Looking Back and Moving Forward: The Evolution and Potential Opportunities for the Future of Alcohol Outlet Density Measurement.

The literature consistently finds that areas with greater density of alcohol outlets (places that sell alcohol) tend to have higher levels of public health harms. However, conflicting findings arise when researchers drill down to identify the type(s) of alcohol outlets with the strongest associations with harms and the mechanisms that explain these associations. These disagreements could be a result of the outdated methods commonly used to quantify the alcohol environment: counts of the number of outlets in an area. This manuscript reviews the events and ideas that shaped the literature on the physical alcohol environment. It then defines the three main methods used to measure alcohol outlet density, conducts an exploratory factor analysis to explore the constructs underlying each method, and presents a novel conceptual framework that summarizes the three methods, their respective underlying constructs, and the setting(s) in which each may be most appropriate. The framework proposes that counts of alcohol outlets measure availability, proximity to the nearest outlet measures accessibility, and spatial access measures measure access, which comprises both availability and accessibility. We argue that researchers should consider using proximity and spatial access measures when possible and outline how doing so may present opportunities to advance theory and the design and implementation of alcohol outlet zoning regulations. Finally, this manuscript draws on research from other areas of the built environment to suggest opportunities to use novel methods to overcome common hurdles (e.g., separating subtypes of outlets, ecologic designs) and a new challenge on the horizon: home delivery.

Using the theory of normative social behavior to understand compliance with a smoke-free law in a middle-income country.

Smoke-free laws, which ban smoking in public venues, can be effective in protecting public health, but it has been difficult to achieve compliance with these laws in low- and middle-income countries. This study was conducted to understand the social norms around public smoking and learn how to improve compliance in Bogor, the first Indonesian city to pass a comprehensive smoke-free law. Eleven stratified focus groups were conducted (n = 89). Data were analyzed using the theory of normative social behavior, which posits that the influence of descriptive norms (perceptions about what other people do) on behavior is moderated by injunctive norms (perceptions about what one is expected to do), outcome expectations and group identity. The findings showed that participants perceived smoking in public to be common for men (descriptive norm). Public smoking is acceptable except in places with air conditioning and around children or pregnant women (injunctive norms). Men smoke without penalty of social or legal sanctions (outcome expectations) and may feel affiliation with other smokers (group identity). Together, these factors support public smoking and inhibit compliance with the smoke-free law. Theory-based communication and policy remedies are suggested that may bolster compliance with Bogor's smoke-free law given the current pro-smoking norms.

Applying commodity chain analysis to changing modes of alcohol supply in a developing country.

Development sociology has used global commodity chains as one way of analyzing the dynamics of power and profit-taking in globalized production networks made up of multiple firms and occurring in multiple national settings. A substantial portion of the alcohol supply in developing countries is now produced through such production networks. Particularly in the beer and spirits trade, a small number of transnational firms control networks of local producers, importers, advertisers and distributors. These networks serve to embed transnational or transnationally backed brands in the local culture, using the tools of market research, product design and marketing to influence local drinking practices. Case materials from Malaysia's beer industry help to illustrate how the transnational firms dominate in those links of the commodity chain in which monopoly or oligopoly control is most likely to be found: the design/recipe and marketing/advertising nodes. Their control of the commodity chains and extraction of monopoly or oligopoly profits from them places substantial resources and influence over drinking settings and practices in foreign hands. The impact of this influence on state efficacy and autonomy in setting alcohol policy is an important subject for future research on the creation and implementation of effective alcohol policies in developing societies.

The global expansion of alcohol marketing: illustrative case studies and recommendations for action.

As evidence emerges showing alcohol's significant share of the global burden of disease, alcohol sales have flattened in the developed countries, but sales are rising in developing and post-communist countries. A three-year study sought to assess the growing impact of global alcohol transnationals in the developing and post-communist countries. Case studies in three countries--Malaysia, Zimbabwe, and Estonia--provide concrete examples of current global alcohol marketing policies and procedures. Recommendations stress the need for national and local governments, international bodies, non-governmental organizations, and the global alcohol companies to adopt specific measures designed to achieve improved monitoring of alcohol problems, greater public awareness of alcohol's impact, stronger and more effective regulation of the alcohol trade, and greater restraint on the part of the companies. Alcohol problems are too serious and too preventable for the world to be left thirsting for action.

