Alcohol outlet density and alcohol related hospital admissions in England: a national small-area level ecological study

The association between off- and on-premise alcohol outlet density and 100% alcohol-attributable emergency department visits by neighbourhood-level socioeconomic status in Ontario, Canada

Alcohol availability is positively associated with alcohol use and harms, but the influence of socioeconomic status (SES) on these associations is not well established. This population-based cross-sectional study examined neighbourhood-level associations between physical alcohol availability (measured as off- and on-premise alcohol outlet density) and 100% alcohol-attributable emergency department (ED) visits by neighbourhood SES in Ontario, Canada from 2017 to 2019 (n = 19,740). A Bayesian spatial modelling approach was used to assess associations and account for spatial autocorrelation, which produced risk ratios (RRs) and 95% credible intervals (95% CrI). Each additional off-premise alcohol outlet in a neighbourhood was associated with a 3% increased risk of alcohol-attributable ED visits in both men (RR = 1.03, 95%CrI: 1.02-1.04) and women (RR = 1.03, 95% CrI: 1.02-1.04). Positive associations were also observed between on-premise alcohol outlet density and alcohol-attributable ED visits, although effect sizes were small. A disproportionately greater association with ED visits was observed with increasing alcohol outlet density in the lowest compared to higher SES neighbourhoods. Reducing physical alcohol availability may be an important policy lever for reducing alcohol harm and alcohol-attributable health inequities.

Alcohol and Substance Use Among the Working Age Population: A Nationwide Study of Fall-Related Emergency Department Visits

OBJECTIVE

Prior studies have linked fall-related emergency department (ED) visits among older adults to alcohol use. Characteristics related to falls in the working age population (WAP; 15-64 years) may vary with alcohol and substance use. This study aimed to identify factors associated with fall-related ED visits related to alcohol and substance use in the WAP.

METHOD

Using nationally representative 2019-2020 National Hospital Ambulatory Medical Care Survey data, fall-related ED visits within 72 hours were stratified by indication of alcohol use, substance use, and concurrent alcohol and substance use. Descriptive statistics accounting for the survey's complex design were used along with multivariable logistic regression to identify associated factors.

RESULTS

Between 2019 and 2020, an estimated 10,800,000 fall-related ED visits occurred among the WAP, with 51.7% related to alcohol use, substance use, or both. Multivariable logistic regression analysis revealed that the WAP with fall-injury ED visits were associated with alcohol use (adjusted odds ratio [AOR] = 2.3, 95% CI [1.0, 5.9]) or concurrent alcohol and substance use (AOR = 8.5, 95% CI [1.6, 43.0]), and individuals with alcohol and substance use with a depression diagnosis are twice as likely to visit EDs with fall injuries.

CONCLUSIONS

Individuals with alcohol and substance use with depression were twice as likely to visit EDs for fall injuries. Higher fall-related ED visits in the WAP were attributed to alcohol and substance use. Identified factors could improve injury prevention and timely intervention among the WAP in the United States.

How Can We Measure Alcohol Outlet Density Around Schools? A Comparison Between Two Buffer-Based Methods

Measuring the density of alcohol outlets around schools is a critical step towards understanding the drivers of drinking among adolescents. Different methodologies have been used in the literature for this purpose, but the implications of using one methodology or another have not been clearly assessed. Our aim was to compare different methods to measure alcohol outlet density and highlight under which characteristics of the environment might be best using each approach. We used Geographic Information Systems to geolocate schools (n = 576) and alcohol outlets (n = 21,732) in Madrid. We defined the density of alcohol outlets as the number of establishments within an area of 400 m around schools measured using two buffering methods: crow flies' and street network distances. We evaluated the agreement between both methods visually and through regression models, including street connectivity, population density, and density of recreational venues as predictors of disagreement. The density of alcohol outlets around schools was higher using crow flies' distances compared to street network distances. The differences between methodologies were wider in areas of higher density of outlets, especially in the downtown areas, where there are higher population density and street connectivity. Our results suggest that the spatial characteristics and morphology of the study area (e.g., street connectivity and population density) should be considered when deciding the methodology to be used to measure alcohol outlet density. Future studies should explore the implications of different exposure measures in their association with drinking prevalence and consumption patterns among different geographical contexts.

