In the past decade, there has been a strategic shift towards alcohol-related trade liberalization in both developed and developing countries that has led to the deregulation of liquor control policies and the development of pro-market practices in the alcohol sector. (1,2) In the past two years, several Canadian provinces, such as New Brunswick, Ontario and British Columbia, have expanded the distribution of alcohol to allow the sale of wine and/ or beer in private agency and grocery stores that are not owned or operated by the provincial liquor corporation. (3-6)

Greater alcohol availability has been identified as a significant public health concern because of the increased consumption and associated alcohol-related harms that result from expanding the places where liquor can be sold in the community. (7) Previous research has found a strong relationship between liquor outlet proximity, alcohol availability, and higher rates of consumption and alcohol-related harms, such as premature mortality and risk of injury, among youth and adults. (8-10) Youth have been found to be especially vulnerable to increased alcohol availability as a result of early exposure to alcohol-related marketing and the normalization of alcohol consumption, which are both strong predictors of substance abuse problems in adulthood. (11-13) Off-sales locations such as agency and grocery stores have been found to be problematic because of poor controls over the sale of alcohol to minors and the availability of large quantities of liquor that can be freely consumed in the community. (14-16) Previous research has shown that outlet density and proximity are important determinants of alcohol consumption among young people. (8,17,18) This has been attributed to underage youth obtaining alcohol from off-sales locations with less stringent selling practices, and the demonstrated relationship between outlet density and exposure to illicit drugs and violence. (8,9,15,19,20)

Despite the known relationship between outlet density, proximity, and alcohol-related harms, there has been limited research completed on how recent changes to liquor policy will affect exposure to, and the availability of, alcohol products in Canadian communities. New Brunswick is an ideal case study to examine liquor policy reform measures and access to alcohol products because of modifications to the distribution of alcohol in recent years, and the high rates of alcohol abuse and binge drinking among youth and adults. (21) The criminal justice, societal, and health care costs associated with alcohol abuse in New Brunswick are the highest in Canada, equalling $597 per resident. (22) Among young people, 43.9% of students in Grade 12 reported binge drinking in the previous month. (21)

In October 2016, the Province of New Brunswick began allowing the sale of wine in selected grocery stores with the goals of improving customer convenience and increasing the revenue generated through the provincial liquor board (NBLiquor). (4,23) As in other Canadian provinces, New Brunswick's alcohol retail system functions within a governmental monopoly, and its operations are monitored by the Ministry of Public Safety and the Solicitor General. (24) NB-Liquor monitors the sale of alcohol to minors through "mystery shopper" tests in conjunction with liquor inspectors and local law enforcement; however, the findings and impact of this internal monitoring system are unclear. (24) To date, an unknown number of grocery stores have been permitted to sell wine in addition to the initial six pilot store sites. (25) Prior to the sale of alcohol in grocery stores, only agency stores (N = 110) were allowed to sell spirits, beer and wine in addition to the existing NB-Liquor stores (N = 43). The purpose of this project was to evaluate how these changes are distributed across urban and rural communities and low- and high-income neighbourhoods. The objectives were to 1) estimate the population living close to alcohol outlets before and after liquor distribution reforms, 2) identify communities or regions that would be more or less affected, and 3) determine whether expanding access to alcohol products would reduce school proximity to retailers.

METHOD

Data sources

Data from Statistics Canada, Desktop Mapping Technologies Inc. (DMTI), and geospatial publicly available data were linked and analyzed using ArcGIS 10.1, SAS 9.3 and SPSS 23. (26,27) The latitude and longitude of NB-Liquor and agency stores were obtained from the NB-Liquor website. (28) The locations of kindergarten to grade 12 schools and grocery stores were sourced from the DMTI Enhanced Point of Interest database. (29) Statistics Canada's PCCF+ (Postal Code Conversion File) was used to obtain neighbourhood socio-economic status and metropolitan influenced zone (MIZ) ranking of postal codes. (30) Data on binge drinking by youth was sourced from the New Brunswick Health Council's "My Community at a Glance"

Community Profiles. (31) The data were compiled and spatially linked to Census Dissemination Areas (DAs) for geospatial analysis.

Data analysis

To estimate the population living within 499 m, 500-999 m and 1-5 km of a liquor sales outlet, buffers were created around each of the geocoded data points using road network data. Statistics Canada's Ecumene file was used to remove geographic areas with no residents from the buffers to more accurately represent the distribution of the population within each buffer. (32) The area of DAs was calculated in metres squared. The population within the buffers was measured using a tabulated intersection that estimated the proportion of the DAs contained within the buffer. This process was repeated for each of the buffers representing <499 m, 500-999 m, and 1-5 km of liquor store, agency store and grocery store locations. The distance from schools to liquor, agency and grocery stores was measured using road files that were modelled by means of the network analysis tool in ArcGIS. The proximity of schools to each type of store was measured in metres and examined for urban and rural, and low-, middle and high-income DAs. The chi-square test of association ([chi square]) was used to measure the association between distance to schools, store type and urban-rural status.

