Effects of Local Alcohol Prevention Initiatives in Swedish Municipalities, 2006–2014

Figures & data

Table A1. Alcohol Prevention Magnitude Measure: categories, indicators, cutoff and points.

Category	Indicator		Cutoff and points
Staff and budget (Max 20 points)	Number of staff positions for alcohol and/or drug prevention in the municipality^a		More than two full-time positions = 8 p
			One to two full-time positions = 6 p
			A half-time up to less than a full-time position = 4 p
			Less than a half-time position = 2 p
			No position = 0 p
	Funding for alcohol and/or drug prevention is provided in the regular budget of the municipality		Yes, all = 8 p
			Almost all = 4 p
			In part = 2 p
			Not at all = 0 p
	A particular alcohol prevention coordinator is designated		Yes = 4 p
			No = 0 p
Policy^b (Max 20 points)	Municipal alcohol policy		Yes = 2 p
			No = 0 p
	Years since alcohol policy was adopted		Five or fewer years ago = 2 p
			More than five years ago = 0 p
	Plan for implementation of the municipal alcohol policy		Yes = 2 p
			No = 0 p
	Measurable goals in municipal alcohol policy		Yes = 2 p
			No = 0 p
	Plan for follow-up in municipal alcohol policy		Yes = 2p
			No = 0 p
	Particular funding set aside to perform activities in municipal alcohol policy		Yes = 2 p
			No = 0 p
	The municipality as an employer has an alcohol policy		Yes = 2 p No = 0 p
	The municipality has a policy on alcohol consumption in public places		Yes = 2 p No = 0 p
	NGOs are required to have an alcohol policy to be eligible for municipal funding		Yes = 2 p
			No = 0 p
	The municipality has a policy for alcohol prevention in elementary schools		Yes = 2 p
			No = 0 p
Organised cooperation with authorities (a), businesses (b), or NGOs (c) as regards alcohol prevention (Max 20 points)	Police (a)		Yes = 2 p
			No = 0 p
	Health-care (a)		Yes = 2 p
			No = 0 p
	Swedish Transport Agency^c (a)		Yes = 2 p
			No = 0 p
	Other municipalities (a)		Yes = 2 p
			No = 0 p
	County administrative board (a)		Yes = 2 p
			No = 0 p
	Restaurant owners (b)		Yes = 2 p
			No = 0 p
	Entertainment businesses (b)		Yes = 2 p
			No = 0 p
	Sports associations (c)		Yes = 2 p
			No = 0 p
	Temperance organizations (c)		Yes = 2 p No = 0 p
	Religious organizations (c)		Yes = 2 p
			No = 0 p
Inspections and licenses (Max 20 points)	Number of regular alcohol licenses to the public per 10,000 inhabitants (age 15+)		0 ≤ and ≤ 2.5 = 5 p
			2.5 < and ≤ 5 = 4.5 p
			5 < and ≤ 7.5 = 4 p
			7.5 < and ≤ 10 = 3.5 p
			10 < and ≤ 12.5 = 3 p
			12.5 < and ≤ 15 = 2.5 p
			15 < and ≤ 17.5 = 2 p
			17.5 < and ≤ 20 = 1.5 p
			20 < and ≤ 22.5 = 1 p
			22.5 < and ≤ 25 = 0.5 p
			More than 25 = 0 p
	Proportion of licensed premises to the public closing later than 1 AM^d		0 = 5 p
			0 < and ≤ 0.05 = 4.5 p
			0.05 < and ≤ 0.10 = 4 p
			0.10 < and ≤ 0.15 = 3.5 p
			0.15 < and ≤ 0.20 = 3 p
			0.20 < and ≤ 0.25 = 2.5 p
			0.25 < and ≤ 0.30 = 2 p
			0.30 < and ≤ 0.35 = 1.5 p
			0.35 < and ≤ 0.40 = 1 p
			0.40 < and ≤ 0.45 = 0.5 p
			0.45 < and ≤ 1 = 0 p
	Extent of supervision at licensed premises (public + private)		More than 1.8 = 5 p
			1.6 < and ≤ 1.8 = 4.5 p
			1.4 < and ≤ 1.6 = 4 p
			1.2 < and ≤ 1.4 = 3.5 p
			1 < and ≤ 1.2 = 3 p
			0.8 < and ≤ 1 = 2.5 p
			0.6 < and ≤ 0.8 = 2 p
			0.4 < and ≤ 0.6 = 1.5 p
			0.2 < and ≤ 0.4 = 1 p
			0 < and ≤ 0.2 = 0.5 p
			0 = 0 p
	Proportion of inspected grocery stores selling alcohol (beer)		More than 0.9 = 5 p
			0.8 < and ≤ 0.9 = 4.5 p
			0.7 < and ≤ 0.8 = 4 p
			0.6 < and ≤ 0.7 = 3.5 p
			0.5 < and ≤ 0.6 = 3 p
			0.4 < and ≤ 0.5 = 2.5 p
			0.3 < and ≤ 0.4 = 2 p
			0.2 < and ≤ 0.3 = 1.5 p
			0.1 < and ≤ 0.2 = 1 p
			0 < and ≤ 0.1 = 0.5 p
			0 = 0 p
Activities (Max 20 points)	Arranging drug-free activities (e.g., school dances, concerts, etc.)		Yes = 2 p
			No = 0 p
	Information to parents (leaflets, brochures, etc.)		Yes = 2 p
			No = 0 p
	Active work with media advocacy in order to increase awareness about alcohol and/or drugs^e		Yes = 2 p
			No = 0 p
	Activities to limit illegal sales to youth (e.g., information campaigns or police intervention)		Yes = 2 p
			No = 0 p
	Activities to enforce age limits for alcohol sales^f		Yes = 2 p
			No = 0 p
	Responsible beverage service (RBS)		Yes = 2 p
			No = 0 p
	Parental program (with educated instructors) on alcohol and drugs when child is in grades 6–9		Yes = 2 p
			No = 0 p
	Group activities for children of substance misusing parents^g		Yes = 2 p
			No = 0 p
	Activity for traffic sobriety, in addition to police efforts		Yes = 2 p
			No = 0 p
	Brief intervention in primary health-care^e		Yes = 2 p
			No = 0 p
Sum	Maximal sum = 100 points (Policy + Staff and budget + Inspections and licenses + Cooperation + Activities)

