Lillian G. Remer

Exploring the Spatial Dynamics of Alcohol Outlets and Child Protective Services Referrals, Substantiations, and Foster Care Entries

Controlling for neighborhood demographic characteristics, this study examined the relationship of alcohol outlets with rates of Child Protective Services (CPS) referrals, substantiations, and foster care entries from 1998-2003 in 579 zip codes in California. Data for this panel study were analyzed using spatial random effects panel models. Zip codes with higher concentrations of off-premise alcohol outlets (e.g., convenience or liquor stores) and proportions of Black residents had higher rates of maltreatment. Higher average household size and median household income were generally related to lower child maltreatment rates. More specifically, the model derived estimates that an average decrease of one off-premise outlet per zip code would reduce total referrals to CPS in the 579 zip codes by 1,040 cases, substantiations by 180 cases, and foster care entries by 93 cases. Characteristics of adjacent zip codes also were related to maltreatment rates in local neighborhoods, indicating a spatial dynamic to this relationship. Reductions in number of alcohol outlets per zip code, particularly off-premise outlets, may result in lower rates of child maltreatment.

Alcohol Outlets, Neighborhood Characteristics, and Intimate Partner Violence: Ecological Analysis of a California City

Neighborhood indicators of social disadvantage, such as poverty and unemployment, are associated with intimate partner violence (IPV). Despite the well-established link between heavy drinking and IPV, few studies have analyzed the contribution of alcohol outlet density to the occurrence of IPV. Greater numbers of alcohol outlets in a community may be a sign of loosened normative constraints against violence, promote problem drinking among at-risk couples, and provide environments where groups of persons at risk for IPV may form and mutually reinforce IPV-related attitudes, norms, and problem behaviors. This study used ecological data to determine if alcohol outlet density (number of bars, restaurants serving alcohol, and off-premise outlets per unit area) is related to rates of IPV-related police calls and IPV-related crime reports in Sacramento, California. Separate analyses for IPV calls and crime reports were conducted using Bayesian space–time models adjusted for area characteristics (poverty rate, unemployment rate, racial/ethnic composition). The results showed that each additional off-premise alcohol outlet is associated with an approximate 4% increase in IPV-related police calls and an approximate 3% increase in IPV-related crime reports. Bars and restaurants were not associated with either outcome. The findings suggest that alcohol outlet density, especially off-premise outlets, appear to be related to IPV events. Further research is needed to understand the mechanisms by which neighborhood factors, such as alcohol outlet density, affect IPV behaviors. Understanding these mechanisms is of public health importance for developing environmental IPV prevention strategies, such as changes in zoning, community action, education, and enforcement activities.

Does Alcohol Outlet Density Affect Youth Access to Alcohol

PURPOSE To investigate how community alcohol outlet density may be associated with alcohol access among adolescents. METHODS Data were collected through a three-wave panel study with youth aged 14-16 at baseline using computer-assisted telephone interviews. Study participants were recruited from 50 zip codes with varying alcohol outlet density and median household income in California. Data analyses were conducted using multilevel, linear growth models and data from 1028 youth (52% male, 51% white). RESULTS After taking into account individual-level factors and zip code median household income, zip code alcohol outlet density was significantly and positively related to the initial levels of the likelihood and frequency of getting alcohol through various sources including commercial outlets, shoulder tapping, home or family members, and underage acquaintances. CONCLUSIONS High levels of alcohol outlets in the community enable youth access to alcohol through commercial outlets, family, and social networks.

Alcohol Outlets, Youth Drinking, and Self-Reported Ease of Access to Alcohol: A Constraints and Opportunities Approach

BACKGROUND Despite recent research examining youth access to alcohol, the extent to which relative ease of access to alcohol from various sources translates into the use of these sources is not known. METHODS Patterns of adolescent alcohol access in California were studied using a hierarchical analysis of self-reported and archival measures. A survey of 30 youths age 14 to 16 in each of 50 zip codes selected to maximize variability in median household income and off-premise outlet densities was conducted. RESULTS (1) Both actual use of and perceived ease of access to formal sources were positively associated with off-premise outlet density (a measure of formal access). (2) Actual use of informal sources was negatively associated with outlet densities. (3) Perceived and realized informal access were associated positively with deviance and negatively with conventionality. (4) Deviance was associated with increased perceived and realized access from both formal and social sources, whereas conventionality was only associated with realized and perceived informal access. CONCLUSIONS Correlates of perceived and actual alcohol access differ somewhat, and the differences between informal and formal access (both perceived and actual) are many, creating a complex picture of the patterns of underage access to alcohol. Youth drinking is affected by opportunities and constraints. Specifically, as one form of access becomes constrained, youth appear to circumvent restrictions by relying on other modes of access. Thus interventions targeting formal alcohol access by youth may result in a shift to reliance on social sources. This complex problem requires a multi-faceted intervention approach.