Measures

Distance

We defined close proximity to liquor outlets as a distance up to 499 m or a six minute walk. This distance was selected because it has been used in previous research that has examined school proximity to other retailers, such as fast-food restaurants, that sell products relevant to public health. (33,34)

Neighbourhood Socio-economic Status

Socio-economic status was measured at the DA level using the PCCF+ program that was created by Statistics Canada. (30) Two variables were used to rank DAs into quintiles that summarized the "neighbourhood income per person equivalent" based on the adjusted household income and the low-income cut-off used in the 2006 Census. (30) The first measure of socio-economic status is described by Statistics Canada as QAIPPE. This scale ranks DAs on the basis of income distribution within the local Census Metropolitan Area (CMA). In contrast, the second measure (QNIPPE) ranks DAs using the national distribution of income quintiles from across Canada, which provides a method to compare communities irrespective of local trends in neighbourhood socioeconomic status by province or region. (30)

Metropolitan Influenced Zones

Urban, suburban, and rural communities were identified using the Statistics Canada MIZ scale, which is used to define suburban, rural and remote places outside of CMAs (urban areas with a population over 100 000 that have 50 000 persons living in the core area) and Census Agglomerations (CAs) (population of 10 000). (30) The MIZ scale is based on the proportion of the population in a census subdivision that commutes to a nearby CMA or CA.

Schools

All public and private kindergarten to grade 12 schools listed in the DMTI Enhanced Points of Interest database were included in the study (N = 378).

Store Types Liquor

NB-Liquor stores are stand-alone stores operated by the provincial New Brunswick Liquor Corporation and staffed by unionized employees of NB-Liquor. (28)

Agency

Agency stores are convenience stores, gas stations and other small businesses that sell a selection of NB-Liquor products. (35) Agency stores typically sell between $350,000 and $3,000,000 worth of alcohol products annually alongside a selection of grocery, automobile and other items. (35)

Grocery

Grocery stores predominantly sell produce, meat and other food-related products. In New Brunswick, most grocery stores are owned and operated by Cooperatives (N = 18), Sobeys (N = 13), Superstore (N = 14), Foodland (N = 5), Price Chopper (N = 4) and Save Easy (N = 9).

Binge Drinking

Alcohol use among youth was measured as "5 or more drinks at one time, at least once a month in the past 12 months" for young people in grades 9-12. (31) These data were collected in 2009 by the Government of New Brunswick as part of the Department of Healthy and Inclusive Communities, Student Wellness Survey. (36)

RESULTS

Alcohol availability and retail expansion

A total of 153 NB-Liquor (N = 43) and agency stores (N = 110) selling alcohol products were identified once geocoded locations had been merged with ecological data from the PCCF+. (30) The locations of liquor outlets by store type are displayed in Figure 1. Permitting the sale of alcohol in all grocery stores throughout the province would increase the number of alcohol outlets by 84.4%, from 153 to 282. Table 1 summarizes the proportion and count of stores by community characteristics. The highest proportion of NB-Liquor (62.79%, N = 27) and agency stores (47.27%, N = 52) were located in urban areas. Allowing the sale of alcohol in all existing grocery stores would increase the overall number of retail outlets in urban areas from 79 to 141 stores. In suburban areas, an additional 40 liquor outlets would be established, and the number of stores would double in rural communities from 26 points of sale to 53.

The local measure of neighbourhood socio-economic status (QAIPPE) ranked 46.1% (N = 130) of stores as located in low-income areas. In contrast, the national indicator (QNIPPE) ranked 78.72% (N = 222) of stores as being in low-income areas. Both measures of neighbourhood socio-economic status indicated that most existing NB-Liquor (QAIPPE: 41.86%, N = 18; QNIPPE: 72.09%, N = 31) and agency stores (QAIPPE: 47.27%, N = 52; QNIPPE: 77.27%, N = 85) were located in low-income communities. Using the national scale of neighbourhood socioeconomic status (QNIPPE), allowing grocery stores to sell alcohol would increase the number of outlets by 91.38% in low-income communities from 116 to 222, compared with a 54.29% increase in middle-income areas from 35 outlets to 54.

Population proximity to liquor outlets

The populations residing within 499 m, 500-999 m, and 1-5 km of agency, NB-Liquor and grocery stores are described in Table 2 and displayed in Figure 2. Expanding liquor sales to grocery stores would increase the population that lives within 5 km of an outlet from 386 686 to 412 982, representing 54.98% of the total population of the province. The largest increase would occur in the population residing within 0-499 m of a liquor sales outlet (either agency, NB-Liquor or grocery store): by 97.49%, from 19 886 to 39 273 residents, if all grocery stores became liquor sales outlets. In contrast, the population living within 500-999 m of a liquor outlet would grow by 66.99% from 52 755 to 88 094, and the number of residents within 1-5 km of a liquor outlet would increase from 341 479 to 386 686.

Distance to schools

There were 30 existing agency (N = 19) and NB-Liquor stores (N = 11) identified that were located within 499 m of a school (Table 3). Permitting the sale of alcohol in grocery stores would result in an additional 35 liquor sales outlets being located within 499 m of schools. Urban areas had the highest proportion of stores located within 499 m of a school (28.92%, N = 35), followed by rural communities (26.67%, N = 12). Low-income neighbourhoods, as measured using the QNIPPE and QAIPPE socioeconomic scales, had the greatest number of stores that were within 499 m of a school (QAIPPE: N = 35, QNIPPE: N = 58).

