Open access Original research Assessing the association between tourism and the alcohol urban environment in Barcelona: a cross-­ sectional study Susanna Puigcorbé,1,2,3 Joan R Villalbí,1,2,3,4 Xisca Sureda,5,6,7,8 Marina Bosque-­Prous ‍ ‍,9,10 Ester Teixidó-Compañó,11 Manuel Franco,5,6,12 Montserrat Bartroli,1,2,3 Albert Espelt4,10,11 To cite: Puigcorbé S, Villalbí JR, ABSTRACT Sureda X, et al. Assessing Strengths and limitations of this study Objectives Alcohol availability and promotion are not the association between distributed equally in the urban context. Evidence shows tourism and the alcohol urban ►► This is the first major study to examine the asso- that the socioeconomic level seems to influence the environment in Barcelona: a ciation between tourism pressure and urban envi- amount of alcohol-­related elements in an area. Some cross-­sectional study. BMJ Open ronment elements related to alcohol, availability and 2020;10:e037569. doi:10.1136/ studies suggest that tourism could also affect the advertising or promotion. bmjopen-2020-037569 distribution of these elements. We explore with a valid ►► We characterised the alcohol urban environment of instrument in a large city whether there is an association ►► Prepublication history for a compact city in Southern Europe in a representa- between high tourism pressure and a greater presence of this paper is available online. tive sample of census tracts using a validated mea- alcohol-­related elements in the urban environment. To view these files, please visit suring tool. Design Observational ecological study. the journal online (http://​dx.​doi.​ ►► The OHCITIES measuring tool captures important org/​10.​1136/​bmjopen-​2020-​ Setting The study was conducted in Barcelona during characteristics of the alcohol environment as they 037569). 2017–2018. are experienced by persons in the street, which are Participants We assessed urban exposure to alcohol difficult to capture using other methods. Received 07 February 2020 by performing social systematic observation using the ►► The study is cross-­sectional in nature, and thus no Revised 12 August 2020 OHCITIES Instrument in a stratified random sample of 170 Accepted 23 August 2020 causality may be derived from associations. census tracts within the city’s 73 neighbourhoods. Primary and secondary outcome measures For each census tract we calculated the density of alcohol premises, and of promotion in public places per 1000 residents. We among them its availability and affordability.3 estimated tourism pressure using the number of tourist Alcohol promotion also seems to be linked beds per 1000 residents in each neighbourhood and to alcohol consumption.4 5 The urban envi- calculated quartiles. To assess the relationship between ronment contains a wide variety of elements rate ratios of elements of alcohol urban environment and related to alcohol availability and to its promo- tourism pressure, we calculated Spearman correlations tion, such as sales premises and alcohol adver- and fitted Poisson regression models with robust error variance. tising. Exposure to alcohol-­related elements Results The median densities obtained were of 8.18 including both points of sale and consump- alcohol premises and of 7.59 alcohol advertising and tion and alcohol promotion may contribute promotion elements visible from the public space per to normalise its use.6 Empirical research has 1000 population. Census tracts with the highest tourism shown it is actually related to higher levels pressure had 2.5 (95% CI: 1.85–3.38) times more outlets of alcohol use.7 8 In some countries, regula- and 2.3 (95% CI: 1.64–3.23) times more promotion tion of alcohol availability and promotion elements per 1000 residents than those in the lowest effectively limits its presence, but in the © Author(s) (or their tourism pressure quartile. absence of such interventions market forces employer(s)) 2020. Re-­use Conclusions We observed a strong association between drive its presence, which finally results from permitted under CC BY-­NC. No tourism pressure and alcohol exposure in the city of commercial re-­use. See rights the balance of supply and demand. Some Barcelona. and permissions. Published by studies have shown a relationship between BMJ. the density of elements related to alcohol For numbered affiliations see INTRODUCTION availability and promotion in the urban envi- end of article. Alcohol use is a risk factor for more than 200 ronment and the socioeconomic level of the Correspondence to diseases and injuries.1 Globally, 2.8 million area.9–13 Other studies suggest that tourism Dr Marina Bosque-­Prous; deaths were attributed to alcohol use in pressure could also have an effect on the ​mbosquep@​uoc.