Alcohol Excessive Consumption: Regulation of Alcohol Outlet Density

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.

Detailed results from the systematic review are available in the published evidence review.

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.

An economic review of this intervention did not find any relevant studies.

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.

The CPSTF identified several areas that have limited information. Additional research and evaluation are needed to answer the following questions and to fill remaining gaps in the evidence base. What are 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?

• 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.

Campbell CA, Hahn RA, Elder R, et al. 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):556–69.

Task Force on Community Services. Recommendations for reducing excessive alcohol consumption and alcohol-related harms by limiting alcohol outlet density. American Journal of Preventive Medicine. 2009;37(6):570-1.

Effectiveness Review

Analytic Framework
When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Alcohol Outlet Density Change

Blake D, Nied A. The demand for alcohol in the United Kingdom. Appl Econ 1997;29:1655 72.

Gruenewald PJ, Ponicki WR, Holder HD. The relationship of outlet densities to alcohol consumption: a time series cross-sectional analysis. Alcohol Clin Exp Res 1993;17(1):38 47.

Gruenewald PJ, Remer L. Changes in outlet densities affect violence rates. Alcohol Clin Exp Res 2006;30(7):1184 93.

Hoadley JF, Fuchs BC, Holder HD. The effect of alcohol beverage restrictions on consumption: a 25-year longitudinal analysis. Am J Drug Alcohol Abuse 1984;10(3):375 401.

Markowitz S, Chatterji P, Kaestner R. Estimating the impact of alcohol policies on youth suicides. J Ment Health Policy Econ 2003;6(1):37 46.

McCarthy P. Alcohol, public policy, and highway crashes: a time-series analysis of older-driver safety. Transp Econ Polcy 2005;39(1):109 25.

McCarthy P. Alcohol-related crashes and alcohol availability in grass-roots communities. Appl Econ 2003;35(11):1331 8.

McCornac DC, Filante RW. The demand for distilled spirits: an empirical investigation. J Stud Alcohol 1984;45(2):176 8.

Norstrom T. Outlet density and criminal violence in Norway, 1960 1995. J Stud Alcohol 2000;61(6):907 11.

Xie X, Mann RE, Smart RG. The direct and indirect relationships between alcohol prevention measures and alcoholic liver cirrhosis mortality. J Stud Alcohol 2000;61(4):499 506.

Privatization

Fitzgerald JL, Mulford HA. Consequences of increasing alcohol availability: the Iowa experience revisited. Br J Addict 1992;87(2):267 74.

Fitzgerald JL, Mulford HA. Privatization, price and cross-border liquor purchases. J Stud Alcohol 1993;54(4):462 4.

Holder HD, Wagenaar AC. Effects of the elimination of a state monopoly on distilled spirits’ retail sales: a time-series analysis of Iowa. Br J Addict 1990;85:1615 25.

MacDonald S. The impact of increased availability of wine in grocery stores on consumption: four case histories. Br J Addict 1986;81:381 7.

Makela P. Whose drinking does the liberalization of alcohol policy increase? Change in alcohol consumption by the initial level in the Finnish panel survey in 1968 and 1969.Addiction 2002;97(6):701 6.

Mulford HA, Fitzgerald JL. Consequences of increasing off-premise wine outlets in Iowa. Brit J Addict 1988;83(11):1271 9.

Mulford HA, Ledolter J, Fitzgerald JL. Alcohol availability and consumption: Iowa sales data revisited. J Stud Alcohol 1992;53(5):487 94.

Ramstedt M. The repeal of medium-strength beer in grocery stores in Sweden-the impact on alcohol-related hospitalizations in different age groups. Finland: Nordic Council for Alcohol and Drug Research (NAD), 2002. No. 42.

Smart RG, Docherty D. Effects of the introduction of on premise drinking on alcohol-related accidents and impaired driving. J Stud Alcohol 1976;37:683 6.

Smart RG. The impact on consumption of selling wine in grocery stores. Alcohol Alcohol 1986;21(3):233 6.