A summary of liquor outlet proximities to schools by health region is contained within Table 4, and a map of health regions and the location of liquor outlets within 499 m of schools is provided in Figure 3. Zone 3 (Fredericton/River Valley Area) had the greatest number of liquor outlets (with and without the introduction of grocery stores) within 499 m of schools (agency and NB-Liquor stores N = 9; total N = 16) followed by Zone 1 (Moncton/South-East Area; agency and NB-Liquor stores N = 6; total N = 13), and Zone 2 (Fundy Shore/Saint John Area; agency and NB-Liquor stores N = 5; total N = 12). As shown in Figure 3, rural areas had substantially fewer liquor outlets within 499 m of a school; however, these regions would have large increases relative to their existing liquor outlets if all grocery stores were permitted to sell alcohol products. For example, the number of liquor outlets within 499 m of a school would double in Zone 6 (Bathurst/Acadian Peninsula Area) from 4 to 8, and it would triple in Zone 7 (Miramichi Area) from 1 to 4. Although no direct causation can be established between outlet proximity and youth binge drinking in this study, the rural health regions that would experience some of the greatest growth in alcohol outlets are regions that have some of the highest rates of youth binge drinking in the province (e.g., Restigouche, Bathurst, and the Acadian Peninsula area, see Table 4).

DISCUSSION

Population proximity to liquor outlets

Allowing grocery stores to sell liquor products would increase the proportion of the population that resides within 5 km of an outlet by 9.47%, from 377 264 to 412 982, whereas there would be a 97.49% increase in the population living within 0-499 m of a liquor outlet, from 19 886 to 39 273. These findings suggest that selling liquor products in grocery stores would potentially affect the density of liquor outlets in neighbourhoods that are already well served as opposed to expanding into areas with poor access to alcohol products. Existing research has consistently found that greater access to alcohol leads to increased levels of alcohol consumption and alcohol-related harms, such as interpersonal violence, injury, and the development of alcohol-related physical and mental health problems. (5,37-40) Research focusing on the introduction of alcohol retail into grocery stores has found increased levels of consumption of the liquor products stocked within the grocery store setting. (41) Other studies support these findings, adding that not only does selling alcohol within grocery stores increase alcohol consumption but that the highest increases can occur in female and rural populations. (42) Research from other Canadian provinces, such as British Columbia, has identified increases in alcohol-related risk outcomes and alcohol-attributable mortality following the expansion of alcohol retail outlets. (5,6) Communities with greater access to alcohol have also been shown to generally have higher rates of violent crime and growth in the number of hospital visits for stress, anxiety and depression. (43-46)

Neighbourhood socio-economic status

While levels of alcohol consumption tend to be somewhat uniform across a population, individuals of lower socio-economic status tend to experience greater levels of alcohol-related harm than individuals of a higher socio-economic status. (47) Exacerbating this issue is the finding that communities with a lower socio-economic status tend to have higher levels of alcohol outlet density and thus greater access to alcohol than those of higher socio-economic status. (44) Furthermore, outlet proximity to schools has been identified in previous research as a risk factor for youth alcohol consumption. (43) In this study, we found that low-income communities have a higher proportion of outlets located near schools, and opening new points of liquor sales in these communities would disproportionately negatively affect youth living there. Overall, regional alcohol policies are a primary determining factor for local levels of alcohol consumption and alcohol-related harm; therefore, strong alcohol control systems can help to mitigate inequitable alcohol-related health impacts across socio-economic groups. (48) Alcohol monopolies represent one of the most effective mechanisms for regulating alcohol in a responsible manner to minimize harm to the public. (37,48) Government-run alcohol monopolies have the potential to regulate alcohol as a controlled substance, as opposed to a regular commodity comparable with subsistence items, such as food, commonly found in grocery store settings. Monopolies offer an opportunity for the government to regulate access, availability, and alcohol marketing in order to encourage responsible consumption and reduce alcohol-related harms, such as drinking and driving, and the sale of liquor products to minors. (5,37)

Youth exposure to alcohol products

Allowing the sale of alcohol in grocery stores would more than double the number of liquor outlets within 499 m of schools, from 30 to 65. This would expand youth exposure to alcohol products and contribute to the normalization of alcohol consumption through product placement in grocery stores that are frequented by youth with and without their parents. Research demonstrates that alcohol marketing in childhood lowers the age that youth begin drinking and increases the amount of alcohol consumed. (49-53) Permitting alcohol retail within grocery stores increases youth exposure to alcohol marketing (including product labeling), which has been found to be an effective method of increasing youth alcohol consumption. (54) Not only does exposure to in-store alcohol marketing pose a risk factor for children and youth but the real and perceived availability of alcohol within the community also influences alcohol consumption by minors. (55,56) In the New Brunswick grocery store sites, alcohol products have been co-located with soda drinks, as well as candy, produce and other non-drug commodities. In this context, it is important to consider the historic and strategic convergence of the soda pop and alcohol markets over time as they target the youth market in an attempt to build brand loyalty at an early age. (57-59) From a public health perspective, placing alcohol products in grocery stores also increases community exposure to end-of-aisle, point-of-purchase, and entryway displays of liquor products that have been found to be effective mechanisms to increase alcohol purchases. (60)

Limitations

There are a number of limitations to consider when interpreting the results of this study. The approach used to estimate the population within each buffered DA assumes that the population is evenly distributed across the area, which is unlikely. We attempted to reduce this limitation by applying Ecumene boundaries to the buffered areas to exclude land within each DA that was not inhabited. The retail store data used for this study were sourced in May 2016 and it is possible that stores have opened or closed during this period.

