Alcohol outlet density and harm: comparing the impacts on violence and chronic harms

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.

Did the association between alcohol outlet density and crime change during COVID shelter-in-place orders?

INTRODUCTION

We investigated whether greater concentrations of on- and off-sale alcohol outlets were associated with crime and whether this association was moderated by COVID-19 shelter-in-place orders (SIP) that restricted on-premises consumption of alcohol.

METHODS

Crimes (2019-2020) and addresses of licenced alcohol outlets in a medium-sized California city were geocoded within census block groups (N = 61). On- and off-sale alcohol outlet density was calculated as licenced outlets/2.59 km2 (1 square mile). Multilevel negative binomial regression analyses were conducted to examine associations between alcohol outlet density and crime, and possible moderating effects of SIP, controlling for block group demographic characteristics and density of other retail businesses.

RESULTS

On-sale outlet density was positively associated with total crimes and Part 2 crimes, while off-sale outlet density was inversely associated with total crime and Part 2 crimes. Overall, SIP was not significantly associated with crime, but moderated the associations of on-sale density with total crime and Part 1 crimes such that reductions in crime during SIP were observed in higher density areas. The association of off-sale outlets with crime was not moderated by SIP policies.

DISCUSSION AND CONCLUSION

On-sale outlet density, but not off-sale density, appears to be associated with increased crime. The results further indicate that restrictions in hours and service imposed by SIP policies reduced crime in high on-sale outlet density areas. These findings reinforce the importance of regulating alcohol outlet density and hours of service, especially for on-sale outlets, as a crime reduction strategy.

The economic costs of alcohol-related harms at the local level in New South Wales

INTRODUCTION

Alcohol is a harmful, toxic and addictive substance that causes many diseases and injuries. Alcohol use also incurs a financial cost to the health care system and wider economy. This project aimed to undertake a cost impact analysis of alcohol-related harms at the local level in New South Wales (NSW). The alcohol-related harms costing model is an interactive tool designed for use by local health districts, stakeholders such as Liquor and Gaming NSW, NSW Independent Liquor and Gaming Authority and community stakeholders.

METHODS

Costs included in the analysis were alcohol-related hospitalisations, deaths, crimes, emergency department attendances, outpatient presentations and their impacts on productivity. Two local government areas (LGA) were used as case studies to demonstrate local impacts.

RESULTS

In 2019-2020, the total cost of alcohol-related harms for NSW was estimated at $9 billion, at a rate of $120.3 million per 100,000 population. The total costs were comprised of alcohol-attributable premature mortality ($8.3 billion), non-fatal health care costs ($275 million) and crime costs ($457 million). A comparative analysis of two case study LGAs estimated that alcohol-related harms cost $195 million for the Northern Beaches LGA and $351 million for the Central Coast LGA.

DISCUSSION AND CONCLUSIONS

This research has developed a 'proof-of-concept' model to estimate the cost of alcohol-related harms at the local level in Australia, empowering health agencies and local community stakeholders to use economic evidence in their submissions in response to new liquor licence applications and other policies that impact their local community. This economic evidence can be used to improve the quality of decisions on alcohol regulation and policies. There are a number of future research opportunities that would enhance the economic evidence available to liquor licensing decision-makers.

Vancouver's Alcohol Knowledge Exchange: lessons learned from creating a peer-involved alcohol harm reduction strategy in Vancouver's Downtown Eastside

Despite high rates of harm attributable to alcohol use itself and the associated marginalization of illicit drinkers in Vancouver's Downtown Eastside (DTES), alcohol-specific harm reduction services there are under-resourced and highly disconnected from one another. In response to these conditions and high rates of death amongst its membership, the Eastside Illicit Drinkers Group for Education, an affiliate group of the Vancouver Area Network of Drug Users, convened a regular meeting of stakeholders, termed a "community of practice" in 2019 to bring together peers who used beverage and non-beverage alcohol, shelter and harm reduction service providers, public health professionals, clinicians, and policymakers to improve system-level capacity to reduce alcohol-related harm. The discussions that followed from these meetings were transformed into the Vancouver Alcohol Strategy (VAS), a comprehensive, harm reduction-oriented policy framework for alcohol harm reduction in the DTES. This article highlights our experiences producing community-led alcohol policy through the VAS with specific attention to the ways in which people who use alcohol themselves were centred throughout the policy development process. We also provide summary overviews of each of the VAS document's 6 thematic areas for action, highlighting a sampling of the 47 total unique recommendations. Historically, people who use non-beverage alcohol and whose use of alcohol in public spaces is criminalized due to housing precarity and visible poverty have been excluded from the development of population-level alcohol policies that can harm this specific population. The process of policy development undertaken by the VAS has attempted to resist this top-down approach to public health policy development related to alcohol control by intentionally creating space for people with lived experience to guide our recommendations. We conclude by suggesting that a grassroots enthusiasm for harm reduction focused policy development exists in Vancouver's DTES, and requires resources from governmental public health institutions to meaningfully prevent and reduce alcohol-related and policy-induced harms.

'A recipe for cultural disaster!'- a case study of Woolworths Group's proposal to build an alcohol megastore in Darwin, Northern Territory

BACKGROUND

The health and wellbeing impacts of commercial activity on Indigenous populations is an emerging field of research. The alcohol industry is a key driver of health and social harms within Australia. In 2016 Woolworths, the largest food and beverage retailer in Australia, proposed to build a Dan Murphy's alcohol megastore in Darwin, near three 'dry' Aboriginal communities. This study examines the tactics used by Woolworths to advance the Dan Murphy's proposal and understand how civil society action can overcome powerful commercial interests to protect Aboriginal and Torres Strait Islander health and wellbeing.

METHODS

Data from 11 interviews with Aboriginal and non-Aboriginal informants were combined with data extracted from media articles and government, non-government and industry documents. Thematic analysis was informed by an adapted corporate health impact assessment framework.

RESULTS

Woolworths employed several strategies including lobbying, political pressure, litigation, and divisive public rhetoric, while ignoring the evidence suggesting the store would increase alcohol-related harm. The advocacy campaign against the proposal highlighted the importance of Aboriginal and non-Aboriginal groups working together to counter commercial interests and the need to champion Aboriginal leadership. Advocacy strategies included elevating the voices of community Elders in the media and corporate activism via Woolworths' investors.

CONCLUSIONS

The strategies used by the coalition of Aboriginal and non-Aboriginal groups may be useful in future advocacy campaigns to safeguard Aboriginal and Torres Strait Islander health and wellbeing from commercial interests.

Understanding the association between neighbourhood socioeconomic status and grocery store alcohol sales following market liberalization in Ontario, Canada

OBJECTIVES

In 2015, Ontario partially deregulated alcohol sales by allowing grocery stores to sell alcohol. The purpose of this study was to evaluate (1) whether neighbourhood-level socioeconomic status (SES) impacted the likelihood that a grocery store began selling alcohol, and (2) whether increases in alcohol retail availability following deregulation differed between neighbourhoods based on SES.