​edu 2016.2 Many factors influence alcohol use, distribution of alcohol-­related elements14–16 Puigcorbé S, et al. BMJ Open 2020;10:e037569. doi:10.1136/bmjopen-2020-037569 1 Open access but, to our knowledge, no study has explored this associ- ation in depth. Barcelona has evolved to become a major tourist desti- nation in the last 25 years.17 From not being a tourist destination it has evolved to become the 12th most tour- istic city worldwide in 2017, and tourism has grown from 2 million visitors per year in the early 1990s to 9 million in 2018 (while having 1.6 million residents).18 Tourism generates economic benefits19 but it may also have unde- sirable effects, such as increases in the cost of housing and gentrification, or the substitution of traditional community shops for tourist-­oriented establishments.17 20 Among the main tourist interests is the local gastronomy including local beverages (such as wine, beer or liquors), and in areas with more tourists business evolves to offer more lodging, eating and drinking options.21–23 Night- clubs, bars, restaurants and liquor stores targeting tourists have as their main goal expanding their drinking expen- ditures, but we may assume that as a side effect they also increase the availability of alcohol for residents, and thus expand their drinking opportunities.14 24 In Barcelona, where the availability and acceptability of alcohol are widespread, we hypothesise that high tourism pressure Figure 1 Census tracts and neighbourhoods in Barcelona, may have had an impact increasing the presence of urban with the study census tracts indicated. elements related to alcohol availability and promotion. As tourism has grown rather abruptly and with an uneven and off-­premises (retail stores), and advertising and distribution across the city, it is an ideal setting to inves- promotion elements in the public space. To obtain repre- tigate its effect.19 Beyond the statistical analysis, further sentative data for the city, we conducted stratified random efforts may focus on clarifying whether urban elements sampling of census tracts in each neighbourhood (except related to alcohol actually exert an influence on alcohol for the two neighbourhoods composed of a single census use, and if a derived harm exists. tract, which were both included). In general, we sampled The objective of this study was to examine the poten- two census tracts for each neighbourhood, but if these tial relationship between tourism pressure in the city of covered less than 5% of the surface, we randomly selected Barcelona and the presence of two markers of the alcohol more until 5% was reached (figure 1). availability and promotion in the urban environment: the density of alcohol premises, and the density of alcohol Measures promotion and advertising visible from public space, Field data collection was carried out using the validated measured using a validated instrument. OHCITIES Instrument.25 OHCITIES is a questionnaire that uses systematic social observation to characterise different variables related to alcohol availability and METHODS promotion in the urban environment. This instrument Design had been previously developed and validated showing We conducted an observational ecological study in Barce- high inter-­rater and test–retest reliability values (higher lona between July 2017 and February 2018. Barcelona is than 0.80) for most of its variables.25 The OHCITIES a dense and compact city, with a population of 1.6 million Instrument works with a mobile application and we in an area of 100 km2, mostly living in apartments. The collected the data using a smartphone. It also allowed municipality is divided into 1068 census tracts within 73 us to geolocate all the recorded information and to take neighbourhoods grouped in 10 districts. Census tracts pictures. Four trained observers completed the obser- are the smallest administrative divisions, defining homo- vations in the 170 selected tracts, randomly distributed geneous territorial zones containing an average of 1000 among observers and observation days. As a previous study voters. observed only minor differences between mornings and evenings,15 data were collected in working days, 16:00– Sample 20:00. Although the reliability of OHCITIES has been A representative sample of 170 census tracts was selected validated previously, in order to detect whether there (figure 1), covering all neighbourhoods, with an average were significant differences in data collection between of two census tracts per neighbourhood. In each census observers and seasons, we performed repeated observa- tract, we collected data on various elements related to tions in 37 census tracts (13 in different seasons, 7 with alcohol availability: on-­premises (bars and restaurants) different observers, and 17 with both different observers 2 Puigcorbé S, et al. BMJ Open 2020;10:e037569. doi:10.1136/bmjopen-2020-037569 Open access and seasons) and found no significant differences (data of values. We mapped the distribution quartiles of the not shown). densities of each variable in the city neighbourhoods. We The main dependent variables for this study were the obtained Spearman correlation coefficients to analyse densities of the urban elements that may foster alcohol the relationship between the census tract densities of consumption: availability of alcohol; and alcohol adver- the alcohol-­related variables