Does the relationship between alcohol retail environment and alcohol outcomes vary by depressive symptoms? Findings from a U.S. Survey of Black, Hispanic and White drinkers

AIMS

To assess whether associations between alcohol availability and consumption, drinking to drunkenness, and negative drinking consequences vary among individuals with elevated depressive symptoms.

METHODS

10,482 current drinkers in 2005-2015 National Alcohol Surveys (50.0% female; 74.4% White, 8.7% Black, 11.1% Hispanic). Elevated depressive symptoms was defined as having symptoms suggestive of major depressive disorder (above CES-D8/PHQ-2 cut-offs) versus no/sub-threshold symptoms (below cut-offs). Inverse probability of treatment weighted and covariate adjusted Poisson models with robust standard errors estimated associations of ZIP-code bar density and off-premise outlet density (locations/1,000 residents), elevated depressive symptoms, and their interaction with past-year volume consumed, monthly drinking to drunkenness, and negative drinking consequences. Models were then stratified by sex and race and ethnicity.

RESULTS

Overall, 13.7% of respondents had elevated depressive symptoms. Regarding density, the only statistically significant association observed was between off-premise density and volume consumed (rate ratio = 1.3, 95% confidence interval = 1.0, 1.7). Elevated depressive symptoms were associated with higher volume consumed, prevalence of drinking to drunkenness, and prevalence of negative consequences when controlling for off-premise density or bar density. However, there was no evidence of interaction between symptoms and density in the full sample nor among subgroups.

CONCLUSION

This study suggests that, while elevated depressive symptoms do not alter associations between alcohol availability and alcohol use and problems, they remain associated with these outcomes among past-year drinkers in a U.S. general population sample even when accounting for differential availability. Addressing depressive symptoms should be considered along with other policies to reduce population-level drinking and alcohol problems.

Increased proportion of alcohol-related trauma in a South London major trauma centre during lockdown: A cohort study

PURPOSE

Alcohol has been associated with 10%-35% trauma admissions and 40% trauma-related deaths globally. In response to the COVID-19 pandemic, the United Kingdom entered a state of "lockdown" on March 23, 2020. Restrictions were most significantly eased on June 1, 2020, when shops and schools re-opened. The purpose of this study was to quantify the effect of lockdown on alcohol-related trauma admissions.

METHODS

All adult patients admitted as "trauma calls" to a London major trauma centre during April 2018 and April 2019 (pre-lockdown, n = 316), and 1st April-31st May 2020 (lockdown, n = 191) had electronic patient records analysed retrospectively. Patients' blood alcohol level and records of intoxication were used to identify alcohol-related trauma. Trauma admissions from pre-lockdown and lockdown cohorts were compared using multiple regression analyses.

RESULTS

Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), vs. pre-lockdown 62/316 (19.6%); (odds ratio (OR): 0.83, 95% CI: 0.38-1.28, p < 0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs. pre-lockdown 179/316 (56.7%); OR: 0.40, 95% CI: 0.79 to -0.02, p = 0.041). No significant difference existed in the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p > 0.05).

CONCLUSIONS

The United Kingdom lockdown was independently associated with an increased proportion of alcohol-related trauma. Trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of further global "waves" of COVID-19, the long-term repercussions of dangerous alcohol-related behaviour to public health must be addressed.

Development and approbation of a tool for assessing municipal infrastructure affecting behavioral risk factors for cardiovascular and other noncommunicable diseases

Aim. To present first results of the study on the assessment of municipal infrastructure using specialized software in a pilot subject of the Russian Federation (Sverdlovsk Oblast).

