Introduction

Alcohol use is one of the leading contributors to the global burden of disease, and the main contributor to premature death and disability worldwide in the age group 15-59.¹ The frequent use of alcohol has been associated with increased risk of liver cirrhosis, cancer, injuries and cardiovascular diseases. In 2012, 7.6% of deaths among males and 4.0% of deaths among females were attributable to alcohol (5.9% of all global deaths). The proportional contribution to morbidity and disability was even higher. According to the World Health Organization, the European Union was the region with the highest alcohol consumption in the world in 2010.¹ Although there are large differences between countries, alcohol consumption in Europe has remained stable over the past decade. In Spain, the 2011-12 survey found that 77.5% of the adult population had consumed alcohol throughout life (65.4% consumed in the past year and 13.8% reported to consume daily).² The same study showed that 75.4% of men and 53.4% of women reported low-risk drinking and that 19.6% of men and 7.1% of women were binge drinkers in the last year. Moreover, the study showed that beer was the drink of choice for 28.7% of the people (wine 23%).²

In recent years, there has been a growing interest in how the social, urban and cultural environments contribute to shaping health outcomes and behavioral risk factors associated with health.³ With respect to alcohol consumption, top panel in Fig. 1 shows several urban factors that could be related with individual alcohol behavior. This framework has been built based on the literature researching alcohol consumption in urban environments. A study based in 59 New York City neighborhoods found that living in deprived built environments was associated with higher alcohol consumption and more negative consequences related to its consumption.⁴ Moreover, contextual factors including alcohol availability and accessibility or advertising and marketing of alcohol have been directly linked to drinking patterns. A literature review exploring the influence on alcohol use of community level availability and marketing of alcohol found that higher outlet density and greater exposure to advertising in a local community might be associated with an increase in alcohol drinking, particularly among adolescents.⁵ Another systematic review focusing on availability of alcohol in terms of hours and days of sale and density of alcohol outlets found that both variables had an impact on one or more of the three main outcomes: overall alcohol consumption, drinking patterns and alcohol damage.⁶

Photographs: Victor G. Carreño.

Figure 1 Urban determinants of alcohol behaviour. 

Measuring the urban environment in relation to alcohol

The pervasiveness of alcohol products in our urban landscape may have favored the normalization of alcohol consumption with disproportionate implications to those who are constantly exposed to a wide variety of alcohol products and advertisements. As part of the European Research Council funded project Heart Healthy Hoods⁷ and of the Plan on Drugs for the city of Barcelona⁸ we are developing specific tools characterizing the presence of alcohol in the urban environment in Barcelona and Madrid. As we directly observed the neighborhoods and streets of these cities we realized that alcohol product availability, its marketing and promotion and visible signs of alcohol consumption are always present in our cities. On the one hand we observed the constant presence of alcohol outlets, both in-premises and off-premises ensures, through different opening times by type of outlet, an extensive supply of alcohol products at different times during the day (panel A in Fig. 1). On the other hand we collected data on the high visibility of alcohol consumption in the street in terms of people consuming alcohol or the presence of discarded bottles or other containers in the public space (panel B in Fig. 1), not only indicating the acceptability of alcohol, but also suggesting incomplete enforcement of existing alcohol related regulations. Finally, the ever presence of alcohol promotion and marketing leads public health practitioners to think about possible policies related to alcohol. Although the direct advertising of spirits is prohibited in Spain in public roads, indirect advertisement and sponsorship are frequently used to circumvent this ban. Alcohol advertisements are present in many alcohol outlets, mainly in in-premises. For example, hospitality venues use their storefronts and terraces to promote alcohol beverages offering drinks at discount prices and advertising beverage brands (panel C in Fig. 1). Moreover, in touristic areas and city centers the marketing and promotion of alcohol are highly visible and evident. We can even find public relations staff offering alcohol discounts and promotions in alcohol drinks.

Within the European Union, policies regulating the alcohol retail environment, marketing and advertising of alcohol vary across countries, and sometimes across jurisdictions within a country, with different levels of restrictions. Advertising restrictions in European countries are inversely associated with the prevalence of risk consumption of alcohol in people aged 50-64 years.⁹ In Spain the sale of alcohol at certain times and places is regulated and its sale to people under 18 is always prohibited. However, the availability of alcoholic beverages at a relatively low cost is the common norm in our environment, and the deregulation of retail trade favored by European Directives has made alcohol availability at night even greater, especially in large cities.¹⁰ Similarly there are policies that partially regulate direct and indirect alcohol advertising in certain public places. However, the pressure by the alcohol industry is evident, and circumventing existing regulation with different strategies such as using sponsorship to advertise spirits or using alcohol outlets to advertise its products via promotions or discounts.

Discussion

Further research should help studying exposure to alcohol urban environment and its association with alcohol consumption and drinking patterns. It is also important to understand the attitudes and practices in relation to alcohol consumption from a cultural and social perspective. Interdisciplinary and innovative approaches are necessary to understand such a complex topic. Future research should combine different quantitative methodologies with the use of qualitative research techniques. Finally, new tools should be developed to systematically characterize the domains of the urban environment that could affect alcohol behavior.

Our experience was based in the cities of Barcelona and Madrid. Our results are part of the project Heart Healthy Hoods that aims to study the associations between the social and physical features of the urban environment in relation to population cardiovascular health. Urban environments have proved to be excellent candidates for research and policy evaluation of population approaches to prevention and, cities, due to their characteristics, show multiple contexts relevant to health.³ The study of urban environments in relation to alcohol wants to highlight the importance of understanding cities in relation to alcohol behavior: previous studies of contextual factors in relation to alcohol use have been developed in urban areas, and there is clearly a need for research on rural areas, although it is out of our reach.^4-6 Future research should also include these areas to have a complete picture of residential environments in relation to harmful use of alcohol.

Building evidence about the exposure to key urban elements and understanding which cultural and social norms may influence alcohol behaviors is critical to support policy interventions aimed at controlling alcohol use. The evidence derived from the characterization of alcohol environment could serve as a basis for policy makers to reduce alcohol exposure and, as a consequence, favor the process of denormalization of alcohol use contributing to reduce alcohol-related health burden and health inequalities.