CONCLUSION_

The results of this study demonstrate the impact of recent and proposed changes to alcohol distribution on access to liquor products, and the proximity of points of sale relative to schools in urban and rural, and low-, middle- and high-income communities in New Brunswick. Expanding the sale of alcohol to all grocery stores will predominantly affect low-income neighbourhoods and increase youth exposure to alcohol products in low-income socioeconomic areas that have the greatest number of schools within 499 m of a liquor outlet. The findings of this study show the importance of considering social, economic and health inequities in the context of formulating responsible alcohol control policies that minimize alcohol-related harms.

doi: 10.17269/CJPH.108.6132

Acknowledgements: AKS extends her thanks to Todd Wuolle for his technical assistance extracting the coordinates of the NB-Liquor and agency store sites. AKS acknowledges the support provided by the New Brunswick Health Research Foundation (NBHRF) and the Canadian Institutes of Health Research (CIHR)Strategy for Patient Oriented Research-Maritime SPOR SUPPORT Unit (MSSU) Post-Doctoral Fellowship award. This project was completed as part of the CIHR-funded Community-Based Primary Health Care Team Grant "Barriers and Facilitators in Access to Child/Youth Mental Health Services: A Mixed Methods, Inter-sectorial Study in Atlantic Canada". CIHR, the MSSU and NBHRF had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript.

REFERENCES

(1.) Moodie R, Stuckler D, Monteiro C, Sheron N, Neal B, Thamarangsi T, et al. Profits and pandemics: Prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013; 381(9867):670-79. PMID: 23410611. doi: 10.1016/S0140-6736(12)62089-3.

(2.) WHO. Global Status Report on Alcohol and Health. Geneva, Switzerland: World Health Organization, 2014:1-100. Available at: entity/substance_abuse/ publications/global_alcohol_report/en/index.html (Accessed January 4, 2017).

(3.) CBC News. Ontario's cancer agency warns about possible risks as grocery stores begin stocking wine--CBC.ca Metro Morning. CBC, Toronto, ON, 2016. Available at: http://www.cbc.ca/news/canada/toronto/programs/ metromorning/cancer-risks-grocery-store-wine-1.3825911 (Accessed January 3, 2017).

(4.) CBC News. NB Liquor may expand wine in grocery stores pilot project New Brunswick--CBC News. CBC News 2014. Available at: http://www.cbc. ca/news/canada/new-brunswick/nb-liquor-may-expand-wine-in-grocerystores-pilot- project-1.2715450 (Accessed January 3, 2017).

(5.) Stockwell T, Zhao J, Macdonald S, Vallance K, Gruenewald P, Ponicki W, et al. Impact on alcohol-related mortality of a rapid rise in the density of private liquor outlets in British Columbia: A local area multi-level analysis. Addiction 2011; 106(4):768-76. PMID: 21244541. doi: 10.1111/j.1360-0443.2010. 03331.x.

(6.) Stockwell T, Zhao J, MacDonald S, Pakula B, Gruenewald P, Holder H. Changes in per capita alcohol sales during the partial privatization of British Columbia's retail alcohol monopoly 2003-2008: A multi-level local area analysis. Addiction 2009; 104(11):1827-36. PMID: 19681801. doi: 10.1111/ j.1360-0443.2009.02658.x.

(7.) Bryden A, Roberts B, McKee M, Petticrew M. A systematic review of the influence on alcohol use of community level availability and marketing of alcohol. Health Place 2012; 18(2):349-57. PMID: 22154843. doi: 10.1016/ j.healthplace.2011.11.003.

(8.) Chen M-J, Grube JW, Gruenewald PJ. Community alcohol outlet density and underage drinking. Addiction 2010; 105(2):270-78. PMID: 20078485. doi: 10. 1111/j.1360-0443.2009.02772.x.

(9.) Chen M-J, Gruenewald PJ, Remer LG. Does alcohol outlet density affect youth access to alcohol? J Adolesc Health 2009; 44(6):582-89. PMID: 19465323. doi: 10.1016/j.jadohealth.2008.10.136.

(10.) Treno AJ, Grube JW, Martin SE. Alcohol availability as a predictor of youth drinking and driving: A hierarchical analysis of survey and archival data. Alcohol Clin Exp Res 2003; 27(5):835-40. PMID: 12766629. doi: 10.1097/ 01.ALC.0000067979.85714.22.

(11.) Bonomo YA, Bowes G, Coffey C, Carlin JB, Patton GC. Teenage drinking and the onset of alcohol dependence: A cohort study over seven years. Addiction 2004; 99(12):1520-28. PMID: 15585043. doi: 10.1111/j.1360-0443.2004. 00846.x.

(12.) McCreanor T, Barnes HM, Kaiwai H, Borell S, Gregory A. Creating intoxigenic environments: Marketing alcohol to young people in Aotearoa New Zealand. Soc Sci Med 2008; 67(6):938-46. PMID: 18619720. doi: 10.1016/j.socscimed. 2008.05.027.

(13.) Gordon R, Harris F, Marie Mackintosh A, Moodie C. Assessing the cumulative impact of alcohol marketing on young people's drinking: Cross-sectional data findings. Addict Res Theory 2011; 19(1):66-75. doi: 10.3109/16066351 003597142.

(14.) Milam AJ, Furr-Holden CDM, Harrell P, Ialongo N, Leaf PJ. Off-premise alcohol outlets and substance use in young and emerging adults. Subst Use Misuse 2014; 49(1-2):22-29. PMID: 23909579. doi: 10.3109/10826084.2013. 817426.