Trolldal B. An investigation of the effect of privatization of retail sales of alcohol on consumption and traffic accidents in Alberta, Canada. Addiction 2005;100(5):662 71.

Trolldal B. The privatization of wine sales in Quebec in 1978 and 1983 to 1984. Alcohol Clin Exp Res 2005;29(3):410 6.

Wagenaar AC, Holder HD. A change from public to private sale of wine: results from natural experiments in Iowa and West Virginia. J Stud Alcohol 1991;52(2):162 73.

Wagenaar AC, Holder HD. Changes in alcohol consumption resulting from the elimination of retail wine monopolies: results from five U.S. states. J Stud Alcohol 1995;56(5):566 72.

Alcohol Bans

Baughman R, Conlin M, Dickert-Conlin S, Pepper J. Slippery when wet: the effects of local alcohol access laws on highway safety. J Health Econ 2001;20(6):1089 96.

Berman M, Hull t, May P. Alcohol control by referendum in Northern native communities: the Alaska local option law. Arctic 2001;54(1):77 83.

Bowerman RJ. The effect of a community supported alcohol ban on prenatal alcohol and other substance abuse. Am J Public Health 1997;87(8):1378 9.

Britt H, Carlin BP, Toomey TL, Wagenaar AC. Neighborhood-level spatial analysis of the relationship between alcohol outlet density and criminal violence. Environ Ecol Stat 2005;12:411 26.

Chiu AY, Perez PE, Parker RN. Impact of banning alcohol on outpatient visits in Barrow, Alaska. JAMA 1997;278(21):1775 7.

Escobedo LG, Ortiz M. The relationship between liquor outlet density and injury and violence in New Mexico. Accid Anal Prev 2002;34(5):689 94.

Gallaher MM, Fleming DW, Berger LR, Sewell CM. Pedestrian and hypothermia deaths among Native Americans in New Mexico: between bar and home. AMA 1992;267(10):1345 8.

Hoadley JF, Fuchs BC, Holder HD. The effect of alcohol beverage restrictions on consumption: a 25-year longitudinal analysis. Am J Drug Alcohol Abuse 1984;10(3):375 401.

Markowitz S, Chatterji P, Kaestner R. Estimating the impact of alcohol policies on youth suicides. J Ment Health Policy Econ 2003;6(1):37 46.

May P. Arrests, alcohol and alcohol legalization among an American Indian tribe. Plains Anthropol 1975;20(68):129 34.

O’Neil JD. Community control over health problems: Alcohol prohibition in a Canadian Inuit village. Int J Circumpolar Health 1984;84:340 3.

Parker DA, Wolz MW, Harford TC. The prevention of alcoholism: an empirical report on the effects of outlet availability. Alcohol Clin Exp Res 1978;2(4):339 43.

Smart RG, Docherty D. Effects of the introduction of on premise drinking on alcohol-related accidents and impaired driving. J Stud Alcohol 1976;37:683 6.

Smart RG. The impact on consumption of selling wine in grocery stores. Alcohol Alcohol 1986;21(3):233 6.

Treno AJ, Gruenewald PJ, Johnson FW. Alcohol availability and injury: the role of local outlet densities. Alcohol: Clin Exper Res 2001;25(10):1467 71.

Wood DS, Gruenewald PJ. Local alcohol prohibition, police presence and serious injury in isolated Alaska Native villages. Addiction 2006;101(3):393 403.

Licensing Policy Changes Affecting Outlet Density

Blose JO, Holder HD. Public availability of distilled spirits: structural and reported consumption changes associated with liquor-by-the-drink. J Stud Alcohol 1987;48(4):371 9.

Makela P. Whose drinking does the liberalization of alcohol policy increase? Change in alcohol consumption by the initial level in the Finnish panel survey in 1968 and 1969.Addiction 2002;97(6):701 6.

