EPIDEMIOLOGY AND POLICY Hours and Days of Sale and Density of Alcohol Outlets: Impacts on Alcohol Consumption and Damage: A Systematic Review

Aims: The aim of this study was to examine recent research studies published from 2000 to 2008 focusing on availability of alcohol: hours and days of sale and density of alcohol outlets. Methods: Systematic review. Results: Forty-four studies on density of alcohol outlets and 15 studies on hours and days of sale were identified through a systematic literature search. The majority of studies reviewed found that alcohol outlet density and hours and days of sale had an impact on one or more of the three main outcome variables, such as overall alcohol consumption, drinking patterns and damage from alcohol. Conclusions: Restricting availability of alcohol is an effective measure to prevent alcohol-attributable harm. BACKGROUND AND CONTEXT The World Health Organization (WHO, 2002) has indicated that in developed countries the harm from alcohol is ranked third out of 26 risk factors examined in terms of their contribution to disease, disability or mortality. The top two were tobacco and blood pressure, respectively. Alcohol was third, and ahead of the following risk factors: high cholesterol, body mass index, low intake of fruit and vegetables, physical inactivity and illicit drugs. However, in contrast, in recent years, there are initiatives in place that promote alcohol, increase access to alcohol and stimulate alcohol sales. For example, in the UK, the rise in the affordability of alcohol by 65% between 1980 and 2006, the extension of hours of sale for both on-premise and offpremise outlets in 2003, combined with extensive advertising and the promotion of alcohol have been linked with an increase in consumption and drinking-related damage (Heather, 2006; Leon and McCambridge, 2006; Anderson, 2007; British Medical Association Board of Science, 2008). In Canada, there has been extensive marketing and promotion of alcoholic beverages by liquor boards working in concert with alcohol producers (Giesbrecht, 2006; Giesbrecht et al., 2006). In recent years, all jurisdictions within Canada have undergone substantial changes in how alcoholic beverages are distributed and sold. These changes have, for the most part, been gradual, while in some cases they have taken place concurrently. The most notable changes have included: an increase in alcohol marketing and promotion, an increase in alcohol density within retail outlets, an extension of hours and days of sale, and the use of discounts or sale prices in order to promote sales. Provincial liquor boards and commissions include management of alcohol sales as part of their mandate. However, the current control functions are narrowly restricted to social responsibility initiatives, interventions to control smuggling, concerns about the quality of products, and some health promotion campaigns, such as prevention of drinking and driving. The social responsibility functions do not include controlling overall sales or reducing high-risk drinking, both of which have been linked with population-level rates of damage, caused by alcohol consumption (Edwards et al., 1994; Babor et al., 2003). This perspective presents an incongruity between, on one hand, the greater commercial orientation and an emphasis on increasing alcohol sales and, on the other, an increase in damage and the costs that this commercial orientation will likely lead to. This skewed current emphasis on the market factors stands in a sharp contrast to over 40 years of international research on the associations between access to alcohol, drinking patterns and damage from alcohol consumption. The body of alcoholrelated research has repeatedly shown that an increase in alcohol sales is strongly linked to an increase in drinking-related damage, as demonstrated by three international projects affiliated with WHO (Bruun et al., 1975; Edwards et al., 1994; Babor et al., 2003). Furthermore, a study of 14 European countries (Norström, 1999) established a strong association between documented trends over a 50-year period, in overall alcohol sales and mortality from alcohol-specific causes (Ramstedt, 2001), trauma (Rossow, 2001; Skog, 2001), chronic disease (Ramstedt, 2004b), as well as total mortality (Norström and Skog, 2001). Similar findings have emerged from a study conducted a few years ago, focusing on Canada and its provinces for the period 1950–2000 (Ramstedt, 2003; Skog, 2003; Norström, 2004; Rossow and Hauge, 2004; Ramstedt, 2004a, 2005). Concurrent with extensive promotion, overall alcohol consumption and high-risk drinking have been increasing in Canada in recent years. In Canada, there has been an increase in the rate of alcohol consumption since about 1996 (Statistics Canada, 2002; Statistics Canada, 2007), with some variation between provinces. During this time, the percentage of drinkers who reported drinking 5+ alcoholic beverages per occasion, at least monthly, has also increased (Statistics Canada, 1997, 2005). It is expected that these initiatives to increase access to alcohol and stimulate higher levels of overall consumption will contribute to an increase in the risks from alcohol, damage from alcohol and attendant health, social and law enforcement costs (Rehm et al., 2006, 2008). This paper examines recent research studies focusing on two interventions that have been shown C © The Author 2009. Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved Hours and Days of Sale and Density of Alcohol Outlets 501 to be particularly potent in the past in controlling consumption and damage from alcohol consumption, namely, hours and days of sale, and alcohol outlet density (AOD) (Babor et al., 2003, chapter 16; Stockwell, 2006).