(15.) Paschall MJ, Grube JW, Black C, Flewelling RL, Ringwalt CL, Biglan A. Alcohol outlet characteristics and alcohol sales to youth: Results of alcohol purchase surveys in 45 Oregon communities. Prev Sci 2007; 8(2):153-59. PMID: 17243019. doi: 10.1007/s11121-006-0063-0.

(16.) Halonen JI, Kivimaki M, Virtanen M, Pentti J, Subramanian SV, Kawachi I, et al. Proximity of off-premise alcohol outlets and heavy alcohol consumption: A cohort study. Drug Alcohol Depend 2013; 132(1):295-300. PMID: 23499055. doi: 10.1016/j.drugalcdep.2013.02.022.

(17.) Rowland B, Toumbourou JW, Satyen L, Tooley G, Hall J, Livingston M, et al. Associations between alcohol outlet densities and adolescent alcohol consumption: A study in Australian students. Addict Behav 2014; 39(1): 282-88. PMID: 24183302. doi: 10.1016/j.addbeh.2013.10.001.

(18.) Young R, Macdonald L, Ellaway A. Associations between proximity and density of local alcohol outlets and alcohol use among Scottish adolescents. Health Place 2013; 19(100):124-30. PMID: 23220375. doi: 10.1016/j.healthplace. 2012.10.004.

(19.) Gosselt JF, van Hoof JJ, de Jong MDT, Prinsen S. Mystery shopping and alcohol sales: Do supermarkets and liquor stores sell alcohol to underage customers? J Adolesc Health 2007; 41(3):302-8. PMID: 17707301. doi: 10.1016/ j.jadohealth.2007.04.007.

(20.) Freisthler B, Johnson-Motoyama M, Kepple NJ. Inadequate child supervision: The role of alcohol outlet density, parent drinking behaviors, and social support. Child Youth ServRev 2014; 43:75-84. PMID: 25061256. doi: 10.1016/ j.childyouth.2014.05.002.

(21.) Officer of the Chief Medical Officer of Health. New Brunswick health indicators: Alcohol and health. Fredericton 2015. Available at: http://www2. gnb.ca/content/dam/gnb/Departments/h-s/pdf/en/Publications/Health IndicatorsAlcoholMay2015.pdf (Accessed January 6, 2017).

(22.) Rehm J, Baliunas D, Brochu S, Fischer B, Gnam W, Patra J, et al. The Costs of Substance Abuse in Canada 2002. Ottawa, ON: Canadian Centre on Substance Abuse, 2006. Available at: http://www.alcsmart.ipin.edu.pl/files/cb02a_ final_csac.pdf (Accessed January 4, 2017).

(23.) Karissa Donkin SF. NB Liquor finds support for wine in grocery stores--New Brunswick--CBC News. CBC News 2016. Available at: http://www.cbc.ca/ news/canada/new-brunswick/nb-liquor-wine-sales-grocery-stores-1.3551851 (Accessed January 3, 2017).

(24.) Asbridge M, Pauley C. Reducing Alcohol-Related Harms and Costs in New Brunswick: A Provincial Summary Report. Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, 2013.

(25.) CBC News. NB Liquor may expand wine in grocery stores--New Brunswick CBC News. CBC News 2016. Available at: http://www.cbc.ca/news/canada/newbrunswick/ nb-liquor-grocery-store-wine-expand-1.3765593 (Accessed January 3, 2017).

(26.) IBM. IBM SPSS 23 for Windows. Armonk, NY: IBM Corp., 2015.

(27.) ESRI. ArcGIS Desktop 10.1. Redlands, CA: ESRI, 2012.

(28.) Alcool NB Liquor. Available at: http://www.nbliquor.com/Home/Stores (Accessed January 4, 2017).

(29.) DMTI Spatial. Enhanced Points of Interest (EPOI) User Manual v2013_3, 2010. Available at: www.dmtispatial.com (Accessed January 4, 2017).

(30.) Statistics Canada. Postal CodeOM Conversion File Plus (PCCF+) Version 6A, Reference Guide. Ottawa, ON: Statistics Canada, 2013. Catalogue No. 82-F0086XDB.

(31.) New Brunswick Health Council. "My Community at a Glance" Community Profiles New Brunswick Health Council. Moncton, NB: New Brunswick Health Council. Available at: https://www.nbhc.ca/community-profiles#.WGx8y 3cZO9Y (Accessed January 4, 2017).

(32.) Statistics Canada. Population Ecumene Census Division Cartographic Boundary File, Reference Guide Standards of Service to the Public. Ottawa, ON: Statistics Canada, 2006.

(33.) Kipke MD, Iverson E, Moore D, Booker C, Ruelas V, Peters AL, et al. Food and park environments: Neighborhood-level risks for childhood obesity in east Los Angeles. J Adolesc Health 2007; 40(4):325-33. PMID: 17367725. doi: 10. 1016/j.jadohealth.2006.10.021.

(34.) van der Horst K, Timperio A, Crawford D, Roberts R, Brug J, Oenema A. The school food environment: Associations with adolescent soft drink and snack consumption. Am J Prev Med 2008; 35(3):217-23. PMID: 18617354. doi: 10. 1016/j.amepre.2008.05.022.