METHODS

This was a repeated cross-sectional analysis of 1062 grocery stores in 17,096 neighbourhoods in urban Ontario. The association between neighbourhood-level SES and whether a grocery store began selling alcohol was modeled using mixed effect logistic regression. The annual change in drive-distance from a neighbourhood to the closest off-premise alcohol outlet between 2015 and 2020 was modeled using mixed effect linear regression. An interaction between time and SES was included to evaluate whether this change differed between neighbourhoods based on SES.

RESULTS

Grocery stores in neighbourhoods in the lowest SES quintile were 39% less likely to start selling alcohol than grocery stores in neighbourhoods in the highest SES quintile (odds ratio (OR): 0.61, 95% confidence interval (CI): 0.39-0.94). As grocery store sales expanded, the distance to the closest off-premise alcohol outlet decreased by 51.8 m annually (95% CI: 48.8-54.9, p < 0.01). A significant interaction between year and SES was observed whereby this trend was more pronounced in high- versus low-SES neighbourhoods.

CONCLUSION

The expansion of grocery store alcohol sales increased alcohol availability, but this increase was proportionately larger in high- versus low-SES neighbourhoods. This reduced historic disparities in alcohol availability between low- and high-SES neighbourhoods.

Exploring the influence of local alcohol availability on drinking norms and practices: A qualitative scoping review

INTRODUCTION

High alcohol availability is related to increased alcohol consumption and harms. Existing quantitative research provides potential explanations for this relationship but there is little understanding of how people experience local alcohol availability. This is the first review to synthesise qualitative research exploring the relationship between alcohol availability and other factors in local alcohol environments.

METHODS

The scoping review includes qualitative studies exploring community-level alcohol availability and other factors, facilitating the purchase and consumption of alcohol. We included studies focusing on children and adolescents as well as adults. Study findings were brought together using thematic analysis and the socio-environmental context model, which explains how certain environments may facilitate drinking.

RESULTS

The review includes 34 articles. The majority of studies were conducted since 2012. Most studies were conducted in the United Kingdom, Australia and South Africa. The physical availability of alcohol and proximity to local amenities and temporal aspects, like late night opening hours, may be linked to social factors, such as normalisation of drinking and permissive drinking environments. The review highlights the importance of social and cultural factors in shaping interactions with local alcohol environments.

DISCUSSION AND CONCLUSION

This qualitative scoping review advances understanding of the pathways linking alcohol availability and alcohol harms by showing that availability, accessibility and visibility of alcohol may contribute towards permissive drinking environments. Further research is needed to better understand how people experience alcohol availability in their local environment and how this can inform alcohol control policies.

Neighborhood Socioeconomic Deprivation and Youth Assault Injuries in Vancouver, Canada

OBJECTIVE

To examine the degree to which neighborhood socioeconomic deprivation influences the risk of youth assault injury.

STUDY DESIGN

Population-based retrospective study of youth aged 10-24 years seeking emergency medical care between 2012 and 2019 at 14 hospitals in Vancouver, Canada. Neighborhood material and social deprivation were examined as independent predictors of assault injury, accounting for spatial autocorrelation and controlling for neighborhood drinking establishment density.

RESULTS

Our data included 4166 assault injuries among 3817 youth. Male sex, substance use, and mental health disorders were common among victims of assault. Relative to the least deprived quintile of neighborhoods, assault injury risk was 2-fold higher in the most materially deprived quintile of neighborhoods (incidence rate ratio per quintile increase, 1.17; 95% CI 1.06-1.30; P < .05), and risk in the most socially deprived quintile was more than 3-fold greater than in the least deprived quintile (incidence rate ratio per quintile increase, 1.35; 95% CI 1.21-1.50; P < .001). Assault risk was 147-fold greater between 2 and 3 AM on Saturday relative to the safest hours of the week.

CONCLUSIONS

Neighborhood socioeconomic deprivation substantially increases the risk of youth assault injury. Youth violence prevention efforts should target socioeconomically deprived neighborhoods.

Association between Nightlife Goers' Likelihood of an Alcohol Use Disorder and Their Preferred Bar's Closing Time: A Cross-Sectional Observational Study in Perth, Australia

Introduction and aims: Associations between longer-term alcohol-related conditions and licensed outlet trading hours are not well understood. We investigated the association between nightlife-goers’ likelihood of an alcohol use disorder (AUD) and their preference for bars with special permits to remain open ‘late’ (i.e., spent more time there compared to any other venue) until 2 a.m. or 3 a.m. (Friday; Saturday) or midnight (Sunday) compared to bars with ‘standard’ closing times of midnight (Friday; Saturday) or 10 p.m. (Sunday). Design and methods: A cross-sectional observational study was conducted in four major nightlife areas of Perth, Australia, in 2015–2016. We conducted weekend street intercept surveys outside bars between 8 p.m. and 3 a.m. and screened participants who reported alcohol use prior to the survey and spent more time in a bar than any other venue type (n = 667) regarding their past year drinking pattern using AUDIT-C (n = 459). We used gender-specific logistic regression models to estimate associations between AUDIT-C categories (1–4, low risk; 5–7, hazardous; 8–12, active AUD) and preference for bars with different closing times (late vs. standard). Results: A large proportion of participants were hazardous drinkers or had active AUD (83% males; 65% females), and over half preferred a late to a standard closing bar. We found evidence of a positive association between preference for late closing bars and hazardous drinking females (OR = 3.48; 95% CI 1.47–8.23; p = 0.01), but not for females with active AUD, male hazardous drinkers, nor males with active AUD. Discussion and conclusions: Our study adds new evidence on associations between likelihood of AUD among nightlife-goers and trading hours. With increasing international relaxation of trading hours, evidence that late closing bars may be preferred by hazardous drinking females will be of concern to policymakers wanting to curb alcohol-related harms in the community.

Washington's liquor license system and alcohol-related adverse health outcomes

BACKGROUND AND AIMS

In June 2012, Washington state (USA) implemented Initiative 1183, privatizing liquor sales. As a result, off-premises outlets increased from 330 to over 1400 and trading hours lengthened. Increased availability of liquor may lead to increased consumption. This study examines the impact of Initiative 1183 on alcohol-related adverse health outcomes, measured by inpatient hospitalizations for alcohol-related disorders and accidental injuries. It further assesses heterogeneity by urbanicity, because outlets increased most in metropolitan-urban areas.

DESIGN

County-by-quarter difference-in-difference linear regression models, estimated statewide and within metropolitan/rural strata.

SETTING AND PARTICIPANTS

Data are from AHRQ Healthcare Cost and Utilization State Inpatient Database 2010-2014 and HHS Area Health Resource File 2010-2014. Changes in the rates of hospitalizations in the 2.5 years following Initiative 1183 in Washington (n = 39 counties) are compared with changes in Oregon (n = 36 counties).