Olafsdottir H. The dynamics of shifts in alcoholic beverage preference: effects of the legalization of beer in Iceland. J Stud Alcohol 1998;59(1):107 14.

Wagenaar AC, Langley JD. Alcohol licensing system changes and alcohol consumption: introduction of wine into New Zealand grocery stores. Addiction 1995;90(6):773 83.

Secondary Evidence

Alaniz ML. Immigrants and violence: The importance of neighborhood context. Hisp Behav Sci 1998;20(2):155 74.

Britt H, Carlin BP, Toomey TL, Wagenaar AC. Neighborhood-level spatial analysis of the relationship between alcohol outlet density and criminal violence. Environ Ecol Stat 2005;12:411 26.

Cohen DA, Mason K, Scribner R. The population consumption model, alcohol control practices, and alcohol-related traffic fatalities. Prev Med 2002;34(2):187 97.

Colon I, Cutter HS. The relationship of beer consumption and state alcohol and motor vehicle policies to fatal accidents. J Safety Res 1983;14(2):83 9.

Colon I. Alcohol availability and cirrhosis mortality rates by gender and race. Am J Public Health 1981;71(12):1325 8.

Colon I. The influence of state monopoly of alcohol distribution and the frequency of package stores on single motor vehicle fatalities. Am J Drug Alcohol Abuse 1982;9(3):325 31.

Dull RT. An assessment of the effects of alcohol ordinances on selected behaviors and conditions. J Drug Issues 1986;16(4):511 21.

Dull RT. Dry, damp, and wet: correlates and presumed consequences of local alcohol ordinances. Am Drug Alcohol Abuse 1988;14(4):499 514.

Escobedo LG, Ortiz M. The relationship between liquor outlet density and injury and violence in New Mexico. Accid Anal Prev 2002;34(5):689 94.

Freisthler B, Gruenewald PJ, Treno AJ, Lee J. Evaluating alcohol access and the alcohol environment in neighborhood areas. Alcohol Clin Exp Res 2003;27(3):477 84.

Freisthler B, Midanik LT, Gruenewald PJ. Alcohol outlets and child physical abuse and neglect: applying routine activities theory to the study of child maltreatment. J Stud Alcohol 2004;65(5):586 92.

Freisthler B, Needell B, Gruenewald PJ. Is the physical availability of alcohol and illicit drugs related to neighborhood rates of child maltreatment? Child Abuse Negl 2005;29(9):1049 60.

Freisthler B. A spatial analysis of social disorganization, alcohol access, and rates of child maltreatment in neighborhoods. Child Youth Serv Rev 2004;26(9):803 19.

Godfrey C. Licensing and the demand for alcohol. App Econ 1988;20:1541 58.

Gorman D, Speer P, Gruenewald P, Labouvie E. Spatial dynamics of alcohol availability, neighborhood structure and violent crime. J Stud Alcohol 2001;62(5):628 36.

Gorman DM, Labouvie EW, Speer PW, Subaiya AP. Alcohol availability and domestic violence.Am J Drug Alcohol Abuse 1998;24(4):661 73.

Gorman DM, Speer PW, Labouvie EW, Subaiya AP. Risk of assaultive violence and alcohol availability in New Jersey. Am J Public Health 1998;88(1):97 100.

Gorman DM, Zhu L, Horel S. Drug ‘hot-spots,’ alcohol availability and violence 220. Drug Alcohol Rev 2005;24(6):507 13.

Gruenewald PJ, Johnson FW, Treno AJ. Outlets, drinking and driving: a multilevel analysis of availability. J Stud Alcohol 2002;63(4):460 8.

Gruenewald PJ, Millar AB, Treno AJ, Yang Z, Ponicki WR, Roeper P. The geography of availability and driving after drinking. Addiction 1996;91(7):967 83.

Gruenewald PJ, Treno AJ, Nephew TM, Ponicki WR. Routine activities and alcohol use: Constraints on outlet utilization. Alcohol Clin Exper Res 1995;19(1):44 53.