Alcohol outlet density and intimate partner violence-related emergency department visits.

BACKGROUND Previous research has identified risk factors for intimate partner violence (IPV) severity, injury, and emergency department (ED) visits. These risk factors have been shown at both the individual level (heavy drinking and other substance use on the part of 1 or both partners) and the neighborhood level (residence in an area characterized by poverty and social disadvantage). Alcohol outlet density has been linked with assaultive violence in community settings, but has not been analyzed in relation to IPV-related ED visits. This study examined the effects of outlet densities on IPV-related ED visits throughout California between July 2005 and December 2008. METHODS Half-yearly counts of ED visits related to IPV (E-code 967.3) were computed for each zip code from patient-level public data sets. Alcohol outlet density measures, calculated separately for bars, off-premise outlets, and restaurants, were derived from California Alcohol Beverage Control records. Census-based neighborhood demographic characteristics previously shown to be related to health disparities and IPV (percent black, percent Hispanic, percentage below 150% of poverty line, percent unemployed) were included in models. This study used Bayesian space-time models that allow longitudinal analysis at the zip code level despite frequent boundary redefinitions. These spatial misalignment models control for spatial variation in geographic unit definitions over time and account for spatial autocorrelation using conditional autoregressive (CAR) priors. The model incorporated data from between 1,686 (2005) and 1,693 (2008) zip codes across California for 7 half-year time periods from 2005 through 2008 (n = 11,836). RESULTS Density of bars was positively associated with IPV-related ED visits. Density of off-premise outlets was negatively associated with IPV-related ED visits; this association was weaker and smaller than the bar association. There was no association between density of restaurants and IPV-related ED visits. CONCLUSIONS Further research is needed to understand the mechanisms by which environmental factors, such as alcohol outlet density, affect IPV behaviors resulting in ED visits.

Spatial panel analyses of alcohol outlets and motor vehicle crashes in California: 1999–2008

Although past research has linked alcohol outlet density to higher rates of drinking and many related social problems, there is conflicting evidence of densitys association with traffic crashes. An abundance of local alcohol outlets simultaneously encourages drinking and reduces driving distances required to obtain alcohol, leading to an indeterminate expected impact on alcohol-involved crash risk. This study separately investigates the effects of outlet density on (1) the risk of injury crashes relative to population and (2) the likelihood that any given crash is alcohol-involved, as indicated by police reports and single-vehicle nighttime status of crashes. Alcohol outlet density effects are estimated using Bayesian misalignment Poisson analyses of all California ZIP codes over the years 1999-2008. These misalignment models allow panel analysis of ZIP-code data despite frequent redefinition of postal-code boundaries, while also controlling for overdispersion and the effects of spatial autocorrelation. Because models control for overall retail density, estimated alcohol-outlet associations represent the extra effect of retail establishments selling alcohol. The results indicate a number of statistically well-supported associations between retail density and crash behavior, but the implied effects on crash risks are relatively small. Alcohol-serving restaurants have a greater impact on overall crash risks than on the likelihood that those crashes involve alcohol, whereas bars primarily affect the odds that crashes are alcohol-involved. Off-premise outlet density is negatively associated with risks of both crashes and alcohol involvement, while the presence of a tribal casino in a ZIP code is linked to higher odds of police-reported drinking involvement. Alcohol outlets in a given area are found to influence crash risks both locally and in adjacent ZIP codes, and significant spatial autocorrelation also suggests important relationships across geographical units. These results suggest that each type of alcohol outlet can have differing impacts on risks of crashing as well as the alcohol involvement of those crashes.

Ecological associations of alcohol outlets with underage and young adult injuries.

OBJECTIVE This paper argues that associations between rates of 3 specific problems related to alcohol (i.e., accidents, traffic crashes, and assaults) should be differentially related to densities of alcohol outlets among underage youth and young adults based upon age-related patterns of alcohol outlet use. METHODS Zip code-level population models assessed local and distal effects of alcohol outlets upon rates of hospital discharges for these outcomes. RESULTS Densities of off-premise alcohol outlets were significantly related to injuries from accidents, assaults, and traffic crashes for both underage youth and young adults. Densities of bars were associated with more assaults and densities of restaurants were associated with more traffic crash injuries for young adults. CONCLUSIONS The distribution of alcohol-related injuries relative to alcohol outlets reflect patterns of alcohol outlet use.

Mapping the spread of methamphetamine abuse in California from 1995 to 2008.

