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Alcohol – Excessive Consumption: Regulation of Alcohol Outlet Density


What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 39 studies (search period through October 2007). Twenty nine studies assessed the effects of interventions that resulted in changes in outlet density, and 10 time-series studies assessed the consequences of changes in outlet density in which the cause of density change was unknown. The review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to preventing excessive alcohol consumption.


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Summary of Results

Detailed results from the systematic review are available in the CPSTF finding pdf icon [PDF - 128 kB].

No studies were found that directly examined the effects of local interventions to limit alcohol outlet density.

Several types of studies were found that consistently indicated that alcoholic beverage outlet density and policy changes that affect alcohol outlet density were associated with excessive alcohol consumption and related harms.

Policy Changes that Increased Alcohol Outlet Density

Four studies qualified for systematic review.

  • Policies that increased alcohol outlet density were found to result in increased excessive alcohol consumption and related harms.

Alcoholic Beverage Retail Privatization

This occurs when governments relinquish monopoly control over the retail sale of alcoholic beverages. Privatization commonly results in increased alcohol outlet density, among other changes.

Seventeen studies that assessed the effects of privatization in 14 settings and one study of government re-monopolization qualified for the review.

  • Privatization of alcohol sales was associated with increases in excessive alcohol consumption of the privatized beverage and minimal effects on beverages not privatized.
  • One study of government re-monopolization indicated that re-monopolization may reduce alcohol-related harms.

Bans Against Alcoholic Beverages

Bans against alcoholic beverages reduce the density of alcohol outlets to zero. Repeal of bans allows for expanded density of outlets.

Seven studies qualified for systematic review.

  • Bans against alcoholic beverages can reduce excessive alcohol consumption and related harms, particularly in isolated environments without other sources of alcohol.

Association Between Alcohol Outlet Density Change and Alcohol-related Harms, in Which the Cause of Density Change Was Not Assessed

Nine studies qualified for systematic review.

  • 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.


Summary of Economic Evidence

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


Findings from this review are likely applicable to settings in the U.S. and Canada, including tribal areas, as well as other high-income countries.

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified Evidence Gaps

Results from the Community Guide review indicate that the regulation of alcohol outlet density can be an effective means of controlling excessive alcohol consumption and related harms. It would be useful, however, to conduct additional research in the following areas to further assess this relationship.

  • There are few, if any, studies evaluating how local decisions are made regarding policies affecting alcoholic beverage outlet density, or the consequences of such policy changes. While such case studies may be difficult to conduct, they could provide important insights to guide policy decisions regarding alcohol outlet density in other communities.
  • The majority of outlet density research explores the impact of increasing alcohol outlet density on alcohol-related outcomes; there is a lack of research on the impact of reducing outlet density. This might be done by observing the impact of temporal changes in outlet density on excessive alcohol consumption and related harms.
  • Relatively little is known about the impact of density changes relative to baseline density levels. Some authors 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. Thus, it would be useful to assess this hypothesis empirically, using econometric methods, with different kinds of alcohol-related outcomes. Such information would allow communities at different alcohol outlet density “levels” to project the possible benefits of reducing density by specific amounts or the potential harms of increasing density.
  • For public health practitioners, legislators, and others attempting to control alcohol outlet density to reduce alcohol-related harms, it would be useful to catalog approaches to regulation beyond licensing and zoning that may have an effect on outlet density (e.g., traffic or parking regulations which, in effect, control the number of driving patrons who may patronize an alcohol outlet).
  • The primary rationale for limiting alcohol outlet density is to improve public health and safety. Furthermore, the economic efficiency of limiting outlet density is difficult to assess without data on the economic impact of this intervention. To remedy this, future studies on the impact of changes in alcohol outlet density should assess both health and economic outcomes, so that the economic impact of this intervention can be assessed empirically.

Study Characteristics

  • 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 remonopolization; conducted in the U.S., 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., the 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 is 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 U.S., Canada, the United Kingdom, and Norway).
  • Secondary evidence included cross-sectional studies, which do not allow the inference of causality.