31/01/2017

1

Alcohol outlet density, health

inequalities and policy translation:

findings from the UK

Professor Jamie PearceChair in Health Geography

Centre for Research on Environment, Society and Health

University of Edinburgh

@jamie0pearce

jamie.pearce@ed.ac.uk

31/01/2017

2

31/01/2017

3

Structure

• Geographies of alcohol

• Alcohol retail environment

• Alcohol environment and health in Scotland

• Research translation

• What is missing?

Geographical Contribution

Pbase.com

31/01/2017

4

Place and Alcohol

• Individual behavioural perspectives

• BUT partial account for social & cultural factors integral to understanding drinking.

• policy response – ‘lifestyle drift’ rather than considered in wider context

• Drinking enabled & constrained by socio-geographical factors

• reality of drinking in everyday life

• how public health messages received, negotiated & mediated

• Individual factors and environments interact to produce spaces that are more or less favourable to drinking

• neighbourhoods, schools, workplaces, etc.

Geographical factors &

alcohol

31/01/2017

5

Inequalities as central

RESEARCH AIMS

• Scottish study examining:

• social & spatial distribution of alcohol

retailing

• associations between the geographies of

alcohol retailing and

(i) alcohol consumption Assess whether these patterns vary by individual level

socio-economic status

(ii) related health outcomes

31/01/2017

6

Methods

Controlled for sex, age, religion, marital & socio-economic status, urbanity, neighbourhood deprivation

ALCOHOL OUTLET DATA

• Premises selling alcohol

licensed under the Licensing

(Scotland) Act 2005

• Postcodes of all licensed

premises (16,159) from

Liquor Licensing Boards

(4,800 off-sales and 11,359

on-sales)

• Created a density measure

at the data zone level for the

whole of Scotland for total

outlets, off-sales outlets and

on-sales outlets

31/01/2017

7

ALCOHOL OUTLET DISTRIBUTION

Alcohol outlet density and

area level deprivation

31/01/2017

8

Alcohol outlet density and

drinking behaviours• Linked outlet data to individual level responses to the Scottish

Health Survey (2008-2011 n = 28,765)

• Four measures of drinking:

• Exceeding recommended weekly and/or daily limits (43.5%)

• Harmful drinking (4.5%)

• Binge drinking (21.2%)

• Problem drinking (8.6%)

• Need to cut down

• Feeling ashamed

• Annoyed by criticism

• Shaky hands

• Drinking in morning

• Unable to stop drinking

0.9

0.95

1

1.05

1.1

1.15

1.2

1.25

1.3

1.35

1.4

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

1.5

1.6

1.7

0.8

0.9

1

1.1

1.2

1.3

1.4

0.8

0.9

1

1.1

1.2

1.3

1.4

1.5

Exceeding Recommendations Harmful Drinking

Binge Drinking Problem Drinking

Controlled for sex, age, religion, marital & socio-economic status, urbanity, neighbourhood deprivation

31/01/2017

9

Income inequalities

0

10

20

30

40

50

60

Exceeding Harmful Binge Problem

% o

f re

sp

on

den

ts

<£16,339

£16340-£31707

>£31708

Exceeding recommendations

0.37

0.34

0.38

0.43

0.42 0.42

0.45 0.45

0.510.52

0.51

0.53

0.30

0.35

0.40

0.45

0.50

0.55

0.60

1 2 3 4

Pro

bab

ilit

y o

f exceed

ing

reco

mm

en

dati

on

s

Lowest Income Middle Income Highest Income

31/01/2017

10

Harmful drinking

0.04

0.04

0.06

0.07

0.03 0.03

0.05

0.050.050.05

0.04 0.04

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

0.10

1 2 3 4

Pro

bab

ilit

y o

f H

arm

ful D

rin

kin

g

Lowest Income Middle Income Highest Income

Binge drinking

0.17

0.16

0.19

0.24

0.19

0.20

0.230.22

0.240.25 0.25

0.25

0.10

0.12

0.14

0.16

0.18

0.20

0.22

0.24

0.26

0.28

0.30

1 2 3 4

Pro

bab

ilit

y o

f b

ing

e d

rin

kin

g

Lowest Income Middle Income Highest Income

31/01/2017

11

Problem drinking

0.10

0.11

0.12

0.15

0.08

0.09

0.11

0.10

0.090.09 0.09 0.08

0.05

0.07

0.09

0.11

0.13

0.15

0.17

0.19

1 2 3 4

Pre

dic

ted

pro

bab

ilit

y o

f p

rob

lem

dri

nkin

g

Lowest Income Middle Income Highest Income

Alcohol outlet density:

mortality and morbidity

• Alcohol-related deaths between 2002 and 2011 from General Register Office for Scotland (GROS) n=12,835

• Alcohol-related hospitalisation indicator from the Health domain of the Scottish Index of Multiple Deprivation 2012 (SIMD)

31/01/2017

12

Alcohol-related death rates for off-sales outlet

availability groups

Increasing Density

Alcohol-related hospitalisations for off-sales

availability groups

Increasing Density

31/01/2017

13

Summary

• The lowest income groups are disproportionately affected by outlet density compared to both mid and higher income groups.

• For all outcomes there is an increase in probability for the lowest income tertile between the lowest and highest outlet density.

• No significant increase for the highest or middle income tertiles for any outcome, regardless of type of outlet.

• Alcohol-related death rates in neighbourhoods with the most alcohol outlets were more than double the rates in those with the fewest outlets.

• Across the whole of Scotland, alcohol-related hospitalisationrates were significantly higher in neighbourhoods with the most alcohol outlets.

Broader research translation

• Making data publically

available

• Twitter, presentations etc

• Blogs

• Infographics

• Commendation in the Scottish

Parliament supported by 27

MSPs

• Amendment proposed to a bill

to create retailers register

31/01/2017

14

31/01/2017

15

31/01/2017

16

Policy message

• Interventions that focus on changing individual behaviouralone, ignoring broader context, will not work.

• Interventions must be designed to reduce inequalities, otherwise they may increase the very inequalities they aim to tackle.

• Tackling alcohol-related harm requires a multi-pronged approach.

• Data should be freely available.

• Need to address the retail environment; in a Scottish context this means defining overprovision and more clearly supporting the public health licensing objective. How does this translate in an Irish context?

• Failure to do so may exacerbate health inequalities.

31/01/2017

17

Biggest challenges

• Public opinion and how it is shaped – Stigma

(including place based stigma)

• Understanding the causal pathway between

environment and health behaviours

• Evidence into policy - conversations

What is lacking?

• Critical global health

• Longitudinal/lifecourse approaches

• Activity spaces

• A focus on co-behaviours (smoking, diet etc)

• A greater focus on inequalities

31/01/2017

18

31/01/2017

19

What is lacking?

• Critical global health

• Longitudinal/lifecourse approaches

• Activity spaces

• A focus on co-behaviours (smoking, diet etc)

• A greater focus on inequalities

Availability of Alcohol AND

Tobacco by deprivation

31/01/2017

20

Funders

• Niamh Shortt, Richard Mitchell, Catherine Tisch, Elizabeth Richardson, Tom Clemens & Esther Rind.

• This work was supported by the European Research Council [ERC-2010-StG Grant 263501]. The work developing the tobacco outlet measures was supported by the Scottish Collaboration for Public Health Research and Policy (SCPHRP).

• All data available at www.cresh.org.uk/webmap

• Twitter @jamie0pearce