Gyimah-Brempong K. Alcohol availability and crime: evidence from census tract data. South Econ J 2001;68(1):2 21.

Harford T, Parker D, Pautler C, Wolz M. Relationship between the number of on-premise outlets and alcoholism. Stud Alcohol 1979;40(11):1053 7.

Jewell RT, Brown RW. Alcohol availability and alcohol-related motor vehicle accidents. Appl Econ 1995;27:759 65.

Kelleher KJ, Pope SK, Kirby RS, Rickert VI. Alcohol availability and motor vehicle fatalities. J Adolesc Health 1996;19(5):325 30.

LaScala EA, Gerber D, Gruenewald PJ. Demographic and environmental correlates of pedestrian injury collisions: a spatial analysis. Accid Anal Prev 2000;32:651 8.

LaScala EA, Johnson FW, Gruenewald PJ. Neighborhood characteristics of alcohol-related pedestrian injury collisions: a geostatistical analysis. Prev Sci 2001;2(2):123 34.

Lipton R, Gruenewald P. The spatial dynamics of violence and alcohol outlets. J Stud Alcohol 2002;63(2):187 95.

Markowitz S, Grossman M. Alcohol regulation and domestic violence towards children.Contemp Econ Policy 1998;16(3):309 20.

Neuman C, Rabow J. Drinkers’ use of physical availability of alcohol: buying habits and consumption level. Inter Addict 1985;20(11 12):1663 73.

Nielsen AL, Martinez R, Lee MT. Alcohol, ethnicity, and violence: the role of alcohol availability for Latino and Black aggravated assaults and robberies. Sociol Q 2005;46:479 502.

Ornstein S, Hanssens D. Alcohol control laws and the consumption of distilled spirits and beer. J Consum Res 1985;12(2):200 13.

Parker DA, Wolz MW, Harford TC. The prevention of alcoholism: an empirical report on the effects of outlet availability. Alcohol Clin Exp Res 1978;2(4):339 43.

Parker DA. Alcohol problems and the availability of alcohol. Alcohol Clin Exp Res 1979;3(4):309 12.

Pollack CE, Cubbin C, Ahn D, Winkleby M. Neighbourhood deprivation and alcohol consumption: does the availability of alcohol play a role? Int J Epidemiol 2005;34(4):772 80.

Rabow J, Watts RK. Alcohol availability, alcoholic beverage sales and alcohol-related problems. J Stud Alcohol 1982;43(7):767 801.

Reid RJ, Hughey J, Peterson NA. Generalizing the alcohol outlet-assaultive violence link: evidence from a U.S. Midwestern city. Subst Use Misuse 2003;38(14):1971 82.

Roncek DW. MP. Bars, blocks, and crimes revisted: linking the theory of routine activities to the empiricism of “hot spots.” Criminol 1991;29(4):725 53.

Rush BR, Gliksman L, Brook R. Alcohol availability, alcohol consumption and alcohol-related damage. I. The distribution of consumption model. J Stud Alcohol 1986;47(1):1 10.

Scribner R, Cohen D, Kaplan S, Allen SH. Alcohol availability and homicide in New Orleans: conceptual considerations for small area analysis of the effect of alcohol outlet density. J Stud Alcohol 1999;60(3):310 6.

Scribner RA, Cohen DA, Fisher W. Evidence of a structural effect for alcohol outlet density: a multilevel analysis. Alcohol Clin Exp Res 2000;24(2):188 95.

Scribner RA, MacKinnon DP, Dwyer JH. Alcohol outlet density and motor vehicle crashes in Los Angeles County cities. J Stud Alcohol 1994;55(4):447 53.

Scribner RA. The risk of assaultive violence and alcohol availability. Am J Public Health 1995;85(3):335 40.

Smart RG. Effects of two liquor store strikes on drunkenness, impaired driving and traffic accidents. J Stud Alcohol 1977;38(9):1785 9.

Speer PW. Violent crime and alcohol availability: relationships in an urban community. J Public Health Pol 1998;19(3):303 18.