MEASUREMENTS

County rates of hospitalizations per 1000 residents, including all records with any-listed ICD-9 Clinical Classification Software code denoting an alcohol-related disorder, and all records with any-listed external cause of injury code denoting an accidental injury.

FINDINGS

The increase in the rate of accidental injury hospitalizations in Washington's metropolitan-urban counties was on average 0.289 hospitalizations per 1000 county residents per quarter greater than the simultaneous increase observed in Oregon (P = 0.017). This result was robust to alternative specifications using a propensity score matched sample and synthetic control methods with data from other comparison states. The evidence did not suggest that Initiative 1183 was associated with differential changes in the rate of hospitalizations for alcohol-related disorders in metropolitan-urban (P = 0.941), non-metropolitan-urban (P = 0.162), or rural counties (P = 0.876).

CONCLUSIONS

Implementing Washington's Initiative 1183 (privatizing liquor sales) appears to have been associated with a significant increase in the rate of accidental injury hospitalizations in urban counties in that state but does not appear to be significantly associated with changes in the rate of hospitalizations specifically for alcohol-related disorders within 2.5 years.

A Multilevel Model of Alcohol Outlet Density, Individual Characteristics and Alcohol-Related Injury in Argentinean Young Adults

OBJECTIVES

Previous research from high-income countries has consistently shown an association between alcohol-related harms and neighborhood characteristics such as alcohol outlet density, but this research has not been extended to middle- and low-income countries. We assessed the role of neighborhood characteristics such as alcohol outlet density, overcrowding and crime rates, and individual characteristics including gender, age, alcohol and marijuana use, and geographic mobility associated with alcohol-related injuries in university students in Argentina.

METHODS

Data were collected from a randomized sample of students attending a national public university (n = 1346). Descriptive, bivariable, and multilevel logistic regression analyses were performed.

RESULTS

In the final model, on-premises alcohol outlet density-but not off-premises outlet density, overcrowding or crime-was associated with past-year and lifetime alcohol-related injury (median odds ratio=1.16). At the individual level, quantity (odds ratio (OR)=1.05, 95% CI=(1.01, 1.10)) and frequency (OR=1.66, 95% CI=(1.41,1.97)) of alcohol consumption and age (OR=0.81, 95% CI=(0.74, 0.88)) were associated with past-year and lifetime alcohol-related injury.

CONCLUSIONS

This study contributes to an area with a paucity of information from non-high-income countries, finding differences with previous literature.

Discrepancies in Local, State, and National Alcohol Outlet Listings: Implications for Research and Interventions

BACKGROUND

The availability of local, state, and national data on alcohol outlet density have important implications for policies and interventions aiming to reduce alcohol-related problems. High-quality data on locations of alcohol outlets is important to accurately inform community interventions and public health initiatives, but such data is often not maintained, readily available, or of sufficient quality. Objectives: This study aims to examine the discrepancies between alcohol outlet databases and how neighborhood characteristics (i.e. income, majority racial population, urbanicity) are associated with the discrepancies between databases. Methods: Data was collected from national (n = 1), local (n = 2), and state databases (n = 3). Negative binomial regression models were used to assess discrepancies in alcohol outlet count at the ZIP code level based on the data source. Results: The average density of alcohol outlets (per 1000 residents) ranged from 0.71 to 2.17 in Maryland, 1.65 to 5.17 in Wisconsin, and 1.09 to 1.22 in Oregon based on different sources of data. Findings suggest high income areas (>200% poverty level) have fewer discrepancies (IR = 0.775, p < 0.01), low income areas (below poverty level) have greater discrepancies (IR = 4.990, p < 0.01), and urban areas tend to have fewer discrepancies (IR = 0.378, p < 0.01) between datasets. Conclusion: Interventions and policies depend on valid and reliable data; researchers, policymakers, and local agencies need to collaborate to develop methods to maintain accurate and accessible data.

Looking Back and Moving Forward: The Evolution and Potential Opportunities for the Future of Alcohol Outlet Density Measurement

The literature consistently finds that areas with greater density of alcohol outlets (places that sell alcohol) tend to have higher levels of public health harms. However, conflicting findings arise when researchers drill down to identify the type(s) of alcohol outlets with the strongest associations with harms and the mechanisms that explain these associations. These disagreements could be a result of the outdated methods commonly used to quantify the alcohol environment: counts of the number of outlets in an area. This manuscript reviews the events and ideas that shaped the literature on the physical alcohol environment. It then defines the three main methods used to measure alcohol outlet density, conducts an exploratory factor analysis to explore the constructs underlying each method, and presents a novel conceptual framework that summarizes the three methods, their respective underlying constructs, and the setting(s) in which each may be most appropriate. The framework proposes that counts of alcohol outlets measure availability, proximity to the nearest outlet measures accessibility, and spatial access measures measure access, which comprises both availability and accessibility. We argue that researchers should consider using proximity and spatial access measures when possible and outline how doing so may present opportunities to advance theory and the design and implementation of alcohol outlet zoning regulations. Finally, this manuscript draws on research from other areas of the built environment to suggest opportunities to use novel methods to overcome common hurdles (e.g., separating subtypes of outlets, ecologic designs) and a new challenge on the horizon: home delivery.

Increase in the incidence of alcoholic pancreatitis and alcoholic liver disease in Iceland: impact of per capita alcohol consumption

Objective: To analyze the incidence of acute alcoholic pancreatitis and of severe alcoholic liver disease (ALD) and its association with per capita alcohol consumption with identification of both alcoholic cirrhosis (AC) and severe alcoholic hepatitis (AH), in a population-based setting.Methods: A search was undertaken in diagnoses database for diagnostic codes in order to find patients hospitalized with incident acute alcoholic pancreatitis (AP) and alcoholic liver disease in Iceland in 2001-2015. Diagnoses were verified in all patients who were retrospectively reviewed. Those with ALD had either AC or AH. Alcohol sales during the study period were obtained from Statistics Iceland.Results: Overall, 273 patients with acute AP, mean age at diagnosis 50 (14) years, 74% males and 159 patients with ALD, mean age 57 (11) years, 73% males, were identified. Mean per capita alcohol consumption was 6.95 (0.4) liters and increased by 21% over the study period. The annual incidence of AP increased from 4.2 per 100.000 to 9.5 and ALD from 1.6 to 6.1 per 100.000. Trend analysis showed a significant annual increase of 7% (RR 1.07, 95%CI 1.04-1.10) for AP and an annual increase of 10.5% (RR 1.10, 95%CI 1.06-1.15) for ALD. The increase was only significant in males.Conclusions: Increase per capita alcohol consumption over a 15 year study period was associated with an increase in the incidence of severe alcoholic liver disease and alcohol-related acute pancreatitis in males but not in females.

Accessibility of 'essential' alcohol in the time of COVID-19: Casting light on the blind spots of licensing?

