摘要：Objectives. Alcohol outlet density has long been associated with alcohol-related harms, and policymakers have endorsed alcohol outlet restriction to reduce these harms. However, potential nonlinearity in the relation between outlet density and alcohol consumption has not been rigorously examined. Methods. We used data from the New York Social Environment Study (n = 4000) to examine the shape of the relation between neighborhood alcohol outlet density and binge drinking by using a generalized additive model with locally weighted scatterplot smoothing, and applied an imputation-based marginal modeling approach. Results. We found a nonlinear relation between alcohol outlet density and binge drinking; the association was stronger at densities of more than 80 outlets per square mile. Binge drinking prevalence was estimated to be 13% at 130 outlets, 8% at 80 outlets, and 8% at 20 outlets per square mile. Conclusions. This nonlinearity suggests that reductions in alcohol outlet density where density is highest and the association is strongest may have the largest public health impact per unit reduction. Future research should assess the impact of policies and interventions that aim to reduce alcohol outlet density, and consider nonlinearity in effects. A substantial body of research has found that availability of alcohol, as measured by alcohol outlet density, is related to societal problems that include driving under the influence, 1,2 automobile crashes, 3–6 injuries, 7 suicide, 6 and violence. 8–22 Alcohol outlet density has also been related to higher mean alcohol consumption, 23–26 binge or heavy drinking, 27,28 alcohol disorders, 29 and liver problems. 30 Recent systematic reviews have concluded that the literature supports restriction of alcohol outlet density as an effective measure to reduce alcohol-related harms. 31,32 Furthermore, a variety of policymaking bodies have endorsed alcohol outlet density restriction, specifically the Task Force on Community Preventive Services, the European Union, the World Health Organization, and Substance Abuse and Mental Health Services Administration. 31,33–36 Although the literature strongly suggests that alcohol outlet density shapes alcohol-related outcomes, most of the existing research makes the implicit assumption that the relation is essentially linear. A recent review called for research that considers the shape of the relation between alcohol outlet density and alcohol-related outcomes because the shape has practical implications for intervention and policy. 31 If the relation were linear, interventions that aim to reduce alcohol outlet density at any baseline density would be equally effective. However, if the shape of the relation were nonlinear, interventions would have differing degrees of effectiveness in reducing alcohol-related harms depending on the baseline alcohol outlet density. There is a limited body of work that has considered the shape of the relation between alcohol outlet density and various outcomes. Two studies on violence assessed potential nonlinear associations with alcohol outlet density, and found stronger relations with violence at higher outlet densities. 37,38 Only 1 study examined potential nonlinearity in the relation between alcohol outlet density and alcohol consumption; this study found substantially stronger relations between outlet density and harmful alcohol consumption for the highest category of outlet density. However, the use of a categorical approach (with an open-ended upper category) to examine density provides a limited assessment of the shape of the relation. 39 There is a need for research that rigorously examines the shape of the relation between alcohol outlet density and alcohol consumption. Building on the extant research, we examined the relation between neighborhood alcohol outlet density and binge drinking in an urban population. We examined the shape of the relation by using a semiparametric general additive model with locally weighted scatterplot smoothing (loess) instead of assuming a standard form. Then we applied a marginal modeling approach to estimate prevalences of binge drinking associated with “setting” neighborhood alcohol outlet density to levels across the range of the data. 40,41