Material and methods. The following infrastructure elements of four municipalities of the Sverdlovsk Oblast have been assessed in the period from January to March 2022: sports facilities, grocery stores, fairs/markets with fresh vegetables and fruits, alcoholic drinks in shops and supermarkets, special liquor stores, tobacco outlets, fast food restaurants). The assessment was made with specialized software developed using Open Street Map (OSM) that allows real-time recording of objects for interactive map data visualization.

Results. The density of sales outlets for tobacco, alcohol, fresh vegetables and fruits was 2,3, 3,4 and 2,4 per 1 km², respectively; the density of sports facilities, fast food and restaurants — 1,3, 0,9 and 0,5, respectively. The number of sales outlets for tobacco, alcohol, fresh vegetables and fruits per 100 thousand people was 111,6, 167,7 and 116,5, respectively, while the number of sports facilities, fast food and restaurants — 63,5, 44,1, 25,0, respectively.

Conclusion. Creation and implementation of integrated system for assessing a unified preventive environment for promoting health and maintaining a healthy lifestyle at the municipal level using a combination of objective (GIS technologies, paraclinical tests) and subjective assessment methods (personal survey), as well as the introduction of interactive maps of municipal infrastructure, will make possible use of evidence to make decisions on the development and implementation of programs for the prevention of cardiovascular diseases and health promotion, as well as their management at the regional/municipal level.

Effects of multi-component programmes in preventing sales of alcohol to intoxicated patrons in nightlife settings in the United Kingdom

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Alcohol service to intoxicated patrons in nightlife settings is common.

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Multi-component interventions can prevent alcohol over-service.

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Effects are stronger for interventions including enhanced law enforcement.

Introduction

Alcohol service to intoxicated patrons is common across nightlife settings and preventing such sales is a key priority globally. In England and Wales, three multi-component programmes have been implemented including: (1) community mobilisation, responsible beverage server (RBS) training and routine law enforcement; (2) community mobilisation and enhanced law enforcement; and, (3) community mobilisation, RBS training and enhanced law enforcement. This study estimates the association between sales of alcohol to pseudo-intoxicated patrons and implementation of three multi-component interventions in four nightlife settings.

Methods

Alcohol test purchases by pseudo-intoxicated actors were implemented at pre (n = 206) and post-intervention (n = 224). Actors/observers recorded venue and test purchase characteristics. Logistic regression assessed service refusal by intervention type, adjusting for venue/test purchase characteristics.

Results

Pre-intervention, 20.9% of sales were refused. Post-intervention, 42.1%, 68.8% and 74.0% of sales were refused in areas with intervention 1, 2, and 3 respectively. In adjusted analyses, compared to pre-intervention, the odds of service refusal were higher for all interventions, with the highest odds when the intervention included enhanced law enforcement (adjusted odds ratios, interventions 1, 2, 3: 2.6, 7.1, 14.4; p < 0.01). Service refusal was higher if the test purchase was implemented on a Saturday/Sunday night; and lower if implemented in a nightclub or if age verification was requested at the bar.

Conclusion

Community-based multi-component interventions were associated with significant increases in service refusal to pseudo-intoxicated actors in nightlife settings in England and Wales. Effects were stronger for interventions including enhanced law enforcement, and particularly if all intervention components were implemented.

Examining how the geographic availability of alcohol within residential neighborhoods, activity spaces, and destination nodes is related to alcohol use by parents of young children

BACKGROUND

Alcohol outlet density and drinking behaviors have been assessed based on where people live, but exposure may differ based on where people spend time. We assessed the relationship between alcohol outlet density (using three measures of geographic availability), frequency of use, and continued volume of alcohol among parents. Parents are a unique population of drinkers where the risk for harm to others can be higher as they are caring for minor children.

METHODS

We conducted a cross-sectional telephone and web-based survey of 1599 parents in 2015 across 30 cities in California. Participants provided information on drinking, residential addresses, and locations of daily activities. We created three measures of alcohol availability using residential neighborhoods, convex hull polygons, and destination nodes. Data were analyzed using zero-inflated negative binomial models.