Among the Australian and UK governments' responses to the COVID-19 pandemic has been the designation of outlets selling alcohol for off-premise consumption as 'essential' services, allowing them to remain open while pubs, hotels and restaurants have been forced to close. In a context of restrictions on movement outside the home in both countries, and where alcohol providers are trying to find new ways to reach their customers, this may lead to an intensification of the social and health harms associated with home drinking. By examining the current situation in both Australia and the UK, we argue that heightened risks from home drinking amid COVID-19 bring into sharp focus long-standing weaknesses within licensing systems in both countries: the regulation of off-premise outlets to minimise harms from drinking at home. We call for critical conversations on how licensing systems should be revised to take more responsibility for protecting people from the health and social harms associated with home drinking, both under COVID-19 and in the future.

Neighborhood Alcohol Environment: Differential Effects on Hazardous Drinking and Mental Health by Sex in Persons Living with HIV (PLWH)

Despite greater mental health co-morbidities and heavier alcohol use among PLWH, few studies have examined the role of the neighborhood alcohol environment on either alcohol consumption or mental health. Utilizing cross-sectional data from a cohort study in a southern U.S. metropolitan area, we examine the association between neighborhood alcohol environments on hazardous drinking and mental health among 358 in-care PLWH (84% African American, 31% female). Multilevel models were utilized to quantify associations between neighborhood alcohol exposure on hazardous drinking and effect modification by sex. Neighborhood alcohol density was associated with hazardous drinking among men but not women. Women living in alcohol dense neighborhoods were nearly two-fold likely to report depression compared to those in less dense neighborhoods, with no association between neighborhood alcohol density and depression among men. Neighborhood alcohol environments may be an important contextual factor to consider in reducing heavy alcohol consumption and improving mental health among PLWH.

The acceptability of alcohol intoxication management services to users: A mixed methods study

Introduction and Aims

Alcohol Intoxication Management Services (AIMS) provide basic care for intoxication and minor injuries, have been increasingly implemented in urban areas characterised by a large number of premises licensed for the sale and on‐site consumption of alcohol, with the goal of reducing alcohol's burden on emergency services, including referrals into hospital emergency departments. The acceptability of new health services to users is a key effectiveness outcome. The aim was to describe patient experiences when attending an AIMS and document the acceptability of AIMS to users.

Design and Methods

A sequential mixed methods study was undertaken involving semi‐structured interviews with participants from four AIMS followed by a survey of users recruited from six AIMS.

Results

Interviewees (N = 19) were positive about the care they received in AIMS and appreciated the friendly, non‐judgemental atmosphere. Survey respondents rated their experience in AIMS positively (on a 0 to 10 Likert scale, mean = 9.34, SD = 1.38, n = 188). Frequently given reasons for attendance included drinking alcohol (57%) and minor injury (42%); 24% said they would have attended the emergency department had the AIMS not been available and 6% said they would have preferred to go to the emergency department; 31% indicated they would have felt unsafe without the AIMS.

Discussion and Conclusions

AIMS are acceptable to users. AIMS are likely to address previously unmet demand for a safe space within the night‐time environment.

Identifying opportunities for engaging the 'community' in local alcohol decision-making: A literature review and synthesis

INTRODUCTION

Engaging communities in actions to reduce alcohol harms has been identified as an international priority. While there exist recommendations for community engagement within alcohol licensing legislation, there is limited understanding of how to involve communities in local decision-making to reduce harms from the alcohol environment.

METHODS

A scoping literature review was conducted on community engagement in local government decision-making with relevance to the alcohol environment. Academic and grey literature databases were searched between April and June 2018 to identify examples of community engagement in local government in the UK, published since 2000. Texts were excluded if they did not describe in detail the mechanisms or rationale for community engagement. Information was extracted and synthesised through a narrative approach.

RESULTS

3030 texts were identified through the searches, and 30 texts were included in the final review. Only one text described community engagement in alcohol decision-making (licensing); other local government sectors included planning, regeneration and community safety. Four rationales for community engagement emerged: statutory consultation processes; non-statutory engagement; as part of broader participatory initiatives; and community-led activism. While not all texts reported outcomes, a few described direct community influence on decisions. Broader outcomes included improved relationships between community groups and local government. However, lack of influence over decisions was also common, with multiple barriers to effective engagement identified.

CONCLUSION

The lack of published examples of community engagement in local alcohol decision-making relevant to the UK suggests little priority has been placed on sharing learning about supporting engagement in this area. Taking a place-shaping perspective, useful lessons can be drawn from other areas of local government with relevance for the alcohol environment. Barriers to engagement must be considered carefully, particularly around how communities are defined, and how different interests toward the local alcohol environment are represented, or not.

Associations Between Alcohol Policies and Adolescent Alcohol Use: A Pooled Analysis of GSHS and ESPAD Data

Aims

Alcohol-attributable harm remains high worldwide, and alcohol use among adolescents is particularly concerning. The purpose of this study is to determine the effect of national alcohol control policies on adolescent alcohol use in low-, middle- and high-income countries and improve on previous cross-national attempts to estimate the impact of alcohol policy on this population.

Methods

Data on adolescent (n = 277,110) alcohol consumption from 84 countries were pooled from the Global School-based Health Survey and the European School Survey Project on Alcohol and Other Drugs. Alcohol use measures included lifetime alcohol use, current (past 30 days) alcohol use and current (past 30 days) binge drinking. Information on national alcohol control policies was obtained from the World Health Organization’s Global Information System on Alcohol and Health and scored for effectiveness. Main effects were estimated using two-level, random intercept hierarchical linear models, and the models were adjusted for sex and age of the participants, and pattern of drinking score, gross domestic product based on purchasing power parity and study at the country level.

Results

Availability (OR [95% CI] = 0.991 [0.983, 0.999]), marketing (OR [95% CI] = 0.994 [0.988, 1.000]) and pricing (OR [95% CI] = 0.955 [0.918, 0.993]) policies were inversely associated with lifetime drinking status. Pricing policies were also inversely associated with current binge drinking status among current drinkers (OR [95% CI] = 0.939 [0.894, 0.986]). There were no associations between the included alcohol policies and current drinking status.

Conclusions

Strong availability, marketing and pricing policies can significantly and practically impact adolescent alcohol consumption.

Open data on health-related neighbourhood features in Great Britain

Our study details the creation of a series of national open source low-level geographical measures of accessibility to health-related features for Great Britain. We create 14 measures across three domains: retail environment (fast food outlets, gambling outlets, pubs/bars/nightclubs, off-licences, tobacconists), health services (General Practitioners, pharmacies, dentists, hospitals, leisure centres) and the physical environment (green space and air quality). Using the network analysis process of Routino, postcode accessibility (km) to each of these features were calculated for the whole of Great Britain. An average score for each domain was calculated and subsequently combined to form an overall Index highlighting 'Access to Healthy Assets and Hazards'. We find the most accessible healthy areas are concentrated in the periphery of the urban cores, whilst the least accessible healthy areas are located in the urban cores and the rural areas. The open data resource is important for researchers and policy makers alike with an interest in measuring the role of spatial features on health.