Stevenson RJ, Lind B, Weatherburn D. The relationship between alcohol sales and assault in New South Wales, Australia. Addiction 1999;94(3):397 410.

Stout EM, Sloan FA, Liang L, Davies HH. Reducing harmful alcohol-related behaviors: effective regulatory methods. J Stud Alcohol 2000;61(3):402 12.

Tatlow JR, Clapp JD, Hohman MM. The relationship between the geographic density of alcohol outlets and alcohol-related hospital admissions in San Diego County. J Community Health 2000;25(1):79 88.

Treno A, Grube J, Martin S. Alcohol availability as a predictor of youth drinking and driving: a hierarchical analysis of survey and archival data. Alcohol Clin Exp Res 2003;27(5):835 40.

Treno AJ, Gruenewald PJ, Johnson FW. Alcohol availability and injury: the role of local outlet densities. Alcohol: Clin Exper Res 2001;25(10):1467 71.

Treno AJ, Gruenewald PJ, Johnson FW. Alcohol availability and injury: the role of local outlet densities. Alcohol: Clin Exper Res 2001;25(10):1467 71.

van Oers JA, Garretsen HF. The geographic relationship between alcohol use, bars, liquor shops and traffic injuries in Rotterdam. J Stud Alcohol 1993;54(6):739 44.

Watts RK. Alcohol availability and alcohol-related problems in 213 California cities. Alcohol Clin Exp Res 1983;7(1):47 58.

Weitzman ER, Folkman A, Folkman MP, Wechsler H. The relationship of alcohol outlet density to heavy and frequent drinking and drinking-related problems among college students at eight universities. Health Place 2003;9(1):1 6.

Wieczorek WF, Coyle JJ. Targeting DWI prevention. J Prev Interv Community 1998;17(1):15 30.

Zhu L, Gorman DM, Horel S. Alcohol outlet density and violence: a geospatial analysis.

Implementation Resources

CDC Alcohol Outlet Density Surveillance Toolkit
Developed by CDC’s Alcohol Program

Strategizer 55 – Regulating Alcohol Outlet Density: An Action Guide
Developed by the Community Anti-Drug Coalitions of America in partnership with the Center on Alcohol Marketing and Youth at the Johns Hopkins Bloomberg School of Public Health

Sacks JJ, Brewer RD, Mesnick J, Holt JB, Zhang X, et al. Measuring alcohol outlet density: an overview of strategies for public health practitioners. Journal of Public Health Management and Practice 2019; epub: doi: 10.1097/PHH.0000000000001023

Rural Health Information Hub, Prevention and Treatment of Substance Use Disorders Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of programs to prevent and treat substance use disorders in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

• Prevention Policies

The following outlines the search strategy used for these reviews of interventions to prevent excessive alcohol consumption: Dram Shop Liability; Increasing Alcohol Taxes; Maintaining Limits on Days of Sale; Maintaining Limits on Hours of Sale; Overservice Law Enforcement Initiatives; Regulation of Alcohol Outlet Density; Enhanced Enforcement of Laws Prohibiting Sales to Minors.

The following databases were searched from their inception up to October 2007 to identify studies assessing the impact of changes for all interventions included in the Community Guide series of alcohol reviews: Econlit, PsycInfo, Sociology Abstracts, Medline, Embase, and EtOH (not available after 2003). The search yielded 6442 articles, books, and conference abstracts, of which 5645 were unique.