OBJECTIVES From 1983 to 2008, the incidence of methamphetamine abuse and dependence (MA) presenting at hospitals in California increased 13-fold. We assessed whether this growth could be characterized as a drug epidemic. METHODS We geocoded MA discharges to residential zip codes from 1995 through 2008. We related discharges to population and environmental characteristics using Bayesian Poisson conditional autoregressive models, correcting for small area effects and spatial misalignment and enabling an assessment of contagion between areas. RESULTS MA incidence increased exponentially in 3 phases interrupted by implementation of laws limiting access to methamphetamine precursors. MA growth from 1999 through 2008 was 17% per year. MA was greatest in areas with larger White or Hispanic low-income populations, small household sizes, and good connections to highway systems. Spatial misalignment was a source of bias in estimated effects. Spatial autocorrelation was substantial, accounting for approximately 80% of error variance in the model. CONCLUSIONS From 1995 through 2008, MA exhibited signs of growth and spatial spread characteristic of drug epidemics, spreading most rapidly through low-income White and Hispanic populations living outside dense urban areas.

Suicide and Alcohol: Do Outlets Play a Role?

BACKGROUND The purpose of this study was to determine whether the number of alcohol outlets in local and adjacent areas, in particular bars, was related over time to completed suicide and suicide attempts. There is evidence both from studies of individuals and time series aggregate studies, mostly at the national level, of substantial alcohol involvement in suicide, but no small-area, longitudinal studies have been carried out. The present study is the first that is both longitudinal and based on a large number of small spatial units, California zip codes, a level of resolution permitting analysis of the relationship between local alcohol access and suicide rates over time. METHOD Longitudinal data were obtained from 581 consistently defined zip code areas over 6 years (1995-2000) using data from the California Index Locations Database, a geographic information system that contains both population and place information with spatial attributes for the entire state. Measures obtained from each zip code included population characteristics (e.g., median age) and place characteristics (e.g., numbers of retail and alcohol outlets) which were related in separate analyses to (i) suicide mortality and (ii) the number of hospitalizations for injuries caused by suicide attempts. The effect of place characteristics in zip code areas adjacent to each of the 581 local zip codes (spatial lags) was also assessed. Analysis methods were random effects models corrected for spatial autocorrelation. RESULTS Completed suicide rates were higher in zip code areas with greater local and lagged bar densities; and higher in areas with greater local but not lagged off-premise outlet densities. Whereas completed suicide rates were lower among blacks and Hispanics, completed suicide rates were higher among low income, older whites living in less densely populated areas, that is, rural areas. Rates of suicide attempts were higher in zip code areas with greater local but not lagged bar densities, and higher among low income younger whites living in smaller households and in rural areas. Rates of attempted suicide were also higher among blacks. Completed suicide and suicide attempt rates were lower in zip code areas with greater local restaurant densities; there were no lagged effects for restaurants. CONCLUSIONS Bar densities in particular appear related to suicide, meaning, because this is an aggregate-level spatial analysis, that suicides, both attempted and completed, occur at greater rates in rural community areas with greater bar densities. Because the suicide rate is highest in rural areas, this study suggests that although the number of completed and attempted suicides is no doubt greater in absolute numbers in urban areas, the suicide rate, both completed and attempted, is greater in rural areas, which draws attention, perhaps much needed, to the problems of rural America.

The economic geography of medical cannabis dispensaries in California

BACKGROUND The introduction of laws that permit the use of cannabis for medical purposes has led to the emergence of a medical cannabis industry in some US states. This study assessed the spatial distribution of medical cannabis dispensaries according to estimated cannabis demand, socioeconomic indicators, alcohol outlets and other socio-demographic factors. METHODS Telephone survey data from 5940 residents of 39 California cities were used to estimate social and demographic correlates of cannabis consumption. These individual-level estimates were then used to calculate aggregate cannabis demand (i.e. market potential) for 7538 census block groups. Locations of actively operating cannabis dispensaries were then related to the measure of demand and the socio-demographic characteristics of census block groups using multilevel Bayesian conditional autoregressive logit models. RESULTS Cannabis dispensaries were located in block groups with greater cannabis demand, higher rates of poverty, alcohol outlets, and in areas just outside city boundaries. For the sampled block groups, a 10% increase in demand within a block group was associated with 2.4% greater likelihood of having a dispensary, and a 10% increase in the city-wide demand was associated with a 6.7% greater likelihood of having a dispensary. CONCLUSION High demand for cannabis within individual block groups and within cities is related to the location of cannabis dispensaries at a block-group level. The relationship to low income, alcohol outlets and unincorporated areas indicates that dispensaries may open in areas that lack the resources to resist their establishment.