Alcohol Excessive Consumption: Regulation of Alcohol Outlet Density
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends the use of regulatory authority (e.g., through licensing and zoning) to limit alcohol outlet density as a strategy to reduce excessive alcohol consumption and related harms.
The full CPSTF Finding and Rationale Statement and supporting documents for Alcohol Excessive Consumption: Regulation of Alcohol Outlet Density are available in The Community Guide Collection on CDC Stacks.
Intervention
Regulation of alcohol outlet density reduces alcoholic beverage outlet density or limits the increase of alcoholic beverage outlet density. Density refers to the number of alcohol outlets in a given area. Regulation is often implemented through licensing or zoning processes.
An alcohol outlet is a place where alcohol may be legally sold for the buyer to drink there (on-premises outlets, such as bars or restaurants) or elsewhere (off-premises outlets, such as liquor stores).
About The Systematic Review
The CPSTF finding is based on evidence from a systematic review of 39 studies (search period through November 2006). Studies evaluated interventions that led to changes in outlet density (29 studies) or assessed the effects of changes in outlet density when the cause of density change was unknown (10 time-series studies).
The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to preventing excessive alcohol consumption.
Study Characteristics
- Because no studies were found that directly examined the effects of local interventions to limit alcohol outlet density, this review used both primary and secondary scientific evidence.
- Primary evidence included studies comparing alcohol-related outcomes before and after a density-related change:
- Studies assessing the impact of privatizing alcohol sales commonly associated with increases in density (17 studies of 11 events of privatization and one of re-monopolization; conducted in the United States, Canada, and Sweden)
- Studies assessing the impact of bans on alcohol sales associated with decreases in density (7 studies, conducted in non-tribal areas of the United States and Canada and within American Indian and Native settings in Alaska, northern Canada, and the southwestern United States)
- Studies of other alcohol licensing policies that directly affect outlet density (e.g., sale of liquor by the drink; 4 studies conducted in Iceland, Finland, New Zealand, and North Carolina)
- Time series studies (i.e., studies in which the association between changes in outlet density and alcohol-related outcomes was assessed over time) were used to provide primary evidence of intervention effectiveness, even when the cause of the observed change in outlet density was unknown (10 studies conducted in the United States, Canada, the United Kingdom, and Norway).
- Secondary evidence included cross-sectional studies, which did not allow the inference of causality.
Summary of Results
The systematic review included 39 studies. Results from different types of studies consistently showed that alcoholic beverage outlet density and policy changes that affect alcohol outlet density were associated with excessive alcohol consumption and related harms.
No studies were found that directly examined the effects of local interventions to limit alcohol outlet density.
Policy Changes that Increased Alcohol Outlet Density
The systematic review included four studies.
- Policies that increased alcohol outlet density led to increases in excessive alcohol consumption and related harms.
Alcoholic Beverage Retail Privatization
The privatization of retail alcohol sales is the repeal of government control over the retail sales of one or more types of alcoholic beverages, thus allowing commercial retailing of those beverages. Privatization commonly results in increased alcohol outlet density, among other changes.
The systematic review included 17 studies that assessed the effects of privatization in 14 settings and one study of government re-monopolization.
- Privatization was associated with increases in excessive consumption of affected beverages and showed minimal effects on consumption of beverages that were not affected.
- One study indicated that government re-monopolization may reduce alcohol-related harms.
Based on evidence from a separate systematic review, the CPSTF recommends against privatization of retail alcohol sales.
Bans Against Alcoholic Beverages
Bans against alcoholic beverages reduce alcohol outlet density to zero. Repeal of bans allows for increased outlet density.
The systematic review included seven studies.
- Bans against alcoholic beverages can reduce excessive alcohol consumption and related harms, particularly in isolated environments without other sources of alcohol.
Unspecified Changes in Alcohol Outlet Density
The systematic review included nine studies that looked at the association between changes in alcohol outlet density and alcohol-related harms when the cause for the density change was not assessed.
- Generally, increased outlet density was associated with increases in alcohol-related harms.
- One possible exception was alcohol-related motor vehicle crashes for which evidence was mixed.
Summary of Economic Evidence
An economic review of this intervention did not find any relevant studies.
Applicability
Findings from this review are likely applicable to settings in the United States and Canada, including tribal areas, as well as other high-income countries.
Evidence Gaps
- How are local decisions made regarding policies that affect alcoholic beverage outlet density, and what are the consequences of such policies?
- What is the impact of reducing alcohol outlet density?
- What is the impact of density changes relative to baseline density levels?
- Some researchers have proposed that the association between outlet density and alcohol consumption follows a demand curve, such that when density is relatively low, increases in density may be expected to have large effects on consumption, and when density is relatively high, increases in density should be expected to have smaller effects.
- Researchers could use econometric methods to assess this hypothesis empirically with different kinds of alcohol-related outcomes. Such information would allow communities at different alcohol outlet density “levels” to project the possible benefits or harms of changing outlet density.
- What are other approaches to regulation beyond licensing and zoning that may affect outlet density (e.g., traffic or parking regulations which, in effect, control the number of driving patrons who may patronize an alcohol outlet)?
- What is the economic impact of reducing alcohol outlet density?
Implementation Considerations and Resources
- Literature suggests that additional benefits of reduced outlet density may include reductions in public nuisance, loitering, vandalism, and prostitution.
- Restrictions on alcohol outlet density may be opposed by firms involved in manufacturing, distributing, or selling alcoholic beverages.
- This review did not address the potential consequence of neighboring areas having differing policies. It is possible that harms (e.g., crashes from driving, drunk or sober, over longer distances) may result when people travel between communities.
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.