^aPoints assigned are based on a mean value of position points adjusted and not adjusted for population size. This calculation was made since small municipalities score higher when positions of staff are in relation to population size and large municipalities score higher when population size is ignored.

^bPolicy often refers to alcohol and/or drugs.

^cSwedish Transport Agency 2010. Swedish Road Administration 2009–2006.

^dOpening hours have been calculated for 2006–2009 using data from 2010 (due to frequent missing data). During 2010 missing data were highly reduced thanks to frequent reminders from SNIPH.

^eNot including 2013–2014. Category points in APMM are adjusted (weighted) to compensate.

^fAnd serving, 2006.

^gOther activities instead of group activities in 2006 and 2007.

Table 1. Indicators of alcohol consumption and alcohol-related harm.

Monitoring	Type	Indicator definition	Expressed as	Source
Consumption	Sales	Sales through the Swedish monopoly stores. Total retail sales of alcoholic beverages (< 3.5% ABV) in liters of pure (100%) alcohol.	Per inhabitant age 15+.	Online database. The Public Health Agency of Sweden.
Traffic	Acute harm	Single-vehicle accidents between 10 PM and 5 AM. Only accidents that resulted in injury were included. Data refer to the regions where the accidents occurred.	Per 10,000 inhabitants.	Online database. The Public Health Agency of Sweden. Data based on police reports about the accidents.
Violence	Acute harm	Police-reported assault^a outdoors, where the perpetrator was unknown to the victim.	Per 10,000 inhabitants age 15+.	Online database. The Swedish National Council for Crime Prevention.
Morbidity	Acute harm	Treated patients, inpatient care, with alcohol intoxication diagnosis as primary and/or bi-diagnosis^a	Per 10,000 inhabitants (age 15+), age-standardized.	Data ordered from the Hospital Discharge Register, at the National Board of Health and Welfare.
Morbidity	Combination of acute and chronic harm	Treated patients, inpatient care, with explicit alcohol diagnosis as primary and/or bi-diagnosis^a	Per 10,000 inhabitants (age 15+), age-standardized.	Data ordered from the Hospital Discharge Register, at the National Board of Health and Welfare.
Morbidity	Chronic harm	Treated patients, inpatient care, with liver disease as primary diagnosis^a	Per 10,000 inhabitants (age 15+), age-standardized.	Data ordered from the Hospital Discharge Register, at the National Board of Health and Welfare.
Mortality	Combination of acute and chronic harm	Deceased with explicit alcohol diagnosis as underlying and/or contributory cause of death^a	Per 10,000 inhabitants (age 15+), age-standardized.	Data ordered from the Cause of Death Register, at the National Board of Health and Welfare.