(35.) New Brunswick Liquor Corporation. Policy for agency store program. Fredericton, NB: New Brunswick Liquor Corporation, 2014. Available at: http://www.nbliquor.com/documents/Agency-Store-Program.pdf (Accessed January 4, 2017).

(36.) New Brunswick Health Council. Appendix H3: Specific indicator sources. Moncton, NB: New Brunswick Health Council, 2014. Available at: https:// www.nbhc.ca/sites/default/files/documents/appendix_h3-specific_indicator_ sources-nbhc.pdf (Accessed January 4, 2017).

(37.) Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, et al. Alcohol: No Ordinary Commodity: Research and Public Policy. Vol 9780199551. Oxford, UK: Oxford University Press, 2010. doi: 10.1093/acprof:oso/ 9780199551149.001.0001.

(38.) Paschall MJ, Grube JW, Kypri K. Alcohol control policies and alcohol consumption by youth: A multi-national study. Addiction 2009; 104(11): 1849-55. PMID: 19832785. doi: 10.1111/j.1360-0443.2009.02698.x.

(39.) Popova S, Giesbrecht N, Bekmuradov D, Patra J. Hours and days of sale and density of alcohol outlets: Impacts on alcohol consumption and damage: A systematic review. Alcohol Alcohol 2009; 44(5):500-16. PMID: 19734159. doi: 10.1093/alcalc/agp054.

(40.) Xuan Z, Blanchette JG, Nelson TF, Nguyen TH, Hadland SE, Oussayef NL, et al. Youth drinking in the United States: Relationships with alcohol policies and adult drinking. Pediatrics 2015; 136(1):18-27. PMID: 26034246. doi: 10. 1542/peds.2015-0537.

(41.) Wagenaar AC, Langley JD. Alcohol licensing system changes and alcohol consumption: Introduction of wine into New Zealand grocery stores. Addiction 1995; 90(6):773-83. PMID: 7633294. doi: 10.1046/j.1360-0443. 1995.9067734.x.

(42.) Room R. The Effects of Nordic Alcohol Policies. NAD Publication No. 42. Helsinki, Finland: Nordic Council for Alcohol and Drug Research, 2002:180 p.

(43.) Campbell CA, Hahn RA, Elder R, Brewer R, Chattopadhyay S, Fielding J, et al. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms. Am J Prev Med 2009; 37(6):556-69. PMID: 19944925. doi: 10.1016/j.amepre.2009.09.028.

(44.) Pereira G, Wood L, Foster S, Haggar F. Access to alcohol outlets, alcohol consumption and mental health. PLoS ONE 2013; 8(1): e53461. PMID: 23341943. doi: 10.1371/journal.pone.0053461.

(45.) Fitterer JL, Nelson TA, Stockwell T. A review of existing studies reporting the negative effects of alcohol access and positive effects of alcohol control policies on interpersonal violence. Front Public Health 2015; 3:253. PMID: 26636055. doi: 10.3389/fpubh.2015.00253.

(46.) White GF, Gainey RR, Triplett RA. Alcohol outlets and neighborhood crime: A longitudinal analysis. Crime Delinq 2015; 61(6):851-72. doi: 10.1177/ 0011128712466386.

(47.) Loring B. Alcohol and Inequities: Guidance for Addressing Inequities in Alcohol-Related Harm. Copenhagen, Denmark: World Health Organization, 2014.

(48.) Gruenewald PJ. Regulating availability: How access to alcohol affects drinking and problems in youth and adults. Alcohol Res Health 2011; 34(2):248-56. PMID: 22330225.

(49.) Anderson P, De Bruijn A, Angus K, Gordon R, Hastings G. Impact of alcohol advertising and media exposure on adolescent alcohol use: A systematic review of longitudinal studies. Alcohol Alcohol 2009; 44(3):229-43. PMID: 19144976. doi: 10.1093/alcalc/agn115.

(50.) Collins RL, Ellickson PL, McCaffrey D, Hambarsoomians K. Early adolescent exposure to alcohol advertising and its relationship to underage drinking. J Adolesc Health 2007; 40(6):527-34. PMID: 17531759. doi: 10.1016/ j.jadohealth.2007.01.002.

(51.) Gordon R, Mackintosh AM, Moodie C. The impact of alcohol marketing on youth drinking behaviour: A two-stage cohort study. Alcohol Alcohol 2010; 45(5):470-80. PMID: 20739441. doi: 10.1093/alcalc/agq047.

(52.) Smith A, Foxcroft R. The effect of alcohol advertising, marketing and portrayal on drinking behaviour in young people: Systematic review of prospective cohort studies. BMC Public Health 2009; 9:51. PMID: 19200352. doi: 10.1186/1471-2458-9-51.

(53.) Snyder LB, Milici FF, Slater M, Sun H, Strizhakova Y. Effects of alcohol advertising exposure on drinking among youth. Arch Pediatr Adolesc Med 2006; 160(1):18-24. PMID: 16389206. doi: 10.1001/archpedi.160.1.18.

(54.) Hurtz SQ, Henriksen L, Wang Y, Feighery EC, Fortmenn SP. The relationship between exposure to alcohol advertising in stores, owning alcohol promotional items, and adolescent alcohol use. Alcohol Alcohol 2007; 42(2):143-49. PMID: 17218364. doi: 10.1093/alcalc/agl119.

(55.) Grier SA, Kumanyika S. Targeted marketing and public health. Annu Rev Public Health 2010; 31:349-69. PMID: 20070196. doi: 10.1146/annurev.publhealth. 012809.103607.