RESULTS

Density of bars in residential neighborhoods were related to more frequent drinking (b = 0.0139, 95% CI = 0.0016, 0.0261) and higher continued volume (b = 0.0295, 95% CI = 0.0067, 0.0522). Density of bars (b = 0.0070, 95% CI = 0.0019, 0.0121) and restaurants (b = 0.0018, 95% CI = 0.0003, 0.0033) in destination nodes were related to drinking a higher continued volume of alcohol. Higher off-premise outlet density was related to a lower continued volume (b = -0.0026, 95% CI = -0.0049, -0.0002).

CONCLUSIONS

Outlet densities in residential neighborhood and destination nodes are related to frequency of drinking and continued volume of alcohol. Future work should seek to determine why and how residential neighborhoods and nodes are related to alcohol use behaviors and if they differ for parents compared to other adults.

Accessibility and availability of alcohol outlets around schools: An ecological study in the city of Madrid, Spain, according to socioeconomic area-level

Neighborhood accessibility and availability of alcohol products has been associated with increased alcohol consumption and harms among adolescents. This availability has been shown to be higher in neighborhoods with lower socio-economic status (SES). The aim of this study was to examine inequalities in alcohol outlet density and proximity around schools by area-level SES in Madrid, Spain. Data on schools, SES, alcohol outlets and population density at census tract level were obtained through public databases from the local government of Madrid. We examined (1) density as the number of alcohol outlets around schools within 3 buffers (i.e. 200 m, 400 m and 800 m) and (2) proximity as the distance from schools to their nearest alcohol outlet. We performed multilevel analyses to examine the associations between alcohol outlet density and proximity and SES, adjusted by population density. Secondary schools (n = 576) located in less deprived areas had lower densities of alcohol outlets at walking distances of 200 and 400 m (50% and 37% lower, respectively p < 0.05). No significant differences were found for the proximity measures. The socioeconomic level of the area in which adolescents go to school is a determinant of their exposure to alcohol, where those who study in high SES areas have lower exposure to alcohol outlets. This study highlights the need to prioritize equity in the design and implementation of policies to limit alcohol accessibility among adolescents, including establishing minimum distances between schools and alcohol outlets or limiting the number of outlets per inhabitant in neighborhoods.

Neighborhood environment: the impact of alcohol and tobacco outlets availability on health of people living in a certain area

Alcohol and tobacco consumption remain significant risk factors (RFs) for morbidity and mortality from noncommunicable diseases (NCDs), including cardiovascular ones, in Russia. The main risk factors contributing to NCDs in addition to traditional risk factors and lifestyle also include the neighborhood environment (NE). The term “neighborhood environment” describes the relationship between the area in immediate vicinity of a person's place of residence, environmental factors, social characteristics of the area, which can have both positive and negative effects on human health.

The aim of this review was to analyze alcohol and tobacco outlets availability as a factor effecting health of people living in a certain area.

It was demonstrated that a high density of alcohol outlets is associated with increased alcohol consumption among both adults and adolescents, with drunk driving and road traffic accidents, injuries, violent crimes, the risk of acute and chronic diseases. A high density of tobacco outlets is associated with an increase in smoking intensity among both adults and adolescents, as well as an increase of secondhand smoke, which increases the risk of NCDs.

The consumption of alcohol and tobacco is associated with a significant increase in risk of NCDs, including cardiovascular ones, and injuries, leading to disability and death. The effectiveness of measures aimed at reducing the consumption of alcohol and tobacco may be reduced due to high density of outlets selling these products. It is necessary to conduct studies aimed at assessing the outlets density and its associations with prevalence of RFs and health status of Russian population. These data will stimulate intersectoral collaboration for planning health protection strategy at municipal level.

