Room This study aims to – Review a literature on the effects of the density of alcohol outlet on consumption and related harms – Suggest ways to conceptualize the relationships – Discuss the implications for reducing alcohol related harms

4. International Health Policy Program -Thailand 4 Overview of alcohol outlet density literature Effects on alcohol consumption Effects on violence Effects on other alcohol-related problems

5. International Health Policy Program -Thailand Overview of alcohol outlet density literature Effects on alcohol consumption – Studies found a mix results – Studies found the positive relationship between outlet density and alcohol consumption in neighborhood-level (New Orleans, USA), rates of binge drinking and student drinking related problems (New Zealand), consumption and alcohol related hospitalization among teenagers (Sweden) – Studies found the negative relationship between outlet density and alcohol consumption, e.g. 1) changes in physical availability of legal alcohol were often related to changes in illegal alcohol without changing the overall consumption, 2) a smaller effect of outlet density on consumption than price 5

6. International Health Policy Program -Thailand Overview of alcohol outlet density literature Effect on violence – Almost all of cross-sectional studies have found significant positive relationships between outlet density and rate of violence – The best evidence on how changes in outlet density will affect violence rates comes from longitudinal studies, e.g. the density of outlet change, the assault rates changed correspondingly. 6

7. International Health Policy Program -Thailand Overview of alcohol outlet density literature Effects on other alcohol-related problems – A substantial number of cross-sectional studies have examined the relationship btw the outlet density and a variety of related harm problems, e.g. drink driving, motor vehicle accidents, pedestrian injury, child maltreatment, neighborhood amenity problems, rates of STDs – Longitudinal studies of these problem have less common – The best evidence from a natural experiment on the effects of a reduction in alcohol outlets is a study from USA on rates of gonorrhea as a measure of risky sexual behavior 7

8. International Health Policy Program -Thailand Alcohol outlet density and theory The theoretical foundations of outlet studies have not yet been fully developed. Many older studies have relied heavily on classic ‘availability theory’ There is a wealth of evidence to support the classic availability theory, but in itself the theory does not adequately explain the variable and complex relationships demonstrated by studies of outlet density and harm 8

9. International Health Policy Program -Thailand Alcohol outlet density and theory Stockwell & Grunerwald have expanded the basic of the theory to consider variation in how changes in availability may be experienced across drinking groups and the contribution of other factors to rate of harm. Therefore, changes in availability are redefined more precisely, in terms of changes in the ‘full price’ of alcohol, incl. the price adjusted for the cost of living and convenience in terms of the time and the effort required to obtain it. 9

10. International Health Policy Program -Thailand Alcohol outlet density and theory Stockwell & Grunerwald suggested the two following postulates: – I : greater availability of alcohol in a society will increase the average consumption of its population when such changes reduce the ‘full price’ of alcohol. (for example, the real price of beverages at the retail markets plus the convenience costs of obtaining them) 10 but they recognized that alcohol-related harms can be affected by changes in availability that do not necessarily alter overall consumption level

11. International Health Policy Program -Thailand Alcohol outlet density and theory Stockwell & Grunerwald’s the second postulate – II : greater availability of alcohol in a society will directly affect alcohol-related harms when such changes affect the distribution of ‘routine drinking activities’; behavior drinkers engage in when consuming alcohol (e.g. drinking at bars VS at home; drinking socially VS alone) 11

12. International Health Policy Program -Thailand Alcohol outlet density and theory The author propose a way the conceptualize the effects of alcohol outlet density: – Proximity effect (how easy one can access alcohol) focus on the effect of outlet density on the convenience cost – Amenity effect (how outlet influence the quality and characteristics of surrounds within the local community) Provide a specific link between outlet density and specific types of routine drinking activities 12

13. International Health Policy Program -Thailand Alcohol outlet density and theory Proximity effect (how easy one can access alcohol) – is the outcome focused on by much of the work on outlet density, which approached the issue from the perspective of simple availability theory. – Increased outlet density makes alcohol more accessible, and it is hypothesized that this increases consumption and alcohol-related harms. – It may also have the second effect that each new outlet potentially increases the competitive pressures on existing outlets, which may result in price reductions which tend to lead to in creased levels of alcohol consumption. 13

14. International Health Policy Program -Thailand Alcohol outlet density and theory Amenity effect (how outlet influence the quality and characteristics of surrounds within the local community) Related to the negative effects of license premises on the neighborhoods. In this perspective, alcohol outlets are seen as the attractor of trouble, which might or might not have happen elsewhere This may increased alcohol consumption overall Both on- and off- premise outlets may have an amenity effect, in term of who they attract and how they behave. 14

15. International Health Policy Program -Thailand Alcohol outlet density and theory Those two different aspects of density of alcohol outlets have different implications for the relationship between outlet density and alcohol-related problems – To examine the level of alcohol consumption should be looking for a proximity effect on alcohol outlet density. – To examine the alcohol-related disorder and violence should be looking for an amenity effect 15 The relationships between outlet density and alcohol related problems are not strictly linear

16. International Health Policy Program -Thailand Gaps in literature The underlying assumption that every outlet is equivalent. Only a handful of studies have incorporate both outlet density and whole sale alcohol process into their analysis. Data relating to specifically identifiable individual premises associated with alcohol-related problems are not routinely collected in many jurisdictions. There is a lack of longitudinal studies assessing how individual alcohol consumption is affected by change in outlet density. 16

17. International Health Policy Program -Thailand Gaps in literature The underlying assumption that every outlet is equivalent. – Two ways to overcome this limitation; – 1) data of alcohol sold by premises would provide an extra dimension for analysis – 2) data linking alcohol-related harms to specific premises would allow a deeper understanding of premise-specific drivers of alcohol-related harm Only a handful of studies have incorporate both outlet density and whole sale alcohol process into their analysis – Expanded collection of those type of data is essential to enable studies that can indicate some of the complex effects of outlet density 17

18. International Health Policy Program -Thailand Gaps in literature Data relating to specifically identifiable individual premises associated with alcohol-related problems are not routinely collected in many jurisdictions. – In many cases, it is not possible to distinguish rates of harm done by type of licenses. There is a lack of longitudinal studies assessing how individual alcohol consumption is affected by change in outlet density. – Further study is necessary to ascertain whether outlet density is related to problematic consumption and long term harm among some sub-group of drinkers 18

19. International Health Policy Program -Thailand The implication for harm reduction Changes to outlet density could markedly affect the consumption and long term health problem of some population sub-groups, sometimes without noticeable changes in population-level consumption estimates. Outlet density are more likely to have an effect – on rates of binge drinking – on alcohol-related injuries and violence, and – on other short-term consequences related to concentrated drinking during discrete occasions 19

20. International Health Policy Program -Thailand The implication for harm reduction Where the aim is to limit or reduce rates of injury and other related problems, particularly violence, greater attention might be paid to bunching than to density. Comprehensive policies for regulating outlet density and bunching should be based firmly on local level information, sound theoretical framework and well designed research 20

21. International Health Policy Program -Thailand Reference “Changing the density of alcohol outlet to reduce alcohol-related problems” by Michael Livingston, Tanya Chikritzhs, and Robin Room, Drug and Alcohol Review (September 2007), 26, 557-566 21