The Effectiveness of Limiting Alcohol Outlet Density As a Means of Reducing Excessive Alcohol Consumption and Alcohol-Related Harms

Abstract

The density of alcohol outlets in communities may be regulated to reduce excessive alcohol consumption and related harms. Studies directly assessing the control of outlet density as a means of controlling excessive alcohol consumption and related harms do not exist, but assessments of related phenomena are indicative. To assess the effects of outlet density on alcohol-related harms, primary evidence was used from interrupted time–series studies of outlet density; studies of the privatization of alcohol sales, alcohol bans, and changes in license arrangements—all of which affected outlet density. Most of the studies included in this review found that greater outlet density is associated with increased alcohol consumption and related harms, including medical harms, injury, crime, and violence. Primary evidence was supported by secondary evidence from correlational studies. The regulation of alcohol outlet density may be a useful public health tool for the reduction of excessive alcohol consumption and related harms.

Introduction

Excessive alcohol consumption, including both binge drinking and heavy average daily alcohol consumption, is responsible for approximately 79,000 deaths per year in the U.S., making it the third-leading cause of preventable death in the nation.¹ Approximately 29% of adult drinkers (≥18 years) in the U.S. report binge drinking (five or more drinks on one or more occasions for men and four or more drinks for women) in the past 30 days, as do 67% of high school students who drink.2, 3 The direct and indirect costs of excessive alcohol consumption in 1998 were $184.6 billion.⁴ The reduction of excessive alcohol consumption is thus a matter of major public health and economic interest.

The density of retail alcohol outlets is often regulated to reduce excessive alcohol consumption and related harms. Alcoholic beverage outlet density refers to the number of physical locations in which alcoholic beverages are available for purchase either per area or per population. An outlet is a setting in which alcohol may be sold legally for either on-premises or off-premises consumption. On-premises settings may include restaurants, bars, and ballparks; off-premises settings may include grocery and convenience stores as well as liquor stores. In 2005, the most recent year for which data are available, there were more than 600,000 licensed retail alcohol outlets in the U.S., or 2.7 outlets per 1000 population aged ≥18 years.⁵ The number of outlets per capita in states with state-owned retail outlets varied from a low of 0.48 per 1000 residents in Mississippi to a high of 7.25 per 1000 in Iowa.⁵

Alcohol outlet density is typically controlled by states. Under state jurisdiction, outlet density may be regulated at the local level through licensing and zoning regulations, including restrictions on the use and development of land.⁶ This regulation may be proactive as part of a community development plan, or in response to specific issues or concerns raised by community leaders. However, local control can be limited by state pre-emption laws, in which state governments explicitly or implicitly curtail the ability of local authorities to regulate outlet expansion.⁷ Thus, both state and local policies need to be considered when assessing factors that affect outlet density.

The WHO has published a review that identifies outlet density control as an effective method for reducing alcohol-related harms.⁸ Similarly, in 1999, the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Prevention review concluded that there was a “medium” level of evidence supporting the use of outlet density control as a means of controlling alcohol-related harms.⁹ In addition, several organizations have advocated the use of outlet density regulation for the reduction of alcohol consumption and alcohol-related harms. These include the European Union (in their 2000–2005 Alcohol Action Plan)¹⁰ and the WHO Western Pacific Region.¹¹ The criteria used in the WHO report are not specified and may be expert opinion rather than systematic assessment of the characteristics of available studies. The SAMHSA review uses specified characteristics of included studies in drawing conclusions; however, the studies included are not up to date. In the present synthesis, 14 of the studies reviewed were published after 2000. Finally, a recent review by Livingston et al.¹² presents useful conceptual hypotheses and notes the importance of outlet “bunching”—which the team referred to as “clustering”—density at a more micro level.

Further, the present review assesses whether interventions limiting alcohol outlet density satisfy explicit criteria for intervention effectiveness of the Guide to Community Preventive Services (Community Guide), and assesses studies available as of November 2006. In addition, unlike any of the prior documents, the present review considers evidence from assessments of policies that are not explicitly considered density-related but that have direct effects on outlet density (i.e., privatization, liquor by the drink, and bans). If effective, policies limiting alcohol outlet density might address several national health objectives related to substance abuse prevention that are specified in Healthy People 2010.¹³

The systematic review described in this report represents the work of CDC staff and collaborators on behalf of the independent, nonfederal Task Force on Community Preventive Services (Task Force). The Task Force is developing the Community Guide with the support of the USDHHS in collaboration with public and private partners. The book The Guide to Community Preventive Services. What Works to Promote Health? presents the background and the methods used in developing the Community Guide.¹⁴