Methods for Evaluating the Association Between Alcohol Outlet Density and Violent Crime.

BACKGROUND: The objective of this analysis was to compare measurement methods-counts, proximity, mean distance, and spatial access-of calculating alcohol outlet density and violent crime using data from Baltimore, Maryland. METHODS: Violent crime data (n = 11,815) were obtained from the Baltimore City Police Department and included homicides, aggravated assaults, rapes, and robberies in 2016. We calculated alcohol outlet density and violent crime at the census block (CB) level (n = 13,016). We then weighted these CB-level measures to the census tract level (n = 197) and conducted a series of regressions. Negative binomial regression was used for count outcomes and linear regression for proximity and spatial access outcomes. Choropleth maps, partial R2 , Akaike's Information Criterion, and root mean squared error guided determination of which models yielded lower error and better fit. RESULTS: The inference depended on the measurement methods used. Eight models that used a count of alcohol outlets and/or violent crimes failed to detect an association between outlets and crime, and 3 other count-based models detected an association in the opposite direction. Proximity, mean distance, and spatial access methods consistently detected an association between outlets and crime and produced comparable model fits. CONCLUSIONS: Proximity, mean distance, and spatial access methods yielded the best model fits and had the lowest levels of error in this urban setting. Spatial access methods may offer conceptual strengths over proximity and mean distance. Conflicting findings in the field may be in part due to error in the way that researchers measure alcohol outlet density.

Outlet Type, Access to Alcohol, and Violent Crime.

BACKGROUND: While there are overwhelming data supporting the association between alcohol outlet density and violent crime, there remain conflicting findings about whether on- or off-premise outlets have a stronger association. This inconsistency may be in part a result of the methods used to calculate alcohol outlet density and violent crime. This analysis uses routine activity theory and spatial access methods to study the association between access to alcohol outlets and violent crime, including type of outlet and type of crime in Baltimore, MD. METHODS: The data in this analysis include alcohol outlets from 2016 (n = 1,204), violent crimes from 2012 to 2016 (n = 51,006), and markers of social disorganization, including owner-occupied housing, median annual household income, drug arrests, and population density. The analysis used linear regression to determine the association between access to alcohol outlets and violent crime exposure. RESULTS: Each 10% increase in alcohol outlet access was associated with a 4.2% increase in violent crime exposure (ß = 0.43, 95% CI 0.33, 0.52, p < 0.001). A 10% increase in access to off-premise outlets (4.4%, ß = 0.45, 95% CI 0.33, 0.57, p < 0.001) and LBD-7 outlets (combined off- and on-premise outlets; 4.2%, ß = 0.43, 95% CI 0.33, 0.52, p < 0.001) had a greater association with violent crime than on-premise outlets (3.0%, ß = 0.31, 95% CI 0.20, 0.41, p < 0.001). CONCLUSIONS: Access to outlets that allow for off-site consumption had a greater association with violent crime than outlets that only permit on-site consumption. The lack of effective measures to keep order in and around off-premise outlets could attract or multiply violent crime.

E-Cigarettes in Baltimore Alcohol Outlets: Geographic and Demographic Correlates of Availability.

There is limited research on e-cigarette availability despite increased use. E-cigarette availability within Baltimore alcohol outlets was analyzed for disparities among residential neighborhoods. Data were obtained via field surveys of alcohol outlets, and then spatially merged with sociodemographic data; 18.8% of alcohol outlets had any e-cigarette availability. Regression models showed greater odds ratios for e-cigarette availability when cigarettes, cigars, or hookah paraphernalia were sold, and lower odds ratios when alcohol outlets had an on-site consumption license. Outlets with e-cigarette availability were in predominantly lower-income, nonwhite neighborhoods. It is important to assess exposure of another potentially damaging substance among perpetually disadvantaged populations.

Brand-specific consumption of alcohol among underage youth in the United States.

BACKGROUND: Little is known about brand-specific alcohol consumption among underage youth, as existing information is collected at the level of alcoholic beverage type. This study identifies the alcohol brands consumed by a nationally representative sample of underage youth in the United States. METHODS: We obtained a national sample of 1,032 underage youth, aged 13 to 20, using a pre-recruited Internet panel maintained by Knowledge Networks. Youth aged 18 to 20 were recruited directly from the panel via email invitation. Teens aged 13 to 17 were identified by asking adult panelists to identify a member of their household. The survey assessed the past 30-day consumption of 898 brands of alcohol among 16 alcoholic beverage types, including the frequency and amount of each brand consumed in the past 30 days. Market share for a given brand was calculated by dividing the total number of drinks for that brand in the past 30 days across the entire sample by the total number of drinks for all identified brands. RESULTS: The alcohol brands with highest prevalence of past 30-day consumption were Bud Light (27.9%, 95% confidence interval [CI] 23.3 to 32.4%), Smirnoff malt beverages (17.0%, 95% CI 12.9 to 21.1%), and Budweiser (14.6%, 95% CI 11.0 to 18.3%). Brand market share was concentrated in a relatively small number of brands, with the top 25 brands accounting for nearly half of all market shares. CONCLUSIONS: Underage youth alcohol consumption, although spread out over several alcoholic beverage types, is concentrated among a relatively small number of alcohol brands. This finding has important implications for alcohol research, practice, and policy.

