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Measuring Alcohol Outlet Density

An Overview of Strategies for Public Health Practitioners

Sacks, Jeffrey J. MD, MPH; Brewer, Robert D. MD, MSPH; Mesnick, Jessica MPH; Holt, James B. PhD, MPA; Zhang, Xingyou PhD; Kanny, Dafna PhD; Elder, Randy PhD, MEd; Gruenewald, Paul J. PhD

Journal of Public Health Management and Practice: May 20, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/PHH.0000000000001023
Practice Full Report: PDF Only

Context: Excessive alcohol use is responsible for 88 000 deaths in the United States annually and cost the United States $249 billion in 2010. There is strong scientific evidence that regulating alcohol outlet density is an effective intervention for reducing excessive alcohol consumption and related harms, but there is no standard method for measuring this exposure.

Program: We overview the strategies available for measuring outlet density, discuss their advantages and disadvantages, and provide examples of how they can be applied in practice.

Implementation: The 3 main approaches for measuring density are container-based (eg, number of outlets in a county), distance-based (eg, average distance between a college and outlets), and spatial access–based (eg, weighted distance between town center and outlets).

Evaluation: While container-based measures are the simplest to calculate and most intuitive, distance-based or spatial access–based measures are unconstrained by geopolitical boundaries and allow for assessment of clustering (an amplifier of certain alcohol-related harms). Spatial access–based measures can also be adjusted for population size/demographics but are the most resource-intensive to produce.

Discussion: Alcohol outlet density varies widely across and between locations and over time, which is why it is important to measure it. Routine public health surveillance of alcohol outlet density is important to identify problem areas and detect emerging ones. Distance- or spatial access–based measures of alcohol outlet density are more resource-intensive than container-based measures but provide a much more accurate assessment of exposure to alcohol outlets and can be used to assess clustering, which is particularly important when assessing the relationship between density and alcohol-related harms, such as violent crime.

Sue Binder Consulting, Inc, Decatur, Georgia (Dr Sacks); Alcohol Program (Drs Brewer and Kanny and Ms Mesnick) and Analytic Methods Team (Dr Holt), National Center for Chronic Disease Prevention and Health Promotion, and Office of Science Quality, Office of the Associate Director for Science (Dr Elder), Centers for Disease Control and Prevention, Atlanta, Georgia; Economic Research Service, US Department of Agriculture, Washington, District of Columbia (Dr Zhang); and Prevention Research Center, Pacific Institute for Research and Evaluation, Berkeley, California (Dr Gruenewald).

Correspondence: Jeffrey J. Sacks, MD, MPH, c/o Sue Binder Consulting, Inc, 201 W. Ponce de Leon Ave, Unit 38, Decatur, GA 30030 (

Jeffrey Sacks received funding for this project from the National Association of Chronic Disease Directors (contract no. 1212018).

A number of individuals reviewed and commented on portions of this work, including Mary Beth Cox, MPH, Injury and Violence Prevention Branch Division of Public Health, North Carolina Department of Health and Human Services; Hillary Kunins, MD, MPH, MS, Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, New York City Department of Health and Mental Hygiene; Timothy Naimi, MD, MPH, Section of General Internal Medicine, Boston Medical Center and Boston University Schools of Medicine and Public Health; Jim Roeber, MSPH, Research/Development and Transition Informatics, Data and Analytics, Presbyterian Healthcare Services; Mandy Stahre, PhD, MPH, Health Care Research Center, Washington State Office of Financial Management; Laura Tomedi, PhD, MPH, Substance Abuse Epidemiology Section, Epidemiology and Response Division, New Mexico Department of Health.

Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.

None of the authors have relevant financial disclosures or conflicts of interest. Jeffrey Sacks conducted this work while an employee of Sue Binder Consulting, Inc. Robert Brewer, Jessica Mesnick, James Holt, Dafna Kanny, Xingyou Zhang, and Randy Elder conducted this work while employees of the Centers for Disease Control and Prevention. Paul Gruenewald conducted this work while an employee of the Pacific Institute for Research and Evaluation.

Disclaimer: The findings and conclusions in this publication are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, and should not be construed to represent any official USDA or U.S. Government determination or policy.

Human participant compliance statement: No human subjects were involved in this work.

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.