CRD summary

The review concluded that greater alcohol outlet density was associated with increased alcohol consumption and related harms that included medical harms, crime and violence; reduced alcohol outlet density can be an effective means of controlling excessive alcohol consumption and harms. The review had some methodological problems and data limitations that limited the reliability of the authors’ conclusions.

Authors' objectives

To determine the effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms.

Searching

MEDLINE, EMBASE, EconLit, Sociological Abstracts, PsycINFO and EMB Reviews were searched from inception to November 2006 for studies published in English.

Study selection

Primary studies that evaluated changes in alcohol outlet density (indirectly as a result of policy change or directly) in high-income nations and reported outcome measure of excessive alcohol consumption or alcohol-related harm were eligible for inclusion (definitions of terms were provided in the review). Studies that were not published in a peer-reviewed journal or a government report were excluded.

The included studies examined policy changes, bans, privatisation and alcohol outlets on alcohol consumption and harms. Harms included violence, car crashes, medical harms and crime. Measures of alcohol consumption were mostly from sales data, with some self report. Studies were undertaken between 1952 and 2002. Most studies were conducted in North America and Scandinavia. Where an intervention was effective, studies assessed barriers to implementation, applicability of the intervention to other settings, populations or circumstances and economic costs and benefits of the intervention.

The authors did not state how many reviewers were involved in study selection.

Assessment of study quality

Studies were assessed according to Community Guide standards of nine quality factors that included study design, potential confounders, attrition bias and measurement of outcome. Studies with one or no validity problems were classified as high quality, those with two to four validity problems were classified as fair quality and studies with five or more quality issues were deemed poor quality. Only studies of good or fair quality of execution and any level of design were included in the review.

Quality assessment was independently undertaken by two reviewers. Disagreements were resolved by discussion.

Data extraction

Data were extracted on measures of alcohol consumption, alcohol-related harm, costs, applicability and barriers. Where possible, summary effect measures showing percentage change in outcome per 1% change in an exposure (such as outlet density) were calculated.

The authors did not state how many reviewers were involved in data extraction.

Methods of synthesis

Studies were narratively synthesised and grouped according to outcomes and study type.

Results of the review

Eighty-eight articles and books were included in the review (some were duplicate publications). Primary evidence was from 10 cross-sectional or single-group time series studies: eight of good execution and two of fair execution. Secondary evidence was from 55 cross-sectional studies of unclear quality.

There was a positive association between alcohol outlet density and alcohol consumption (five studies) and harm (five studies); evidence on motor-vehicle crashes and other injuries was mixed. Permissive licensing laws generally increased the number of alcohol outlets and there was an accompanying increase in alcohol consumption and harms. Privatisation appeared to increase the sale of privatised alcohol (17 studies), but had little effect on non-privatised alcohol (five studies). Alcohol bans were generally effective only in isolated communities (12 studies) where people had limited opportunity to purchase alcohol in other areas nearby; when bans were imposed in more densely populated areas, they tended to cause more harm than good due to increased travel between banned and non-banned areas. Licensing policy changes (four studies) that increased outlet density generally increased sales of spirits and alcohol consumption; one study showed an increase in alcohol-related motor vehicle crashes.

Secondary evidence was reported in the review and generally supported the findings from primary studies.

Cost information

No published economic evaluations were found.

Authors' conclusions

Greater alcohol outlet density was associated with increased alcohol consumption and related harms that included medical harms, crime and violence; reduced alcohol outlet density can be an effective means of controlling excessive alcohol consumption and harms.

CRD commentary

Inclusion criteria for the review were broadly defined and several relevant databases were searched. The restriction to published English-language articles meant that there was potential for publication and language biases; publication bias was not formally assessed. The authors attempted to minimise reviewer error and bias during quality assessment; it was unclear whether they made similar efforts during data extraction and study selection. Quality assessment was based on a simple checklist with limited results, which made it difficult to determine the quality of the included studies. Limited study details were provided, which made interpretation of the results problematic; the information provided indicated heterogeneity between studies and some of the studies were quite dated (more than 40 years old). Studies were narratively synthesised, which appeared appropriate for the type of data. Most studies were based on indirect measures. The generalisability of findings to other settings was questionable.

Given the data limitations and methodological problems with the review, the authors’ conclusions need to be interpreted with caution.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that future research needed to examine the effects of decreased alcohol outlet density (instead of the effects of increased density) and examine the effects of baseline density. Research also needed to examine policy changes and the association of on- and off-premise alcohol consumption. Future studies should aim to estimate the economic impact of decreased alcohol outlet density.

Funding

The authors reported that there were no financial disclosures.

Bibliographic details

Campbell CA, Hahn RA, Elder R, Brewer R, Chattopadhyay S, Fielding J, Naimi TS, Toomey T, Lawrence B, Middleton JC, Task Force on Community Preventive Services. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms. American Journal of Preventive Medicine 2009; 37(6): 556-569. [PubMed: 19944925]

Original Paper URL

http://www.ajpm-online.net/article/S0749-3797(09)00604-7/abstract

Indexing Status

Subject indexing assigned by NLM

MeSH

Alcoholic Beverages /supply & distribution; Alcoholic Intoxication /prevention & control; Alcoholism /prevention & control; Commerce /legislation & jurisprudence; Government Regulation; Humans; United States

AccessionNumber

12010001949

Database entry date

16/03/2011

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.