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ecommendations for Reducing Excessive Alcoholonsumption and Alcohol-Related Harms by Limitinglcohol Outlet Density

he Task Force on Community Preventive Services

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he serious toll that alcohol imposes on the popu-lation of the U.S. led the Task Force on Commu-nity Preventive Services (Task Force) to include

he reduction of excessive alcohol consumption and re-ated harms as a priority topic in its earliest planningessions.1 As the third-leading cause of preventable deathn the nation,2 excessive use of alcohol is a public healthhallenge that can be approached from many directions.he Task Force first studied and made recommendationsn several ways to reduce alcohol-impaired driving.3–7 Itext assessed ways to reduce excessive alcohol consump-

ion,8 exploring the effectiveness of interventions to main-ain limits on the days on which alcohol can be soldrecommended); increase taxes on alcoholic beveragesrecommended); limit privatization of alcohol sales (in-ufficient evidence to determine effectiveness); enhancenforcement of laws prohibiting sales to minors (recom-ended); and regulate alcohol outlet density, reviewed in

he accompanying article.9

ntervention Recommendation

n the basis of the reviewed evidence, the Task Forceound sufficient evidence of a positive association betweenutlet density and excessive alcohol consumption andelated harms to recommend limiting alcohol outletensity through the use of regulatory authority (e.g.,

icensing and zoning) as a means of reducing or control-ing excessive alcohol consumption and related harms.

A diverse group of studies of the association of outletensity with alcohol consumption and related harms

ndicates that when the density of on- or off-premiseslcohol outlets is high or increases, the level of alcoholonsumption is correspondingly high or increases, andxcessive consumption and its diverse related harmsccur. A smaller number of studies indicates the con-erse association. The validity of the causal link betweenutlet density and excessive alcohol consumption and

ts related harms is further supported by evidence fromvaluations of related interventions that affect outletensity (e.g., bans or privatization of alcohol sales). Onhe basis of this evidence, the Task Force concludes thatimiting on- and off-premises alcoholic beverage outletensity—either by reducing current density levels or

imiting density growth—can be an effective means of w

70 Am J Prev Med 2009;37(6)© 2009 American Journal of Preventive Medicine • Publish

educing the harms associated with excessive alcoholonsumption. It may also provide additional benefitsor quality of life by reducing community problemsuch as loitering, public disturbances, and vandalism.

nformation from Other Advisory Groupsealthy People 2010 goals and objectives

he intervention reviewed here may be useful in reach-ng objectives specified in Healthy People 2010,10 theisease prevention and health promotion agenda forhe U.S. The objectives most directly relevant to thiseview are those to reduce excessive alcohol consump-ion (26–11 and 26–12); reduce average annual alco-ol consumption (26–12); and reduce key adverseonsequences of excessive alcohol consumption (26–1,6–2, and 26–5 through 26–8). Healthy People 2010 alsootes that excessive alcohol consumption is related toeveral other public health priorities, including cancer,ducational achievement, injuries, risky sexual activity,nd mental health.

urgeon General’s Workshop on Drunk Driving

his workshop, held in 1988, was a multi-agency efforto address the problem of drunk driving. Recommen-ations were made in several areas. To reduce availabil-

ty of alcoholic beverages, workshop participants in-luded a recommendation to strengthen laws concerningours of sale, characteristics and density of outlets, andther factors relating to retail availability of alcoholiceverages.11 The workshop also recommended futureesearch to document the contribution of location, den-ity, and hours of sale of alcohol outlets to alcohol-mpaired driving and resulting injuries and fatalities.

nterpreting and Using the Recommendation

his recommendation can be used to support efforts byommunity-based and grassroots organizations to limithe density of alcohol outlets in their communities.tate and local officials can use this recommendation toelp enact or reform laws concerning density of outlets

here alcohol is available.