Alcohol's harms to others in Wales, United Kingdom: Nature, magnitude and associations with mental well-being

Aim

To explore the nature and magnitude of alcohol's harms to others (AHTOs), and associations with mental well-being.

Methods

Cross-sectional survey implemented amongst 891 randomly selected Welsh residents (aged 18+ years), via computer assisted telephone interviews. Questions established past 12-month experience of nine direct harms resulting from another person's alcohol consumption (e.g. violence) and five linked outcomes (e.g. concern for a child). The source (e.g. partner/stranger) and frequency of the AHTO were collected, and respondents' socio-demographics, drinking behaviours and mental well-being status.

Results

During the past 12 months, 43.5% of respondents had experienced at least one direct harm (45.5% at least one direct harm/linked outcome). In demographically adjusted analyses, the odds of experiencing any direct harm decreased sequentially as age group increased (Adjusted Odds Ratio [AORs]: 1.9 [age 65–74 years] - 4.2 [age 18–34 years]), and was higher amongst binge drinkers (AOR, 1.5, p < 0.05). Associations between age group and suffering the direct harms anxiety, disrupted sleep, feeling threatened, property damage and emotional neglect were found. Experience of feeling threatened was lower amongst females (AOR 0.6, p < 0.05). In demographically adjusted analyses, low mental well-being was higher amongst those who had suffered alcohol-related financial issues (AOR 2.2, p < 0.001), emotional neglect (AOR 2.3, p < 0.01) and property damage (AOR 2.2, p < 0.05).

Conclusion

AHTOs place a large, although unequal burden on adults in Wales. Individuals' drinking patterns are associated with experience of AHTOs. Critically, experience of some harms is associated with low mental well-being.

•

The harms from alcohol extend from the drinker to those around them (i.e. alcohol's harms to others [AHTOs]).

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AHTOs place a large, although unequal burden on the Welsh adult population, with young people and binge drinkers most at-risk.

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Experience of some AHTOs is associated with low mental well-being.

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AHTOs should be a consideration in the development, targeting and evaluation of alcohol policy and prevention activity.

Methods for Evaluating the Association Between Alcohol Outlet Density and Violent Crime

BACKGROUND

The objective of this analysis was to compare measurement methods-counts, proximity, mean distance, and spatial access-of calculating alcohol outlet density and violent crime using data from Baltimore, Maryland.

METHODS

Violent crime data (n = 11,815) were obtained from the Baltimore City Police Department and included homicides, aggravated assaults, rapes, and robberies in 2016. We calculated alcohol outlet density and violent crime at the census block (CB) level (n = 13,016). We then weighted these CB-level measures to the census tract level (n = 197) and conducted a series of regressions. Negative binomial regression was used for count outcomes and linear regression for proximity and spatial access outcomes. Choropleth maps, partial R² , Akaike's Information Criterion, and root mean squared error guided determination of which models yielded lower error and better fit.

RESULTS

The inference depended on the measurement methods used. Eight models that used a count of alcohol outlets and/or violent crimes failed to detect an association between outlets and crime, and 3 other count-based models detected an association in the opposite direction. Proximity, mean distance, and spatial access methods consistently detected an association between outlets and crime and produced comparable model fits.

CONCLUSIONS

Proximity, mean distance, and spatial access methods yielded the best model fits and had the lowest levels of error in this urban setting. Spatial access methods may offer conceptual strengths over proximity and mean distance. Conflicting findings in the field may be in part due to error in the way that researchers measure alcohol outlet density.

'A true partner around the table?' Perceptions of how to strengthen public health's contributions to the alcohol licensing process

INTRODUCTION

There are increased opportunities for public health practitioners (PHPs) in England to shape alcohol availability and reduce harms through a statutory role in licensing processes in local government. However, how public health can effectively influence alcohol licence decision-making is little understood.

METHODS

A mixed methods study was conducted to identify challenges faced by PHPs and mechanisms to strengthen their role. This involved a survey of practitioners across London local authorities (n = 18) and four focus group discussions with a range of licensing stakeholders (n = 36).

RESULTS

Survey results indicated a varied picture of workload, capacity to respond to licence applications and levels of influence over decision-making among PHPs in London. Practitioners described a felt lack of status within the licence process, and difficulties using and communicating public health evidence effectively, without a health licensing objective. Strategies considered supportive included engaging with other responsible authorities and developing understanding and relationships over time.

CONCLUSIONS

Against political and resource constraints at local and national government levels, pragmatic approaches for strengthening public health influence over alcohol licensing are required, including promoting relationships between stakeholders and offering opportunities for PHPs to share best practice about making effective contributions to licensing.

Assessing the impact of alcohol taxation on rates of violent victimization in a large urban area: an agent-based modeling approach

AIMS

To use simulation to estimate the impact of alcohol taxation on drinking, non-fatal violent victimization and homicide in New York City (NYC). We simulate the heterogeneous effects of alcohol price elasticities by income, level of consumption and beverage preferences, and examine whether taxation can reduce income inequalities in alcohol-related violence.

DESIGN

Agent-based modeling simulation.

SETTING

NYC, USA.

PARTICIPANTS

Adult population aged 18-64 years in the year 2000 in the 59 community districts of NYC. The population of 256 500 agents approximates a 5% sample of the NYC population.

MEASUREMENTS

Agents were parameterized through a series of rules that governed alcohol consumption and engagement in violence. Six taxation interventions were implemented based on extensive reviews and meta-analyses, increasing universal alcohol tax by 1, 5 and 10%, and beer tax by 1, 5 and 10%.

FINDINGS

Under no tax increase, approximately 12.2% [95% credible interval (prediction interval, PI) = 12.1-12.3%] were heavy drinkers. Taxation decreased the proportion of heavy drinkers; a 10% tax decreased heavy drinking to 9.6% (95% PI = 9.4-9.8). Beer taxes had the strongest effect on population consumption. Taxation influenced those in the lowest income groups more than the highest income groups. Alcohol-related homicide decreased from 3.22 per 100 000 (95% PI = 2.50-3.73) to 2.40 per 100 000 under a 10% universal tax (95% PI = 1.92-2.94). This translates into an anticipated benefit of ~1200 lives/year.

CONCLUSION

Reductions in alcohol consumption in a large urban environment such as New York City can be sustained with modest increases in universal taxation. Alcohol tax increases also have a modest effect on alcohol-related violent victimization. Taxation policies reduce income inequalities in alcohol-related violence.

