Potential consequences of replacing a retail alcohol monopoly with a private licence system: results from Sweden

Relationships Between Alcohol Policies and Infant Morbidities and Injuries

INTRODUCTION

Previous research has found that policies specifically focused on pregnant people's alcohol use are largely ineffective. Therefore, the purpose of this study is to analyze the relationships between general population policies regulating alcohol physical availability and outcomes related to pregnant people's alcohol use, specifically infant morbidities and injuries.

METHODS

Outcome data were obtained from Merative MarketScan, a longitudinal commercial insurance claims data set. Policy data were obtained from the National Institute on Alcohol Abuse and Alcoholism's Alcohol Policy Information System, the National Alcohol Beverage Control Association, and Liquor Handbooks and merged using policies in effect during the estimated year of conception. Relationships between state-level policies regulating sites, days/hours, and government monopoly of liquor sales and infant morbidities and injuries were examined. Analyses used logistic regression with individual controls, fixed effects for state and year, state-specific time trends, and SEs clustered by state. The study analysis was conducted from 2021 to 2023.

RESULTS

The analytic sample included 1,432,979 infant-birthing person pairs, specifically people aged 25-50 years who gave birth to a singleton between 2006 and 2019. A total of 3.1% of infants had a morbidity and 2.1% of infants had an injury. State government monopoly on liquor sales was associated with reduced odds of infant morbidities and injuries, whereas gas station liquor sales were associated with increased odds of infant morbidities and injuries. Allowing liquor sales after 10PM was associated with increased odds for infant injuries. No effect was found for allowing liquor sales in grocery stores or on Sundays.

CONCLUSIONS

Findings suggest that limiting alcohol availability for the general population may help reduce adverse infant outcomes related to pregnant people's alcohol use.

The public-private decision for alcohol retail systems: Examining the economic, health, and social impacts of alternative systems in Finland

Background: Organising alcohol retail systems with more or less public ownership has implications for health and the economy. The aim of the present study was to estimate the economic, health, and social impacts of alcohol use in Finland in 2018 (baseline), and in two alternative scenarios in which current partial public ownership of alcohol retail sales is either increased or fully privatised. Methods: Baseline alcohol-attributable harms and costs were estimated across five categories of death, disability, and criminal justice. Two alternate alcohol retail systems were defined as privately owned stores selling: (1) only low strength alcoholic beverages (public ownership scenario, similar to Sweden); or (2) all beverages (private ownership scenario). Policy analyses were conducted to estimate changes in alcohol use per capita. Health and economic impacts were modelled using administrative data and epidemiological modelling. Results: In Finland in 2018, alcohol use was estimated to be responsible for €1.51 billion (95% Uncertainty Estimates: €1.43 billion, €1.58 billion) in social cost, 3,846 deaths, and 270,652 criminal justice events. In the public ownership scenario, it was estimated that alcohol use would decline by 15.8% (11.8%, 19.7%) and social cost by €384.3 million (€189.5 million, €559.2 million). Full privatisation was associated with an increase in alcohol use of 9.0% (6.2%, 11.8%) and an increase in social cost of €289.7 million (€140.8 million, €439.5 million). Conclusion: The outcome from applying a novel analytical approach suggests that more public ownership of the alcohol retail system may lead to significant decreases in alcohol-caused death, disability, crime, and social costs. Conversely, full privatisation of the ownership model would lead to increased harm and costs.

Förnuft och känsla Kunskapsbruk hos gårdagens förbudskritiker och dagens alkoholliberaler

Aim: The aim is to study non-governmental actors’ production and use of alcohol policy knowledge in the early 20th and the 21st century respectively, by analyzing their main arguments, knowledge substantiation and their overarching discursive legitimacy. Design: The first impact focuses on prohibitionist-critical actors’ engagement against the alcohol ban in the years 1916–1922. The second impact focuses on the Swedish think tank Timbro’s engagement in alcohol policy in the years 2012–2020. The analysis of the two empirical cases was based on an open coding strategy with a focus on what type of knowledge claims that were made and how which reasoning was put forward in relation to these. Results: Great similarities are distinguished between the two time periods. Alcohol is an issue of freedom and at the same time a threat of crucial importance for the future society. The arguments are supported by historical, international, media and scientific evidence. The biggest difference lies in the legitimization of the argumentation. In the early 20th century this is rooted in democracy and the will of the people while the arguments of the 21st century are rooted in public health and governmentally sanctioned knowledge. Conclusion: The knowledge processes are explored as matters of political appropriation that takes place through processes of directing and stealing the spotlight. These processes show how the aspiring democracy and the existing public health policy respectively are productive preconditions for what kind of knowledge that can be brought forward. This enables a renegotiation regarding what democracy and public health policy can involve.