and tourism pressure. We tising and promotion visible from the public space. Avail- considered as census tracts enduring high tourism pres- ability of alcohol included on-­premises (bars, restaurants, sure those located in neighbourhoods with the highest pubs) and off-­ premises (supermarkets, grocery stores, quartile of tourist beds relative to the resident population. specialised alcohol outlets), regardless of whether they We fitted Poisson regression models with robust error were open or closed at the time of the observation. As variance obtaining crude rate ratios for each category elements promoting alcohol, we included both the with their respective 95% CIs. We used the lowest level number of premises that had any alcohol advertising of tourism pressure as the reference category. Finally, to or promotion visible from the street (posters, awnings, control for confounding by socioeconomic level, we fitted signs, items with logos in the premises’ terrace), and another Poisson regression model with robust error vari- the number of advertising or promotion items located ance adjusting for the neighbourhood AFII. All statistical in outdoor public places beyond the outlets (billboards, analyses were carried out using the Stata V.14 software posters on bus stop shelters, vinyls on urban buses). We package while the spatial analyses were done with QGIS 3. obtained the densities of each element by calculating the number of elements recorded in a census tract per 1000 residents in that census tract. Independent variables were derived from the city statis- RESULTS tical reports, which provide most data at the neighbour- Descriptive analyses of the alcohol urban environment hood level. Thus, for these variables we ascribed to each are shown in table 1. Within the 170 census tracts studied, census tract its neighbourhood value. The main indepen- we identified a total of 5210 urban elements related to dent variable was tourism pressure,26 which we estimated alcohol availability and promotion. Of these, 2391 were using a previously proposed indicator.26 27 We created alcohol outlets: 70% were on-­ premise alcohol outlets, this indicator by computing the number of tourist beds 29% were off-­premise alcohol outlets and 1% were other (including hotels, hostels, touristic apartments, bed and outlets that sold alcohol as a minor part of the business breakfast rooms, and other touristic lodgings) in each (such as souvenir shops offering customised sangria neighbourhood per population in that neighbourhood bottles). There were 2263 alcohol promotion elements: in 2016. The density of tourist beds ranged among neigh- 80% were visible alcohol advertising or promotion bourhoods from 0 to 674/1000 residents, and its median elements related to alcohol premises; 7% were alcohol was 29/1000 residents. The other independent variable advertising or promotion elements related to commer- was the socioeconomic level, a potential confounding cial settings different from alcohol premises and the variable as it has been linked to the urban elements remaining 13% were alcohol advertising or promotion related to alcohol.9 To estimate neighbourhoods’ socio- beyond outlets, mostly on streets. In relative terms, the economic level, we used the Available Family Income median densities found were 8.18 alcohol-­selling prem- Index (AFII) in 2016, an indicator of per capita wealth, ises per 1000 inhabitants and 7.59 alcohol advertising where the mean value for the city is 100 and neighbour- and promotion elements per 1000 inhabitants. The hoods rank from 34.3 to 242.4.28 This index combines highest densities of both on-­premises and off-­premises five weighted socioeconomic variables: education level sales and advertising or promotion elements were found (proportion of people with a university degree), employ- in central census tracts, with a strong correlation with the ment (number of employed people as a proportion of the neighbourhood distribution of tourist beds in the city working-­age population), number of vehicles per capita, (p=0.54 and p=0.49, respectively). The distribution of the the engine size of new vehicles purchased by residents densities of each element in the city neighbourhoods is and the market price of residences. shown in figure 2, as well as the distribution of tourism pressure and socioeconomic level. Statistical analyses As shown in table 2, we found that tourism pressure We described the number of elements related to alcohol was significantly associated with the density of premises availability and promotion found in the urban environ- that sell alcohol, and with the density of advertising and ment and its median densities, by level of tourism pressure. promotion elements. Neighbourhood socioeconomic Due to the different number of census tracts selected in level was not associated with alcohol urban environment each neighbourhood, we used sampling weights to obtain when adjusting for tourism pressure. Neighbourhoods more representative values for the whole city. To explore in the highest quartile of tourism pressure