Observational study of the association between diverse licensed premises types and alcohol-related violence in an inner-London borough

BACKGROUND

An ecological correlation has been observed between licensed premises and alcohol-related violence (ARV). In the UK to date, no evidence directly connects alcohol-related harm to a single premises type. Recent policies have called for a diversified alcohol offer, yet quantitative evidence in support remains sparse. This study aims to inform policy by determining whether diversification of the alcohol economy is desirable and to inform the licensing process and submission of public health evidence.

METHODS

Using 11 years of local licensing data from the London Borough of Southwark, alcohol availability over time was approximated by the number of extant alcohol licences, categorised by outlet type: drinking establishments, eateries, takeaways, off-sales and 'other'. Harm was quantified drawing on law enforcement intelligence that recorded ARV. A linked data set was analysed using negative binomial regression, contrasting cumulative impact zones (CIZ)-a common alcohol control policy-with non-CIZ geographies.

RESULTS

Each licensed drinking establishment was associated with a 1.6% (95% CI 0.7% to 2.6%; p=0.001) increase in ARV, respectively. 'Other' outlets had a protective effect and were associated with a 1.8% (95% CI 1.0% to 2.5%; p<0.001) decrease in ARV.

CONCLUSION

This study provides direct evidence for an association between alcohol-related harm and licensed premises. The varying associations between outlet type and ARV provide local public health stakeholders with an evidence base upon which to advocate for licensing policies that diversify alcohol availability.

Forecasting the 2021 local burden of population alcohol-related harms using Bayesian structural time-series

BACKGROUND AND AIMS

Harmful alcohol use places a significant burden on health services. Sophisticated nowcasting and forecasting methods could support service planning, but their use in public health has been limited. We aimed to use a novel analysis framework, combined with routine public health data, to improve now- and forecasting of alcohol-related harms.

DESIGN

We used Bayesian structural time-series models to forecast alcohol-related hospital admissions for 2020/21 (from 2015 to 2016).

SETTING

England.

PARTICIPANTS

We developed separate models for each English lower-tier local authority.

MEASUREMENTS

Our primary outcome was alcohol-related hospital admissions. Model covariates were population size and age-structure.

FINDINGS

Nowcasting validation indicated adequate accuracy, with 5-year nowcasts underestimating admissions by 2.2% nationally and 3.3% locally, on average. Forecasts indicated a 3.3% increase in national admissions in 2020/21, corresponding to a 0.2% reduction in the crude rate of new admissions, due to population size changes. Locally, the largest increases were forecast in urban, industrial and coastal areas and the largest decreases in university towns and ethnically diverse areas.

CONCLUSIONS

In 2020/21, alcohol-related hospital admissions are expected to increase in urban and coastal areas and decrease in areas associated with inward migration of younger people, including university towns and areas with greater ethnic diversity. Bayesian structural time-series models enable investigation of the future impacts of alcohol-related harms in population subgroups and could improve service planning and the evaluation of natural experiments on the impact of interventions to reduce the societal impacts of alcohol.

Local Alcohol Policy Implementation in Scotland: Understanding the Role of Accountability within Licensing

Scotland has been ambitious in its policy and legislative efforts to tackle alcohol-related harm, efforts which include the innovative feature of a ‘public health objective’ within local alcohol licensing. However, the persistence of alcohol-related harms and inequalities requires further examination of both the overarching Scottish alcohol strategy and its specific implementation. A qualitative case study was undertaken to explore how alcohol policy is implemented locally in Scotland, with data generated from (i) documentary analysis of 12 relevant policies, legislation, and guidance documents; and (ii) a thematic analysis of semi-structured interviews with 54 alcohol policy implementers in three Scottish localities and nine national-level stakeholders. The data suggest there is a tension between the intentions of licensing legislation and the way it is enacted in practice, and that accountability emerges as an important factor for understanding why this occurs. In particular, there are a lack of accountability mechanisms acting upon Scottish Licensing Boards to ensure they contribute to the public health goals of the Scottish alcohol strategy. From a public health perspective, this has perpetuated a system in which Licensing Boards continue to act with autonomy from the rest of the alcohol policy implementation system, creating a challenge to the achievement of public health goals. Alcohol policy in Scotland is likely to fall short of intended goals as long as the tension between licensing legislation and enacted licensing practices remains.