Understanding the relationship between alcohol outlet density and life expectancy in Baltimore City: The role of community violence and community disadvantage

This research investigated the relationship between alcohol outlet density (AOD) and life expectancy, as mediated by community violence and community disadvantage. We used linear regression models to assess bivariate and multivariate relationships. There was a negative bivariate association between liquor store density and average life expectancy (β = -7.3370, p < 0.001). This relationship was partially attenuated when controlling for community disadvantage and fully attenuated when controlling for community violence. Bars/taverns (i.e., on-premise) were not associated with average life expectancy (β = -0.589, p = 0.220). Liquor store density is associated with higher levels of community disadvantage and higher rates of violence, both of which are associated with lower life expectancies. Future research, potential intervention, and current related policies are discussed.

Evaluation of a local government "shelter and van" intervention to improve safety and reduce alcohol-related harm

Background

The entertainment precincts of cities, while contributing to local economies, need to be carefully managed to mitigate harms. Individual behaviours and government regulation have typically been the foci of interventions aimed at reducing alcohol-related harm. Little is known about how changes to the built environment might influence alcohol-related harms in these settings. The aim of this study was to explore how a public shelter and a volunteer-funded and staffed mobile van in a regional city influenced perceptions of safety and reduction in alcohol-related harm.

Methods

An intrinsic case-study approach was used. Document reviews, qualitative interviews with 16 key informants (volunteers, licensees, police, local business owners, patrons, community members and security guards), observation, and secondary data analysis were conducted in 2016. A conceptual framework of the causative pathways linking the drivers of alcohol consumption with social and health outcomes was used to inform the analysis.

Results

The shelter and van were frequently utilised but there was no significant association with a reduction in the proportion of alcohol-related hospital emergency department presentations or police incident reports. Occupational health and safety risks were identified for the volunteers which had no management plan.

Conclusions

The findings highlight the challenge faced by local governments/authorities wanting to provide community-based interventions to complement other evidence-based approaches to reduce alcohol-related harm. Local governments/authorities with restricted regulatory oversight need to collaborate with key agencies for targeted upstream and evidence-based alcohol prevention and management interventions before investing resources. Such approaches are critical for improving community safety as well as health and social outcomes in communities at greatest risk of alcohol-related harm.

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.

Outlet Type, Access to Alcohol, and Violent Crime

BACKGROUND

While there are overwhelming data supporting the association between alcohol outlet density and violent crime, there remain conflicting findings about whether on- or off-premise outlets have a stronger association. This inconsistency may be in part a result of the methods used to calculate alcohol outlet density and violent crime. This analysis uses routine activity theory and spatial access methods to study the association between access to alcohol outlets and violent crime, including type of outlet and type of crime in Baltimore, MD.

METHODS

The data in this analysis include alcohol outlets from 2016 (n = 1,204), violent crimes from 2012 to 2016 (n = 51,006), and markers of social disorganization, including owner-occupied housing, median annual household income, drug arrests, and population density. The analysis used linear regression to determine the association between access to alcohol outlets and violent crime exposure.

RESULTS

Each 10% increase in alcohol outlet access was associated with a 4.2% increase in violent crime exposure (β = 0.43, 95% CI 0.33, 0.52, p < 0.001). A 10% increase in access to off-premise outlets (4.4%, β = 0.45, 95% CI 0.33, 0.57, p < 0.001) and LBD-7 outlets (combined off- and on-premise outlets; 4.2%, β = 0.43, 95% CI 0.33, 0.52, p < 0.001) had a greater association with violent crime than on-premise outlets (3.0%, β = 0.31, 95% CI 0.20, 0.41, p < 0.001).

CONCLUSIONS

Access to outlets that allow for off-site consumption had a greater association with violent crime than outlets that only permit on-site consumption. The lack of effective measures to keep order in and around off-premise outlets could attract or multiply violent crime.

Intergenerational Continuity in Adverse Childhood Experiences and Rural Community Environments

OBJECTIVES

To understand the role of the community environment on intergenerational continuity in adverse childhood experiences (ACEs) among a rural White sample.

METHODS

Parents in 12 counties in rural Iowa reported retrospectively on their own ACEs in 1989. We measured their child's ACEs retrospectively and prospectively across adolescence (n = 451 families). We measured structural and social process-related measures of community environment (i.e., community socioeconomic status, parents' perception of community services, perceived community social cohesion, and neighborhood alcohol vendor density) on multiple occasions during the child's adolescence.

RESULTS

The 4 measures of community environment were all correlated with the child's ACEs, but only alcohol vendor density predicted ACEs after inclusion of covariates. Intergenerational continuity in ACEs was moderated by both social cohesion (b = -0.11; SE = 0.04) and alcohol vendor density (b = -0.11; SE = 0.05).

CONCLUSIONS

Efforts to increase community social cohesion and manage alcohol vendor density may assist families in breaking the cycle of maltreatment across generations.

Associations between proposed local government liquor store size classifications and alcohol consumption in young adults

The prevalence of warehouse-style liquor stores has prompted alarm from local communities and public health advocates. To increase local government control over liquor stores, one proposed planning response is to distinguish between 'small' (i.e., ≤ 300 m²) and 'large' (i.e., > 300 m²) liquor stores. We mapped the size and location of liquor stores in Perth, Western Australia, and tested associations between liquor store exposure and alcohol consumption (grams ethanol/day) in young adults (n = 990). The count of liquor stores of any size within 1600 m and 1601-5000 m of home were significantly associated with increased alcohol intake, whereas larger stores (i.e., > 300 m² and > 600 m²) were not associated with alcohol intake. Young adults' alcohol consumption appears to be impacted by liquor store density and convenience, rather than outlet size. However, the presence of multiple stores close to home increases market competition, driving alcohol prices down, and plausibly results in alcohol prices similar to those at liquor superstores.

Alcohol Availability and Onset and Recurrence of Alcohol Use Disorder: Examination in a Longitudinal Cohort with Cosibling Analysis

BACKGROUND

Recent reviews of associations of alcohol availability with alcohol outcomes suggest findings are highly inconsistent and highlight a lack of longitudinal and causal evidence. Effect modification (moderation or statistical interaction), which could contribute to the inconsistent picture in the existing literature, has not been systematically assessed. We examined associations of alcohol availability with onset and recurrence of alcohol use disorder (AUD) using multilevel, longitudinal population data from Sweden and tested hypothesized effect modifiers to identify groups for whom increased alcohol availability may be particularly risky. We also employed cosibling models to assess potential causality for AUD onset by accounting for genetic and shared-environment confounders.

METHODS

Data come from all individuals born in Sweden between 1950 and 1975 who were registered in a residential neighborhood at the end of 2005 (N = 2,633,922). We used Cox proportional hazards models to investigate time to AUD onset and logistic regression to assess the odds of AUD recurrence over an 8-year period.

RESULTS

Living in a neighborhood with at least 1 alcohol outlet of any type was associated with a small increase in the likelihood of developing AUD, with an adjusted hazard ratio (HR) of 1.16 (95% CI: 1.13 to 1.19). Among people with a prior AUD registration, alcohol availability was not significantly associated with recurrence of AUD, with an adjusted odds ratio of 1.02 (95% CI: 1.00 to 1.05). Associations of alcohol availability with AUD onset varied according to sex, age, education, neighborhood deprivation, and urbanicity. HRs from the sibling models were similar to those in the general population models, with an adjusted HR = 1.19 (95% CI: 1.15 to 1.24).