(56.) Stanley LR, Henry KL, Swaim RC. Physical, social, and perceived availabilities of alcohol and last month alcohol use in rural and small urban communities. J Youth Adolesc 2011; 40(9):1203-14. PMID: 20532969. doi: 10.1007/s10964010- 9556-z.

(57.) Mosher JF, Johnsson D. Flavored alcoholic beverages: An international marketing campaign that targets youth. J Public Health Policy 2005; 26(3):326-42. PMID: 16167560. doi: 10.1057/palgrave.jphp.3200037.

(58.) Mosher JF. Joe camel in a bottle: Diageo, the Smirnoff brand, and the transformation of the youth alcohol market. Am J Public Health 2012; 102(1):56-63. PMID: 22095339. doi: 10.2105/AJPH.2011.300387.

(59.) Sargent J. Alcohol marketing and underage drinking: Time to get real. Alcohol Clin Exp Res 2014; 38(12):2886. PMID: 25581644. doi: 10.1111/acer.12584.

(60.) Nakamura R, Pechey R, Suhrcke M, Jebb SA, Marteau TM. Sales impact of displaying alcoholic and non-alcoholic beverages in end-of-aisle locations: An observational study. Soc Sci Med 2014; 108:68-73. PMID: 24632050. doi: 10. 1016/j.socscimed.2014.02.032.

Received: February 20, 2017

Accepted: July 7, 2017

Amanda K. Slaunwhite, PhD, [1,2] Julie McEachern, MSc, [3] Scott T. Ronis, PhD, [4] Paul A. Peters, PhD [5]

Author Affiliations

[1.] Institute for Circumpolar Health Studies, University of Alaska Anchorage, Anchorage, USA

[2.] Centre for Addictions Research of British Columbia, Victoria, BC

[3.] School of Social and Political Science, Global Public Health Unit, University of Edinburgh, Edinburgh, UK

[4.] Department of Psychology, University of New Brunswick, Fredericton, NB

[5.] Department of Health Sciences, Carleton University, Ottawa, ON

Correspondence: Amanda Slaunwhite, PhD, Institute for Circumpolar Health Studies, University of Alaska Anchorage, 3211 Providence Drive, Anchorage, AK 99508, USA, Tel: 907-786-6585, E-mail: aslaunwhite@alaska.edu

Conflict of Interest: None to declare.

Caption: Figure 1. Liquor sales outlets by store type

Caption: Figure 2. Proximity to liquor, agency, and grocery stores by urban, rural, and suburban area

Caption: Figure 3. Liquor outlets within 499 m of schools by store type, community characteristics, and health region. * Health Regions: 1) Moncton; 2) Saint John; 3) Fredericton; 4) Edmundston; 5) Campbellton; 6) Bathurst; and 7) Miramichi

Table 1. Community characteristics by store type

                         Liquor store type, proportion (number)

                         NB-Liquor store   Agency store

Metropolitan influence   zone
  Urban                  62.79 (27)        47.27 (52)
  Suburban               20.93 (9)         35.45 (39)
  Rural                  16.28 (7)         17.27 (19)

Neighbourhood socio-economic status
QAIPPE
  Low                    41.86 (18)        47.27 (52)
  Middle                 41.86 (18)        29.09 (43)
  High                   16.28 (7)         13.64 (15)
QNIPPE
  Low                    72.09 (31)        77.27 (85)
  Middle                 25.58 (11)        21.87 (24)
  High                    2.32 (1)          0.91 (1)

Mean distance to         1133.4 (23.76,    4501.9 (92.21,
school (minimum,            3690.15)         39 522.06)
maximum) *

Mean distance to          1688.1 (6.79,    10 874.0 (3.77,
another liquor outlet      10 361.71)        42 770.31)
(minimum, maximum) *

                         Liquor store type, proportion (number)

                         Grocery store

Metropolitan influence
  Urban                  48.06 (62)
  Suburban               31.08 (40)
  Rural                  20.93 (27)

Neighbourhood socio-economic status
QAIPPE
  Low                    46.51 (60)
  Middle                 41.86 (54)
  High                   11.63 (15)
QNIPPE
  Low                    82.17 (106)
  Middle                 14.72 (19)
  High                    3.10 (4)

Mean distance to         2607.1 (68.18,
school (minimum,           28 146.77)
maximum) *

Mean distance to         2768.6 (3.79,
another liquor outlet      30 816.08)
(minimum, maximum) *

Distance is measured in metres using the New Brunswick
Road Network files.

Table 2. Population estimates by distance to NB-Liquor, agency,
and grocery stores

Distance *                      NB-Liquor store   Agency

[less than or equal to] 499 m    12 912              7002
500-999 m                        37 361            18 862
1-5 km                          268 856           180 596
Total ([dagger])                306 218           206 462

Distance *                      NB-Liquor or agency store

[less than or equal to] 499 m    19 886 ([dagger])
500-999 m                        52 755 ([dagger])
1-5 km                          341 479 ([dagger])
Total ([dagger])                377 264 ([double dagger])

Distance *                      Grocery store

[less than or equal to] 499 m    27 412
500-999 m                        56 025
1-5 km                          264 516
Total ([dagger])                347 958

Distance *                      Proportion and number of the
                                provincial population within
                                distance of a NB-Liquor,
                                agency, or grocery store

[less than or equal to] 499 m    5.23% (39,273) ([dagger])
500-999 m                       11.72% (88,094) ([dagger])
1-5 km                          51.48% (386,686) ([dagger])
Total ([dagger])                54.98% (412,982) ([double dagger])

* Distance is measured in metres using the New Brunswick road network
files.