Exploring correlates of support for restricting breast cancer awareness marketing on alcohol containers among women.

BACKGROUND: Although alcohol consumption increases breast cancer risk, some alcohol products include breast cancer awareness marketing (i.e., pink ribbons) on alcohol containers, which poses a contradiction. Some researchers and advocacy groups have called for restrictions on use of the pink ribbon and other breast cancer awareness marketing on alcohol products. This exploratory study aimed to describe individual and behavioral correlates (age, knowledge, attitudes, purchase intention) of reported support for potential policy restrictions of pink ribbon labeling on alcohol containers. METHODS: The study sample was drawn from the Prolific crowd-sourced research platform in September 2020. Eligible participants included U.S. women aged 21+ years. The primary outcome was policy position for restrictions on pink ribbon labeling on alcohol containers, coded as support, neutral, or oppose. The association between pink ribbon labeling attitudes and support or opposition (vs neutral) was examined using multinomial logistic regression. Covariates were 1) knowledge of the alcohol-cancer link; 2) likelihood of buying an alcohol product with pink ribbon labeling; and 3) age. Models were used to calculate adjusted predicted probabilities for support, oppose, and neutral. RESULTS: The analytic sample included 511 women. Overall, 46% of women opposed, 34% were neutral, and 20% supported restricting pink ribbon labeling on alcohol containers. Controlling for all covariates, women who reported that wine increases cancer risk had the highest probability of opposing restrictions on pink ribbon labeling (56.4% [95%CI: 48.1%-64.8%]). Women who reported wine had no effect on cancer risk had the highest probability of being neutral about restrictions on pink ribbon labeling (45.5% [95% CI: 35.7%-55.3%]). Across levels of knowledge about the alcohol-cancer risk association, as favorable attitudes toward pink ribbon labeling increased, the probability of policy opposition increased and the probability of being policy neutral decreased. CONCLUSION: Findings from this study suggest women's favorable attitudes toward pink ribbon labeling on alcohol containers are a stronger predictor of support or opposition for restrictions on pink ribbon labeling than knowledge of the alcohol-cancer link. Future research could examine whether pink ribbon labeling may interact with potential or current health warnings on alcohol containers.

Awareness of Alcohol as a Carcinogen and Support for Alcohol Control Policies.

INTRODUCTION: Alcohol use increases cancer risk, yet awareness of this association is low. Alcohol control policies have the potential to reduce alcohol-caused cancer morbidity and mortality. Research outside the U.S. has found awareness of the alcohol-cancer link to be associated with support for alcohol control policies. The purpose of this study is to estimate the prevalence of support for 3 communication-focused alcohol policies and examine how awareness of the alcohol-cancer link and drinking status are associated with policy support among U.S. residents. METHODS: Investigators analyzed data from the 2020 Health Information National Trends Survey 5 Cycle 4. Analyses were performed in 2021. The proportion of Americans who supported banning outdoor alcohol advertising and adding warning labels and drinking guidelines to alcohol containers was estimated. Weighted multivariable logistic regression was used to examine how awareness of the alcohol-cancer link and drinking status were associated with policy support. RESULTS: Most Americans supported adding warning labels (65.1%) and drinking guidelines (63.9%), whereas only 34.4% supported banning outdoor alcohol advertising. Americans reporting that alcohol had no effect/decreased cancer risk had lower odds of support for advertising ban (OR=0.56), warning labels (OR=0.43), and guidelines (OR=0.46) than Americans aware of the alcohol-cancer link. Moreover, heavier drinkers had lower odds of support for advertising ban (OR=0.41), warning labels (OR=0.59), and guidelines (OR=0.60) than nondrinkers. CONCLUSIONS: Awareness of the alcohol-cancer link was associated with policy support. Increasing public awareness of the alcohol-cancer link may increase support for alcohol control policies.

Awareness of Alcohol and Cancer Risk and the California Proposition 65 Warning Sign Updates: A Natural Experiment.

In 1986, California enacted Proposition 65 (P65), requiring businesses to display warning signs informing consumers that specific chemicals and alcohol exposure increase the risk of cancer and reproductive harm. In 2018, the P65 alcohol warning signs were updated to include an informational P65 website link, and the update was associated with media coverage and increased enforcement of warning requirements. This study examines knowledge of the association between alcohol use and cancer risk in California compared to the rest of the US before and after the 2018 P65 update. We analyzed state-level data on alcohol and cancer knowledge from the Health Information National Trends Survey from 2017 (n = 3285), 2019 (n = 5438), and 2020 (n = 3865). We performed multinomial logistic regressions to examine knowledge levels by survey year and location (California vs. all other states) and reported the predicted marginals of knowledge by survey year and location. The adjusted prevalence of respondents who reported an association between alcohol and cancer risk was higher in California (41.6%) than the remaining states (34.1%) (p = 0.04). However, knowledge levels decreased significantly over survey years, and there was no evidence for an effect of the P65 update on knowledge in California compared to other states based on the testing of an interaction between state and year (p = 0.32). The 1986 warning signs may have had an enduring effect on awareness, though the update, so far, has not. Further efforts are needed to determine how to increase alcohol and cancer knowledge to address the burden of alcohol-attributable cancers.