^a ICD and crime codes can be obtained from the first author.

Table 2. Socioeconomic characteristics among municipalities in the study and all municipalities in Sweden, 2014.

Socio-economic variables	Municipalities included in study (N = 207)			All municipalities in Sweden (N = 290)
	Mean	Median	SD	Mean	Median	SD
Population (age 15+)	26,459	15,308	27,419	27,812	12,900	57,430
Net median income. Swedish kronor, thousands. (Population, age 16 +).	198.3	193.4	21.2	197.2	192.6	21.5
Post-secondary education, percent. (Population, age 25–74).	30.2	27.8	9.4	29.6	27.3	9.3
Unemployed, percent. (Population, age 16–64).	4.1	4.1	1.3	4.2	4.1	1.3

Table 3. Prevention, consumption and harm indicators among municipalities in the study and all municipalities in Sweden, 2014.

Prevention, consumption and harm indicators (see also Table 1 above and Table A1 in the appendix for more details)	Municipalities included in study (N = 207)			All municipalities in Sweden (N = 290)
	Mean	Median	SD	Mean	Median	SD
Alcohol prevention, APMM (Points)	55.7	56.0	14.0	53.2	53.0	15.2
Consumption (N = 182, Liters pure alcohol, per inhab. 15+) (Consumption, N = 207 Liters pure alcohol, per inhab. 15+)	5.5 (6.5)	5.2 (5.2)	1.5 (7.9)	6.4	5.3	6.9
Single-vehicle accidents (Per 10,000 inhab.)	1.3	1.0	1.2	1.3	1.0	1.2
Assaults (Per 10,000 inhab., 15+)	15.6	14.8	7.8	15.8	14.6	8.6
Treated for alcohol intoxication (Per 10,000 inhab. 15+)	9.5	8.5	5.2	9.4	8.4	5.2
Treated for explicit alcohol diag. (Per 10,000 inhab. 15+)	30.1	30.8	9.3	32.6	31.6	9.3
Treated for liver disease (Per 10,000 inhab. 15+)	1.9	1.7	1.1	1.8	1.7	1.2
Deceased with explicit alcohol diag. (Per 10,000 inhab. 15+)	2.2	2.3	1.2	2.3	2.3	1.3

Figure 1. Trends in prevention (N = 207), consumption (N = 182), and harm (N = 207) indicators among municipalities in the study, 2006–2014.

Table 4. Estimated prevention effects (weighted prevention index, WAPMM, direct and one-year lag prevention effect combined) on indicators of consumption and alcohol-related harm in percent, 2006–2014, controlled for population size, median income, unemployment, and post-secondary education.

	Policy	Staff and budget	Cooperation	Inspections and licenses	Activities	APMM sum
	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect
Alcohol consumption	−0.0008	−0.005	−0.0002	0.020	−0.006	−0.017
P > |z|	0.001	0.035	0.107	0.006	0.013	0.001
Single-vehicle accident	−0.050	−0.102	−0.084	0.074	−0.180	−0.356
P > |z|	0.386	0.036	0.033	0.464	< 0.001	< 0.001
Assaults	−0.017	−0.036	0.011	0.023	0.046	0.033
P > |z|	0.595	0.278	0.696	0.674	0.219	0.587
Treated alc. intox.	0.049	0.034	0.013	0.103	0.024	0.097
P > |z|	0.057	0.108	0.520	0.083	0.251	0.052
Treated alc. diagnosis	0.005	0.004	−0.006	−0.050	−0.011	−0.006
P > |z|	0.513	0.563	0.390	0.011	0.190	0.761
Treated liver disease	0.172	0.060	0.087	−0.219	0.030	0.205
P > |z|	0.018	0.334	0.153	0.016	0.656	0.182
Deceased alc. diagnosis	−0.044	−0.200	−0.117	−0.211	−0.105	−0.262
P > |z|	0.301	< 0.001	< 0.001	0.024	0.002	< 0.001

Consumption, N = 182, number of observations = 1,456. Harm, N = 207, number of observations = 1,656. Bold figures highlight significant results as p ≥ .050. Example of interpretation of results; a 1% increase in APMM (WAPMM) is associated with a 0.262% decrease of alcohol-related mortality, controlled for changes in population size, median income, unemployment and post-secondary education.