CONCLUSIONS

Effects varied among neighborhood residents, but greater alcohol availability was a risk factor for AUD onset (but not relapse) in all groups examined except women. Cosibling models suggest there may be a causal relationship of greater alcohol availability with adult-onset AUD.

Neighborhood conditions and trajectories of alcohol use and misuse across the early life course

While neighborhood conditions have been linked to alcohol misuse, less is known about the long-term consequences of exposure to adverse neighborhood conditions early in the life course. Using data from the National Longitudinal Survey of Adolescent to Adult Health, we examined how trajectories of alcohol behaviors from ages 12 to 32 varied according to neighborhood disorder, disadvantage, and advantage. Early exposure to adverse neighborhood conditions placed individuals at greater risk of being a current drinker and alcohol misuse, though these individuals never reached the same levels as those in more stable, advantaged neighborhoods. Early exposure appears to place individuals at risk for alcohol misuse across the early life course.

Addiction research centres and the nurturing of creativity: The Centre for Alcohol Policy Research (CAPR), Melbourne: a decade on

Established in 2006, the Centre for Alcohol Policy Research (CAPR) is Australia's only research centre with a primary focus on alcohol policy. CAPR has four main areas of research: alcohol policy impacts; alcohol policy formation and regulatory processes involved in implementing alcohol policies; patterns and trends in drinking and alcohol problems in the population; and the influence of drinking norms, cultural practices and social contexts, particularly in interaction with alcohol policies. In this paper, we give examples of key publications in each area. During the past decade, the number of staff employed at CAPR has increased steadily and now hovers at approximately 10. CAPR has supported the development of independent researchers who collaborate on a number of international projects, such as the Alcohol's Harm to Others study which is now replicated in approximately 30 countries. CAPR receives core funding from the Foundation for Alcohol Research and Education, and staff have been highly successful in securing additional competitive research funding. In 2016, CAPR moved to a new institutional setting at La Trobe University and celebrated 10 years of operation.

Judicial intervention in alcohol regulation: an empirical legal analysis

OBJECTIVE

While governments draft law and policy to promote public health, it is through cases put before the judiciary that the implementation of law can be challenged and where its practical implications are typically determined. In this paper, we examine the role of court judgements on efforts in Australia to regulate the harmful use of alcohol.

METHODS

Australian case law (2010 to June 2015) involving the judicial review of administrative decisions relating to development applications or liquor licences for retail liquor outlets (bottle shops), hotels, pubs and clubs was identified using a case law database (WestLaw AU). Data were extracted and analysed using standard systematic review techniques.

RESULTS

A total of 44 cases were included in the analysis. Of these, 90% involved appeals brought by industry actors against local or state government stakeholders seeking to reject applications for development applications and liquor licences. The proportion of judicial decisions resulting in outcomes in favour of industry was 77%.

CONCLUSIONS

Public health research evidence appeared to have little or no influence, as there is no requirement for legislation to consider public health benefit. Implications for public health: A requirement that the impact on public health is considered in legislation will help to offset its strong pro-competition emphasis, which in turn has strongly influenced judicial decision making in this area.

Does alcohol outlet density differ by area-level disadvantage in metropolitan Perth?

INTRODUCTION AND AIMS

Research suggests that there are area-level disparities in alcohol outlets, with greater density in disadvantaged areas. In part, this might be explained by the inequitable distribution of retail, attracted by lower rents to disadvantaged neighbourhoods. This ecological study examines the distribution of liquor licences in Perth, Australia, and whether discrepancies in the distribution of retail land-uses could account for a socio-economic gradient.

DESIGN AND METHODS

Area disadvantage was determined for each Statistical Area 1 (SA1) using the Australian Bureau of Statistics Index of Relative Socio-economic Disadvantage, and licence locations were mapped in GIS. Negative binomial loglinear models examined whether licence densities within SA1s differed by area disadvantage, controlling for demographics and spatial correlation. Models included an offset term, so the estimated effects of area-level disadvantage were on licences per km² , or licences per retail destination.

RESULTS

In the area-based analyses, for every unit increase in disadvantage decile (i.e. a reduction in relative disadvantage), general licences reduced by 15% (P = 0.000) and liquor stores reduced by 7% (P = 0.004). These gradients were not apparent when licences were examined as a function of retail; however, for every unit increase in disadvantage decile, the density of on-premise licences per retail destination increased by 14% (P = 0.000).

DISCUSSION AND CONCLUSIONS

The direction of the socio-economic gradient for general licences and liquor stores in Perth is concerning, as all licences selling packaged alcohol were more abundant in disadvantaged areas. However, the over-representation of packaged liquor in disadvantaged areas may relate to the increased provision of retail.

Liquor landscapes: Does access to alcohol outlets influence alcohol consumption in young adults?

Few longitudinal studies have examined the impact of liquor licences on alcohol consumption, and none in young adults, the life stage when alcohol intake is at its highest. We examined associations between liquor licences (i.e., general licences, on-premise licences, liquor stores, and club licences) and alcohol consumption at 20-years (n=988) and 22-years (n=893), and whether changes in the licences between time-points influenced alcohol consumption (n=665). Only general licences were associated with alcohol consumption at 20-years (p=0.037), but by 22-years, all licences types were positively associated with alcohol consumption (p<0.05). Longitudinal analyses showed that for each increase in liquor stores over time, alcohol consumption increased by 1.22g/day or 8% (p=0.030), and for each additional club licence, consumption increased by 0.90g/day or 6% (p=0.007). Limiting liquor licences could contribute to a reduction in young adults' alcohol intake.

Association Between Neighborhood Violence and Biological Stress in Children

Importance

Exposure to violence continues to be a growing epidemic, particularly among children. An enhanced understanding of the biological effect of exposure to violence is critical.

Objective

To examine the association between neighborhood violence and cellular and biological stress in children.

Design, Setting, and Participants

A matched, cross-sectional study of 85 black children aged 5 to 16 years from 52 neighborhoods took place in the greater New Orleans, Louisiana, area between January 1, 2012, and July 31, 2013.

Exposures

Density of businesses where individuals can purchase alcohol as measured by rates per capita of liquor or convenience stores, and violence as measured by reports of violent crime and reports of domestic violence, operationalized as reports per capita of crime and domestic violence. Rates of exposure within a 500-, 1000-, and 2000-m radius from the child's home were calculated.

Main Outcomes and Measures

Primary biological outcomes were telomere length and cortisol functioning.