Media advocacy: lessons from community experiences.

Media advocacy is the strategic use of mass media and community organizing as a resource for advancing a social or public policy initiative. Across the United States, communities are using media advocacy to promote healthier public policies and environments. The U.S. Center for Substance Abuse Prevention commissioned numerous case studies of media advocacy on alcohol and tobacco issues in a diverse array of communities, including efforts in African-American and Latino communities or using computer-based electronic communication systems. The paper describes these efforts briefly, and summarizes lessons learned, including: media advocacy can lead to larger victories when used as a complement to community organizing in the context of a larger strategic vision for policy change; like policy advocacy, media advocacy is best done in the context of clear long-term goals; conscious framing, guiding the choice of spokespeople, visuals, and messages, can alter media coverage and public debate of health policies; advocates need to respect the media but also remember that they have power in relation to the media; and media advocacy is often controversial and not suited to every situation. The case studies show that media advocacy is a potent tool for public health workers, making an important contribution to campaigns to promote healthier public policies.

Alcohol-related problems and public hospitals: defining a new role in prevention.

Application of the public health model of primary prevention to the prevention of alcohol-related problems suggests that public hospitals can be significant partners in community-based prevention efforts. Injury and illness related to alcohol use place a high level of demand on public hospital resources, and their participation in prevention efforts is a promising and underutilized way of reducing this demand. Avenues of participation in prevention include improved data collection and reporting, identification and referral of problem-drinking patients, greater dissemination of data on alcohol-related problems to the general public, liaison with victim assistance groups and community-based alcohol-problem prevention organizations, involvement in public policy regarding alcohol use, and the development of prevention messages from a medical perspective. Implementing some or all of these approaches can be done with little extra cost, through using local government alcohol program staff and resources, integration of alcohol-related problem prevention issues into staff training, liaison with professional educational institutions with expertise on alcohol, networking with alcohol policy organizations, incentives for staff participation in health-related professional organizations giving alcohol policy issues higher priority, and the development of a permanent on-site prevention component.

Alcohol use patterns, problems and policies in Malaysia.

The roots of Malaysia's drinking patterns lie in the introduction of most forms of alcohol by Europeans. Although Malaysia today has relatively low per capita alcohol consumption, available studies and interviews with alcohol industry officials point to a small segment of the population that drinks heavily and causes and experiences substantial alcohol related-problems. Indians are over-represented in this sub-population, but studies also reveal substantial drinking problems among Chinese and Malays. Government officials categorize alcohol as an Indian problem. The government devotes little resources to monitoring drinking patterns, use or problems; or to preventing, treating or educating the public about alcohol-related problems. Alcohol-producing transnational corporations own shares of all of Malaysia's major alcohol producers. In the face of high alcohol taxes and a ban on broadcast advertising of alcoholic beverages, these companies market alcohol aggressively, making health claims, targeting heavy drinkers and encouraging heavy drinking, employing indirect advertising, and using women in seductive poses and occupations to attract the mostly male drinking population. Monitoring of the country's alcohol problems is greatly needed in order to establish alcohol consumption more clearly as a national health and safety issue, while stronger controls and greater corporate responsibility are required to control alcohol marketing.

Towards a global alcohol policy: alcohol, public health and the role of WHO.

In 1983 the World Health Assembly declared alcohol-related problems to be among the world's major health concerns. Since then, alcohol consumption has risen in developing countries, where it takes a heavy toll. Alcohol-related problems are at epidemic levels in the successor states of the Soviet Union and are responsible for 3.5% of disability-adjusted life years (DALYs) lost globally. Substantial evidence exists of the relationship between the levels and patterns of alcohol consumption on the one hand and the incidence of alcohol-related problems on the other. Over the past 20 years, research has demonstrated the effectiveness of public policies involving, for example, taxation and restrictions on alcohol availability, in reducing alcohol-related problems. In the wake of rapid economic globalization, many of these policies at national and subnational levels have been eroded, often with the support of international financial and development organizations. Development agencies and international trade agreements have treated alcohol as a normal commodity, overlooking the adverse consequences of its consumption on productivity and health. WHO is in a strong position to take the lead in developing a global alcohol policy aimed at reducing alcohol-related problems, providing scientific and statistical support, capacity-building, disseminating effective strategies and collaborating with other international organizations. Such leadership can play a significant part in diminishing the health and social problems associated with alcohol use.