([dagger]) Totals exceed 100% because of distance bands overlapping
between one or more locations by store type.

([double dagger]) Final population estimates with dissolved distance
bands to eliminate overlapping boundaries between stores.

Table 3. Distance to school by store type and community
characteristics

                        Distance to school

                        [less than or equal to] 499 m   500-999 m

Store type (proportion, N) * [chi square] = 25.041, df : = 6,
p = 0.001
  Liquor store          16.92 (11)                      18.33 (11)
  Agency store          29.23 (19)                      28.33 (17)
  Grocery store         53.85 (35)                      53.33 (32)

Metropolitan influence zone* [chi square] = 9.662, df = 6, p = 0.140
  Urban                 53.85 (35)                      56.67 (34)
  Suburban              27.69 (18)                      18.33 (11)
  Rural                 18.46 (12)                      25.00 (15)

QAIPPE * ([dagger])
  Low                   53.85 (35)                      60.00 (36)
  Middle                33.85 (22)                      35.00 (21)
  High                  12.31 (8)                        5.00 (3)

QNIPPE * ([dagger])
  Low                   89.23 (58)                      81.67 (49)
  Middle                 9.23 (6)                       16.67 (10)
  High                   1.54 (1)                        1.67 (1)

                        Distance to school

                          1-5 km

Store type (proportion, N) * [chi square] = 25.041, df : = 6,
p = 0.001
  Liquor store          18.91 (21)
  Agency store          38.74 (43)
  Grocery store         42.34 (47)

Metropolitan influence zone* [chi square] = 9.662, df = 6, p = 0.140
  Urban                 46.85 (52)
  Suburban              36.94 (41)
  Rural                 16.22 (18)

QAIPPE * ([dagger])
  Low                   33.33 (37)
  Middle                49.55 (55)
  High                  17.12 (19)

QNIPPE * ([dagger])
  Low                   67.57 (75)
  Middle                28.83 (32)
  High                   3.6 (4)

* About 46 stores were located more than 5 km away from schools.

([dagger]) [chi square] was not conducted as one or more cells
had a count of less than five.

Table 4. Distance to school by health region and store type

                                            Health region

                                        Zone 1--        Zone 2--
                                        Moncton/      Fundy Shore/
                                       South-East      Saint John
                                          Area            Area

Youth binge drinking mean 5           51.8 (39, 59)   42.7 (17, 59)
(minimum, maximum)

[less than or equal to] 499 m
to school (Proportion, N)
  Liquor store                          15.4 (2)        16.7 (2)
  Agency store                          30.8 (4)        25.0 (3)
  Grocery store                         53.8 (7)        58.3 (7)
  Total                                  20 (13)        18.5 (12)
500-999 m to school (Proportion, N)
  Liquor store                          21.4 (3)        36.4 (4)
  Agency store                          14.3 (2)        27.3 (3)
  Grocery store                         64.3 (9)        36.4 (4)
  Total                                 23.3 (14)       18.3 (11)

                                             Health region

                                        Zone 3--        Zone 4--
                                      Fredericton/     Madawaska/
                                      River Valley     North West
                                          Area            Area

Youth binge drinking mean 5           49.2 (17, 68)   57.0 (40, 68)
(minimum, maximum)

[less than or equal to] 499 m
to school (Proportion, N)
  Liquor store                          18.8 (3)        11.1 (1)
  Agency store                          37.5 (6)        22.2 (2)
  Grocery store                         43.8 (7)        66.7 (6)
  Total                                 24.6 (16)       13.8 (9)
500-999 m to school (Proportion, N)
  Liquor store                            0(0)            0 (0)
  Agency store                          36.4 (4)        66.7 (4)
  Grocery store                         63.6 (7)        33.33 (2)
  Total                                 18.3 (11)         10(6)

                                              Health region

                                        Zone 5--         Zone 6--
                                       Restigouche      Bathurst/
                                          Area           Acadian
                                                      Peninsula Area

Youth binge drinking mean 5           59.0 (53, 68)   58.2 (53, 68)
(minimum, maximum)

[less than or equal to] 499 m
to school (Proportion, N)
  Liquor store                          33.3 (1)         12.5 (1)
  Agency store                          33.3 (1)         37.5 (3)
  Grocery store                         33.3 (1)         50.0 (4)
  Total                                  4.6 (3)         12.3 (8)
500-999 m to school (Proportion, N)
  Liquor store                            0 (0)          27.3 (3)
  Agency store                            0 (0)          18.2 (2)
  Grocery store                          100 (2)         54.5 (6)
  Total                                  3.3 (2)        18.3 (11)

                                      Health region

                                        Zone 7--
                                        Miramichi
                                          Area

Youth binge drinking mean 5           56.4 (50, 67)
(minimum, maximum)

[less than or equal to] 499 m
to school (Proportion, N)
  Liquor store                          25.0 (1)
  Agency store                            0 (0)
  Grocery store                         75.0 (3)
  Total                                  6.1 (4)
500-999 m to school (Proportion, N)
  Liquor store                           20 (1)
  Agency store                           40 (2)
  Grocery store                          40 (2)
  Total                                  8.3 (5)