Results

Among the 85 children in the study, (mean [SD] age, 9.8 [3.1] years; 50 girls and 35 boys) significant variation in telomere length and cortisol functioning was observed at the neighborhood level, with intraclass correlation coefficients of 6% for telomere length, 3.4% for waking cortisol levels, and 5.5% for peak cortisol levels following a stressor. Density of liquor or convenience stores within a 500-m radius of a child's home was associated with a decrease in mean telomere length by 0.004 for each additional liquor store or convenience store (β [SE], -0.004 [0.002]; P = .02). The rate of domestic violence was significantly and inversely associated with a decrease in mean telomere length by 0.007 for each additional report of domestic violence in a 500-m radius of a child's home (β [SE], -0.007 [0.001]; P < .001). The rate of violent crime was significantly associated with a decrease in mean telomere length by 0.006 for each additional report of violent crime in a 500-m radius of a child's home (β [SE], -0.006 [0.002]; P < .001). Children exposed to more liquor and convenience stores within 500 m of their home were significantly less likely to reduce cortisol levels after a reactivity test (β, 0.029; P = .047), as were children exposed to high rates of domestic violence (β, 0.088; P = .12) and violent crime (β, 0.029; P = .006). Children exposed to more liquor and convenience stores within 500 m of their home had a steeper diurnal decline in cortisol levels during the day (β [SE], -0.002 [0.001]; P = .04), as did children exposed to more violent crime within 500 m of their home (β [SE] -0.032 [0.014]; P = .02).

Conclusions and Relevance

Neighborhoods are important targets for interventions to reduce the effect of exposure to violence in the lives of children. These findings provide the first evidence that objective exposures to neighborhood-level violence influence both physiological and cellular markers of stress, even in children.

Investigation of the Association Between Alcohol Outlet Density and Alcohol-Related Hospital Admission Rates in England: Study Protocol

Background

Availability of alcohol is a major policy issue for governments, and one of the availability factors is the density of alcohol outlets within geographic areas.

Objective

The aim of this study is to investigate the association between alcohol outlet density and hospital admissions for alcohol-related conditions in a national (English) small area level ecological study.

Methods

This project will employ ecological correlation and cross-sectional time series study designs to examine spatial and temporal relationships between alcohol outlet density and hospital admissions. Census units to be used in the analysis will include all Lower and Middle Super-Output Areas (LSOAs and MSOAs) in England (53 million total population; 32,482 LSOAs and 6781 MSOAs). LSOAs (approximately 1500 people per LSOA) will support investigation at a fine spatial resolution. Spatio-temporal associations will be investigated using MSOAs (approximately 7500 people per MSOA). The project will use comprehensive coverage data on alcohol outlets in England (from 2003, 2007, 2010, and 2013) from a commercial source, which has estimated that the database includes 98% of all alcohol outlets in England. Alcohol outlets may be classified into two broad groups: on-trade outlets, comprising outlets from which alcohol can be purchased and consumed on the premises (eg, pubs); and off-trade outlets, in which alcohol can be purchased but not consumed on the premises (eg, off-licenses). In the 2010 dataset, there are 132,989 on-trade and 51,975 off-trade outlets. The longitudinal data series will allow us to examine associations between changes in outlet density and changes in hospital admission rates. The project will use anonymized data on alcohol-related hospital admissions in England from 2003 to 2013 and investigate associations with acute (eg, admissions for injuries) and chronic (eg, admissions for alcoholic liver disease) harms. The investigation will include the examination of conditions that are wholly and partially attributable to alcohol, using internationally standardized alcohol-attributable fractions.

Results

The project is currently in progress. Results are expected in 2017.

Conclusions

The results of this study will provide a national evidence base to inform policy decisions regarding the licensing of alcohol sales outlets.

Differential Effects of Neighborhood Type on Adolescent Alcohol Use in New Zealand

Identifying neighborhood typologies associated with adolescent alcohol use can inform the development of harm reduction strategies. Utilizing data from a nationally representative youth survey (n = 4267) in New Zealand, latent class analysis was used to categorize neighborhood types (defined by 10 demographic, social and environmental indicators) to investigate their association with alcohol consumption and related harm. Three neighborhood types were distinguished: (1) "high outlet density and economic deprivation" (30 % of all neighborhoods); (2) "high deprivation, social disorganization, and unsafe" (38 %); and (3) "higher income, safe, and socially organized" (32 %). Significant ethnic variation was evident between neighborhood types. There was an age-group interaction in the main effects with significant associations between neighborhood type and drinking measures and harm most apparent among younger adolescents (<16 years), as described next. Compared to students residing in "higher income, safe, and socially organized" neighborhoods, the frequency of binge drinking and high typical consumption was significantly higher in students residing in "high outlet density and economic deprivation" and "high deprivation, social disorganization, and unsafe", with students residing in "high outlet density and economic deprivation" also experiencing higher levels of alcohol-related harm. The findings that neighborhoods characterized by high deprivation and alcohol outlet density and low social organization and perceptions of safety were associated with risky drinking patterns and harm, specifically among young adolescents, underscores the importance of adopting a developmental approach to the study of contextual effects on adolescents.

Psychological Distress and Problem Drinking

We examine the influence of harmful alcohol use on mental health using a flexible two-step instrumental variables approach and household survey data from nine countries of the former Soviet Union. Using alcohol advertisements to instrument for alcohol, we show that problem drinking has a large detrimental effect on psychological distress, with problem drinkers exhibiting a 42% increase in the number of mental health problems reported and a 15% higher chance of reporting very poor mental health. Ignoring endogeneity leads to an underestimation of the damaging effect of excessive drinking. Findings suggest that more effective alcohol policies and treatment services in the former Soviet Union may have added benefits in terms of reducing poor mental health.

Exploring Alcohol Policy Approaches to Prevent Sexual Violence Perpetration

Sexual violence continues to be a significant public health problem worldwide with serious consequences for individuals and communities. The implementation of prevention strategies that address risk and protective factors for sexual violence at the community level are important components of a comprehensive approach, but few such strategies have been identified or evaluated. The current review explores one potential opportunity for preventing sexual violence perpetration at the community level: alcohol policy. Alcohol policy has the potential to impact sexual violence perpetration through the direct effects of excessive alcohol consumption on behavior or through the impact of alcohol and alcohol outlets on social organization within communities. Policies affecting alcohol pricing, sale time, outlet density, drinking environment, marketing, and college environment are reviewed to identify existing evidence of impact on rates of sexual violence or related outcomes, including risk factors and related health behaviors. Several policy areas with initial evidence of an association with sexual violence outcomes were identified, including policies affecting alcohol pricing, alcohol outlet density, barroom management, sexist content in alcohol marketing, and policies banning alcohol on campus and in substance-free dorms. We identify other policy areas with evidence of an impact on related outcomes and risk factors that may also hold potential as a preventative approach for sexual violence perpetration. Evidence from the current review suggests that alcohol policy may represent one promising avenue for the prevention of sexual violence perpetration at the community level, but additional research is needed to directly examine effects on sexual violence outcomes.