Alcohol outlet density and alcohol related hospital admissions in England: a national small-area level ecological study

BACKGROUND AND AIMS

Excessive alcohol consumption has a substantial impact on public health services. A key element determining alcohol availability is alcohol outlet density. This study investigated the relationship between on-trade and off-trade outlets and hospital admission rates in local neighbourhoods.

DESIGN

National small-area level ecological study.

SETTING AND PARTICIPANTS

All 32 482 lower layer super output census areas (LSOAs) in England (42 227 108 million people aged 15+ years). Densities for six outlet categories (outlets within a 1-km radius of residential postcode centroids, averaged for all postcodes within each LSOA) were calculated.

MEASUREMENTS

Main outcome measures were admissions due to acute or chronic conditions wholly or partially attributable to alcohol consumption from 2002/03 to 2013/14.

FINDINGS

There were 1 007 137 admissions wholly, and 2 153 874 admissions partially, attributable to alcohol over 12 years. After adjustment for confounding, higher densities of on-trade outlets (pubs, bars and nightclubs; restaurants licensed to sell alcohol; other on-trade outlets) and convenience stores were associated with higher admission rate ratios for acute and chronic wholly attributable conditions. For acute wholly attributable conditions, admission rate ratios were 13% (95% confidence interval = 11-15%), 9% (7-10%), 12% (10-14%) and 10% (9-12%) higher, respectively, in the highest relative to the lowest density categories by quartile. For chronic wholly attributable conditions, rate ratios were 22% (21-24%), 9% (7-11%), 19% (17-21%) and 7% (6-9%) higher, respectively. Supermarket density was associated with modestly higher acute and chronic admissions but other off-trade outlet density was associated only with higher admissions for chronic wholly attributable conditions. For partially attributable conditions, there were no strong patterns of association with outlet densities.

CONCLUSIONS

In England, higher densities of several categories of alcohol outlets appear to be associated with higher hospital admission rates for conditions wholly attributable to alcohol consumption.

Domestic gardens and self-reported health: a national population study

BACKGROUND

There is a growing recognition of the health benefits of the natural environment. Whilst domestic gardens account for a significant proportion of greenspace in urban areas, few studies, and no population level studies, have investigated their potential health benefits. With gardens offering immediate interaction with nature on our doorsteps, we hypothesise that garden size will affect general health-with smaller domestic gardens associated with poorer health.

METHODS

A small area ecological design was undertaken using two separate analyses based on data from the 2001 and 2011 UK census. The urban population of England was classified into 'quintiles' based on deprivation (Index of Multiple Deprivation) and average garden size (Generalised Land Use Database). Self-reported general health was obtained from the UK population census. We controlled for greenspace exposure, population density, air pollution, house prices, smoking, and geographic location. Models were stratified to explore the associations.

RESULTS

Smaller domestic gardens were associated with a higher prevalence of self-reported poor health. The adjusted prevalence ratio of poor self-reported general health for the quintile with smallest average garden size was 1.13 (95% CI 1.12-1.14) relative to the quintile with the largest gardens. Additionally, the analysis suggested that income-related inequalities in health were greater in areas with smaller gardens. The adjusted prevalence ratio for poor self-reported general health for the most income deprived quintile compared against the least deprived was 1.72 (95% CI 1.64-1.79) in the areas with the smallest gardens, compared to 1.31 (95% CI 1.21-1.42) in areas with the largest gardens.

CONCLUSIONS

Residents of areas with small domestic gardens have the highest levels of poor health/health inequality related to income deprivation. Although causality needs to be confirmed, the implications for new housing are that adequate garden sizes may be an important means of reducing socioeconomic health inequalities. These findings suggest that the trend for continued urban densification and new housing with minimal gardens could have adverse impacts on health.