Table A2. Estimated prevention effects (direct effect) on indicators of consumption and alcohol-related harm in percent, for 2006–2014, controlled for population size, median income, unemployment, and post-secondary education.

	Policy	Staff and budget	Cooperation	Inspections and licenses	Activities	APMM sum
	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect
Alcohol consumption	−0.004	−0.003	−0.002	0.011	−0.002	−0.010
P > |z|	0.004	0.029	0.087	0.012	0.070	0.004
Single-vehicle accident	−0.065	−0.070	−0.083	−0.035	−0.076	−0.276
P > |z|	0.047	0.005	< 0.001	0.648	0.006	< 0.001
Assaults	0.034	−0.016	−0.009	0.043	0.000	0.027
P > |z|	0.075	0.258	0.532	0.171	0.979	0.523
Treated alc. intox.	0.020	0.004	0.001	0.090	−0.006	0.046
P > |z|	0.161	0.683	0.961	0.018	0.633	0.199
Treated alc. diagnosis	−0.003	0.000	−0.001	−0.002	−0.003	−0.003
P > |z|	0.590	0.911	0.797	0.860	0.545	0.782
Treated liver disease	0.018	−0.010	0.022	−0.127	0.006	0.015
P > |z|	0.604	0.760	0.435	0.077	0.824	0.874
Deceased alc. diagnosis	−0.032	−0.048	−0.003	−0.191	−0.026	−0.080
P > |z|	0.223	0.055	0.856	0.004	0.272	0.124

Consumption, N = 182, number of observations = 1,638. Harm, N = 207, number of observations = 1,863. Bold figures highlights significant results as p ≥ 0.050. Example of interpretation of results; a 1% increase in APMM is associated with a 0.010% decrease in alcohol consumption controlled for changes in population size, median income, unemployment and post-secondary education.

Table A3. Estimated prevention effects (one-year lagged effect) on indicators of consumption and alcohol-related harm in percent, for 2006–2014, controlled for population size, median income, unemployment, and post-secondary education.

	Policy	Staff and budget	Cooperation	Inspections and licenses	Activities	APMM sum
	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect	Estimated prevention effect
Alcohol consumption	−0.002	−0.001	−0.001	0.003	−0.003	−0.006
P > |z|	0.239	0.650	0.077	0.478	0.038	0.062
Single-vehicle accident	0.009	−0.008	−0.016	0.109	−0.059	−0.097
P > |z|	0.799	0.795	0.559	0.164	0.037	0.203
Assaults	−0.023	−0.021	−0.013	−0.032	0.001	−0.030
P > |z|	0.251	0.116	0.353	0.317	0.966	0.469
Treated alc. intox.	−0.014	−0.002	−0.003	0.021	−0.012	0.002
P > |z|	0.303	0.853	0.803	0.586	0.423	0.969
Treated alc. diagnosis	−0.003	0.002	0.004	−0.040	0.001	−0.003
P > |z|	0.607	0.684	0.281	0.003	0.893	0.855
Treated liver disease	0.065	0.024	0.030	−0.101	0.008	0.141
P > |z|	0.099	0.497	0.351	0.179	0.795	0.171
Deceased alc. diagnosis	−0.001	−0.057	−0.034	−0.107	−0.028	−0.139
P > |z|	0.986	0.012	0.042	0.128	0.147	0.004

Consumption, N = 182, number of observations = 1,456. Harm, N = 207, number of observations = 1,656. Bold figures highlights significant results as p ≥ 0.050. Example of interpretation of results; a 1% increase in APMM is associated with a 0.139% decrease in alcohol-related mortality controlled for changes in population size, median income, unemployment and post-secondary education.

Figure A1. Prevention categories within APMM. Average points based on 207 municipalities, 2006–2014.