Alcohol Outlet Density and Area-Level Heavy Drinking Are Independent Risk Factors for Higher Alcohol-Related Complaints

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.

Estimating the public health impact of disbanding a government alcohol monopoly: application of new methods to the case of Sweden

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.

Alcohol policy and fatal alcohol-related crashes in Finland 2000-2016

OBJECTIVE

The purpose of this study was to explore the relationship between annual alcohol consumption per capita/alcohol price index and the number of alcohol-related fatal motor vehicle accidents (AFMVAs). We were particularly interested in whether a tax reduction in 2004 increased the number of alcohol-related accidents.

METHOD

The data consisted of all fatal motor vehicle accidents (FMVAs) during the years 2000-2016 obtained from a database maintained by the Finnish Crash Data Institute (OTI). The data included all fatally injured drivers. We compared the OTI data to official statistics on annual alcohol consumption and the alcohol price index.

RESULTS

There were 3,447 fatally injured drivers, of which 25% (n = 869) were intoxicated (blood alcohol concentration [BAC] ≥ 0.05%). After the reduction of the alcohol tax in 2004, the alcohol consumption rose 12.4% from 2003 to 2005 and AFMVAs rose 38%. There was a strong correlation (r = 0.7000, P < .018) between the recorded consumption of alcohol and the number of AFMVAs. There was a strong negative correlation between AFMVAs and the combined (retail + restaurant sales) alcohol price index (r = -0.7863, P = .0005). A linear mixed-effects model showed that a 1-L increase in total alcohol consumption per capita per year increases AFMVAs by 10.6 and a one-unit increase in the price index decreases AFMVAs by 1.8 per year.

CONCLUSIONS

The correlation between alcohol consumption and alcohol-related crashes should be considered when making political decisions regarding alcohol price and availability. Any further liberalization of the alcohol policy would likely lead to an increase in alcohol-related fatal motor vehicle accidents. Similar consequences are likely to occur with drugs. Alcohol price policy is an effective way to improve road safety, but other measures taken to prevent FMVAs also seem to reduce the prevalence of AFMVAs.

Queensland Alcohol-related violence and Night Time Economy Monitoring project (QUANTEM): a study protocol

BACKGROUND

Alcohol-related harm is a substantial burden on the community in Australia and internationally, particularly harm related to risky drinking practices of young people in the night-time economy. This protocol paper describes a study that will report on the changes in a wide range of health and justice outcome measures associated with major policy changes in the state of Queensland, Australia. A key element includes trading hours restrictions for licensed premises to 2 am for the state and 3 am in Safe Night Precincts (SNPs). Other measures introduced include drinks restrictions after midnight, increased patron banning measures for repeat offenders, mandatory ID scanning of patrons in late-night venues, and education campaigns.

METHODS

The primary aim of the study is to evaluate change in the levels of harm due to these policy changes using administrative data (e.g., police, hospital, ambulance, and court data). Other study elements will investigate the impact of the Policy by measuring foot traffic volume in SNPs, using ID scanner data to quantify the volume of people entering venues and measure the effectiveness of banning notices, using patron interviews to quantify the levels of pre-drinking, intoxication and illicit drug use within night-time economy districts, and to explore the impacts of the Policy on business and live music, and costs to the community.

DISCUSSION

The information gathered through this project aims to evaluate the effectiveness of the Policy and to draw on these findings to inform future prevention and enforcement approaches by policy makers, police, and venue staff.

Alcohol Retailing in Canadian and Nordic Contexts: Challenges and Opportunities in Balancing Trade and Prevention Agendas

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.

Change and Stability?

Over the past two decades, alcohol consumption in Sweden has grown by 20 per cent as a result of an increasing consumption of wine and strong beer. The rise is driven by a combination of factors such as the higher physical availability and lower real prices of alcohol, which suggests that alcohol has become much more affordable. In addition, the possibilities to bring back cheaper alcohol from other EU countries have been greatly extended during the Swedish EU membership. No definite patterns were found with respect to certain social and demographic changes during the study period. Despite the significant increase in consumption, indicators of alcohol-related harms did not show consistently increasing trends. It is not evident why the increasing availability should have such different effects on various population sub-groups, and there are obviously other relevant factors at play. Widespread political concern at the implications of the rising availability of alcohol has led Sweden to spend more per capita than any other European country on alcohol policy and prevention initiatives. It will be a continuous challenge for policy makers to find measures that limit the harms caused by alcohol in the Swedish society.