Company-Specific Revenues From Underage Drinking.

OBJECTIVE: Alcohol is the most commonly used illegal drug among U.S. high school students. This study aimed to estimate the proportion of drinks and sales revenue accruing to alcoholic beverage companies that were attributable to underage consumption in 2011 and 2016. METHOD: We used national survey data to estimate the number of adult and underage past-30-day drinkers, median volume of alcohol consumed, beverage preferences, and alcohol price by beverage type. We used Impact Databank to determine the total number of alcoholic drinks sold. After adjusting for underreporting, we applied the percentage of alcohol reported to be consumed by underage youth on surveys to the alcohol sales data by beverage type and assigned a beverage-specific cost. RESULTS: Underage youth drank 11.73% of the alcoholic drinks sold in the U.S. market in 2011 and 8.6% in 2016. Total sales revenue attributable to underage consumption was $20.9 billion (10.0%) out of a total of $208.0 billion in 2011 and $17.5 billion (7.4%) out of $237.1 billion in 2016. Three alcoholic beverage companies represented nearly half (43.5%) of the market share of beverages consumed by underage youth. CONCLUSIONS: Despite the alcoholic beverage industry's stated commitment to reducing underage drinking, significant revenues appear to accrue from this activity. This presents an opportunity to enact and enforce policies--such as alcohol taxes or required company funding of independently managed youth drinking prevention initiatives--that recover these revenues from the industry and use them to help achieve the goal of preventing youth alcohol consumption.

Alcohol Advertising and Violence.

INTRODUCTION: Numerous studies have found associations between alcohol outlet density and violence, but it is unknown whether alcohol advertisements visible outside outlets are also associated with violent crime. Baltimore City, MD enacted restrictions on retail alcohol establishment advertising practices as of June 5, 2017. This study examines the association between alcohol advertisements visible outside off-premise alcohol outlets and violent crime before this restriction. METHODS: Outlet observations (n=683) were conducted in summer 2015, and violent crime data (n=24,085) were from June 5, 2015, through June 4, 2017. The number of violent crimes per square mile within 1,000 feet of outlets was summed using kernel density estimation. In 2018-2019, authors used mixed models with a Simes-Benjamini-Hochberg correction for multiple testing. RESULTS: Roughly half (47%, n=267) of the outlets with complete data (n=572) had alcohol advertisements visible from the exterior. Outlets with alcohol advertisements had 15% more violent crimes per square mile within 1,000 feet (eß=1.15, 95% CI=1.07, 1.25, q<0.001) after adjusting for neighborhood context. All associations between alcohol advertisements and specific types of violent crime were significant, with the association strongest for homicides (eß=1.28, 95% CI=1.13, 1.46, q<0.001). There was no association between cigarette advertisements and violent crime (eB=1.08, 95% CI=0.92, 1.26, q=0.43). CONCLUSIONS: Alcohol advertisements visible outside off-premise outlets were associated with increased violent crime over and above the association between the outlets themselves and violent crime. Reducing alcohol advertising visible from the street may decrease risk of violent crime that is associated with alcohol outlets.

The Violence Prevention Potential of Reducing Alcohol Outlet Access in Baltimore, Maryland.

OBJECTIVE: There are few cost-effectiveness analyses that model alcohol outlet zoning policies. This study determines the potential decreases in homicides, disability-adjusted life years (DALYs), and victim and criminal justice costs associated with four policy options that would reduce the alcohol outlet access in Baltimore. METHOD: This cost-effectiveness analysis used associations between on-premise (incidence rate ratio [IRR] = 1.41), off-premise (IRR = 1.76), and combined on- and off-premise outlet density (IRR = 1.07) and homicide in Baltimore. We determined the potential change in the level of homicide that could occur with changes in the density of alcohol outlets, assuming that 50% of the association was causal. RESULTS: Reducing alcohol outlet density in Baltimore City by one quintile was associated with decreases of 51 homicides per year, $63.7 million, and 764 DALYs. Removing liquor stores in residential zones was associated with 22 fewer homicides, which would cost $27.5 million and lead to 391 DALYs. Removing bars/taverns operating as liquor stores was associated with a decrease of one homicide, $1.2 million, and 17 DALYs. Removing both the liquor stores in residential zones and the bars/taverns operating as liquor stores was associated with 23 fewer homicides, which translated to $28.7 million and 409 DALYs. CONCLUSIONS: For preventing homicides, the strategy of removing liquor stores in residential zones was preferred because it was associated with substantial reductions in homicides without closing unacceptably high numbers of outlets. It is possible that policies that close the bars/taverns operating as liquor stores would be associated with decreases in other types of violent crime.