0749-3797/09/$–see front mattered by Elsevier Inc. doi:10.1016/j.amepre.2009.09.021

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Implementers may encounter barriers, including pre-mption laws at higher levels of government (a state lawhat takes precedence over and thus allows what a localaw is trying to restrict) and opposition by groups whoseommercial interests may be affected.

he names and affiliations of the Task Force members areisted below and at www.thecommunityguide.org.

ask Force on Community Preventive Services Members (June 2009)

onathan E. Fielding, MD, MPH, MBA (Chair)irector of Public Health and Health Officerounty of Los Angelesepartment of Healthos Angeles CA

arbara K. Rimer, DrPH, MPH (Vice-Chair)ean, School of Public Healthniversity of North Carolina at Chapel Hillhapel Hill NC

na Abraido-Lanza, PhDssociate Professor, Department of Sociomedical Sciencesailman School of Public Healtholumbia Universityew York NY

ed Calonge, MD, PhDhief Medical Officerolorado Department of Public Health and Environmentenver CO

ohn M. Clymer, Vice President and Health Science Officerenior Advisorlliance of the Healthiest Nation and Association ofirectors of Health Promotion and Educationurke VA

aren Glanz, PhD, MPHrofessor of Behavioral Sciences and Health Educationeorgia Cancer Coalition Distinguished Research Scholarirector, Emory Prevention Research Centerollins School of Public Healthmory Universitytlanta GA

on Z. Goetzel, PhDesearch Professor and Director

nstitute of Health and Productivity Studiesollins School of Public Healthmory Universityice President, Consulting and Applied Researchhomson Healthcareashington DC

arry Green, DrPHdjunct Professor, Epidemiology and Biostatisticschool of Medicine and Comprehensive Cancer Center

niversity of California at San Franciscoan Francisco CA

1

ecember 2009

obert L. Johnson, MDhe Sharon and Joseph L. Muscarelle Endowed

nterim Dean,rofessor of Pediatrics and Psychiatry,irector, Division of Adolescent and Young Adult MedicineMDNJ—New Jersey Medical Schoolepartment of Pediatricsewark NJ

. Tracy Orleans, PhDistinguished Fellow and Senior Scientistepartment of Research and Evaluationobert Wood Johnson Foundationrinceton NJ

ico P. Pronk, PhDourneyWellenior Research Investigator, HealthPartners Research Foundationloomington MN

ilbert Ramirez, DrPHssociate Dean–Academic and Student Affairsobert Stempel College of Public Health and Social Worklorida International Universityiami FL

No financial disclosures were reported by the authors ofhis paper.

eferences1. Zaza S, Lawrence RS, Mahan CS, et al. Scope and organization of the Guide

to Community Preventive Services. Am J Prev Med 2000;18(1S):27–34.2. CDC. Alcohol-attributable deaths and years of potential life lost—United

States, 2001. MMWR Morb Mort Wkly Rep 2004;53(37):866–70.3. Ditter SM, Elder RA, Shults RA, et al. Effectiveness of designated driver

programs for reducing alcohol-impaired driving: a systematic review. Am JPrev Med 2005;28(5S):280–7.

4. Elder RA, Shults RA, Sleet DA, et al. Effectiveness of mass media campaignsfor reducing drinking and driving and alcohol-involved crashes: a system-atic review. Am J Prev Med 2004;27(1):57–65.

5. Elder RA, Nichols JL, Shults RA, Sleet DA, Barrios LC. Effectiveness ofschool-based programs for reducing drinking and driving and riding withdrinking drivers: a systematic review. Am J Prev Med 2005;28(5S):288–304.

6. Task Force on Community Preventive Services. Recommendation for use ofmass media campaigns to reduce alcohol-impaired driving. Am J Prev Med2004;27(1):66.

7. Zaza S, Thompson RS, eds. The Guide to Community Preventive Services.Reducing injuries to motor vehicle occupants. Systematic reviews of evi-dence, recommendations from the Task Force on Community PreventiveServices, and expert commentary. Am J Prev Med 2001;21(1S):1–90.

8. Preventing excessive alcohol use. www.thecommunityguide.org/alcohol/index.html. 2009.

9. Campbell AC, Hahn RA, Elder RA, et al. The effectiveness of limitingalcohol outlet density as a means of reducing excessive alcohol consump-tion and alcohol-related harms. Am J Prev Med 2009;37(6):556–69.

0. USDHHS. Healthy People 2010; www.healthypeople.gov/.

1. Office of the Surgeon General. Surgeon General’s Workshop on Drunk

Driving: proceedings. profiles.nlm.nih.gov/NN/B/B/B/W/.

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