1) Alcohol Keywords

• (Alcoholic drink$ OR alcoholic beverage* OR alcohol OR liquor OR beer OR wine OR spirits OR drunk OR intoxicat$ OR alcoholic binge* OR binge drinking)

2) Keywords for interventions of interest (assume ORs between bullets) {Target intervention}

• ((day$ or hour$ or sale$) and (limit$ or sale$ or extend$ or restrict$ or trading)) {Restrictions on days and hours of sale}
  • (day OR hour OR “time of day” OR time) AND (sale* OR trading OR commerce) AND (limit OR restrict OR regulate)
• (tax or taxes or taxation or cost or costs$ or prices or price) {Increased alcohol taxes}
  • (tax*) AND (increase OR raise)
• (social and (host$ or liability or provider$ or provision)) {Social host liability}
  • (“social host” OR provider* OR provision) AND (liability OR responsibility)
• ((underage or minor or youth or young or teenage$) and licens$ and (enforcement or fee$ or driver$)) {License suspension/revocation for non-MV alcohol violations among underage drinkers}
  • (underage OR minor OR youth OR adolescent OR teen*) AND (“drivers license” OR) AND (suspension OR revocation OR revoke) AND (“non-mv alcohol violation” OR (“alcohol violation” NOT (driving OR “motor vehicle”))
• (privatiz$ or monopol$ or ((sale$ or distribut$ or industry) and (ban$ or strike$ or prohibition))) {Government monopolies on off-premise outlets}
  • (“off-premise”) AND (“government monopoly” OR government OR privatiz* OR monopoly) AND (sale* OR distribut* OR industry)
• (minimum age or drinking age or purchase age or legal age or MDA or MLDA or ((teen$ or adolescen$ or young or college$ or youth$ or student$ or underage$ or minor$) and (enforce$ or deterrence$ or avail$ or access$ or crackdown or ID or identification or compliance))) {Enhanced enforcement of laws prohibiting possession or consumption of alcohol by minors}
  • (underage OR minor OR youth OR adolescent OR teen*) AND (possess* OR consum* OR access*) AND (law* OR regulat* OR enforce* OR deter* OR crackdown OR complia*) AND (“minimum age” OR “drinking age” OR “purchase age” OR “legal age” OR “MDA” OR “MLDA”)
• (advertis$ or marketing or promotion$ or internet or product placement or billboard$ or sponsorship) {Limiting advertising exposure}
  • (advertis* OR market* OR promotion* OR internet OR www OR World Wide Web OR “product placement” OR billboard* OR sponsor* OR target*) AND (underage OR minor OR youth OR adolescent OR teen*) AND (limit OR reduc* OR restrict* OR regulat*)
• (compliance check$ or sting$ or decoy$ or purchase attempt or dram shop) {Enhanced enforcement of laws prohibiting provision of alcohol to minors}
  • (“dram shop” OR “on-premise” OR provider) AND (“compliance check*” OR “purchase attempt*” OR enforce*) AND (law* OR regulat* OR prohibit*) AND (underage OR minor OR youth OR adolescent OR teen*)
• (((manager$ or management or serv$ or clerk$ or seller$) and (liabilit$ or practice$ or training or beverage$)) or liquor liability) {Responsible beverage server programs/Dram shop liability}
  • (provider OR manage* OR serv* OR “dram shop” OR “on-premise” OR sale*) AND ((liabil* OR responsib*) OR (“responsible beverage server program*” OR training OR program*)
• (gas station or self service or ((outlet$ or store$ or bar or bars or establishment) and (density or densities or on-sale or off-sale or type or types or number$ or location$ or concentration or zoning))) {Outlet density and zoning restrictions}
  • (“gas station” OR store OR bar* OR establishment* OR sale*) AND (zon* OR restriction* OR regulat* OR law*) AND (dens*)
• (happy hour$ or liquor by the drink or ladies night or (drink$ and (special$ or discount$ or pric$)) { Decreasing promotional pricing}
  • (promot* OR special OR discount OR “happy hour” OR “ladies night”) AND (pric*) AND (decrease OR restrict* OR regulat* OR limit OR reduc*)

3) Exclusionary keywords

• (air and quality) or pollution
• methanol or methyl
• solvent$

Search for (1) AND (2), NOT (3)

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• 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.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of people under 21 years who engaged in binge drinking in the past month — SU-09
• Reduce the proportion of people aged 21 years and over who engaged in binge drinking in the past month — SU-10