had a rate of the associations between different alcohol-­related vari- alcohol-­selling premises and of advertising and promo- ables and tourism pressure, we categorised the density of tion elements that were 2.50 (95% CI: 1.85–3.38) and tourist beds in three groups (1st quartile, quartiles 2–3 2.30 (95% CI: 1.64–3.23) times greater than those in the and 4th quartile) in order to overcome the wide range bottom quartile, respectively. Puigcorbé S, et al. BMJ Open 2020;10:e037569. doi:10.1136/bmjopen-2020-037569 3 Open access Table 1 Number, median and quartiles of alcohol sales premises and advertising in a sample of the city census tracts, by tourism pressure, Barcelona, 2017–2018 n % Q1* Median* Q3* Alcohol premises in general Low tourism pressure 278 11.6 4.82 6.97 9.74 Medium tourism pressure 974 40.7 4.68 7.19 10.25 High tourism pressure 1139 47.7 8.52 14.55 17.83 Total † 2391 100 5.36 8.18 13.88  On-­premises  Low tourism pressure 185 11 2.79 4.24 7.68  Medium tourism pressure 659 39.2 2.71 4.14 6.51  High tourism pressure 838 49.8 4.87 9.11 12.97 Total   1682 100 3.19 5.15 8.64  Off-­premises  Low tourism pressure 91 13.3 1.3 2.4 3.39  Medium tourism pressure 308 44.8 1.42 2.49 3.7  High tourism pressure 288 41.9 2.32 3.49 5.11 Total   687 100 1.6 2.73 3.91 Advertising and promotion Low tourism pressure 283 12.5 4.1 5.64 8.58 Medium tourism pressure 906 40 4.26 6.39 9.66 High tourism pressure 1074 47.5 8.58 11.61 16.29 Total † 2263 100 5 7.59 12.37  Advertising and promotion in public places unrelated to premises  Low tourism pressure 55 18.1 0 0 1.03  Medium tourism pressure 142 46.9 0 0.82 1.57  High tourism pressure 106 35 0 0.81 1.79 Total   303 100 0 0.78 1.57  Premises with alcohol advertising and promotion elements  Low tourism pressure 219 12 4.82 4.82 8.04  Medium tourism pressure 709 39 3.28 5.12 7  High tourism pressure 893 49 6.23 10.88 13.7  Total 1821 100 1.7 5.85 10.08 Tourism pressure is categorised using quartiles: low: Q1; medium: Q2–Q3; high: Q4. *Estimation for all Barcelona, densities per 1000 inhabitants (weighted). †There were further 22 alcohol premises classified as ‘other outlets that sold alcohol as a minor part of the business’ and 139 alcohol promotion elements classified as ‘alcohol advertising or promotion elements related to commercial settings different from alcohol premises’ not shown in this table due to small numbers. DISCUSSION from the public space are essentially placed in alcohol The main finding of this study is that the density of outlets. alcohol, alcohol-­selling premises, and advertising or This is, to our knowledge, the first major study to promotion-­related elements in the urban environment examine the association between tourism pressure and varies markedly between the census tracts of Barcelona, the elements related to alcohol availability, advertising and that this variation appears to be now mostly related or promotion in the urban environment. We character- to tourism pressure. Independently of the socioeconomic ised the alcohol urban environment of Barcelona in a level of the neighbourhood, tourism pressure is positively representative sample of census tracts using a validated and significantly associated with the density of alcohol measuring tool, the OHCITIES Instrument.25 OHCI- outlets, and with advertising and promotion elements. TIES captures important characteristics of the alcohol Further, most advertising and promotion elements visible environment as they are experienced by persons while 4 Puigcorbé S, et al. BMJ Open 2020;10:e037569. doi:10.1136/bmjopen-2020-037569 Open access promotion elements in the urban environment. Higher density of alcohol outlets and promotion elements may be conducive to more drinking by the exposed persons, both tourists and permanent residents.29 Only a handful of studies explore tourism as a factor related to the alcohol availability or promotion elements. An Austra- lian study found a positive association between tourism pressure and the presence of on-­premise and off-­premise outlets.13 Caribbean islands with high levels of tourism had more outlets and higher levels of alcohol production, import and distribution than islands with lower levels of tourism.14 In Cyprus some decades ago, bars were only present in tourist areas, but have expanded to other areas as tourism has grown.16 These results are in line with our findings: urban areas in Barcelona that have the greatest tourism pressure also have greater availability of alcohol, and more advertising and promotion elements. However, in Spain and other wine-­growing countries of Southern Europe drinking is culturally accepted and drinks are in general widely available and relatively inexpensive3 : this context must be kept in mind. In fact, we also found that Barcelona has a high density of elements related to alcohol in its urban environment. While on-­premises and off-­premises medians obtained in the city were 5.15 and Figure 2 Neighbourhood means of the studied census tracts density of alcohol premises, alcohol promotion 2.73 per 1000 inhabitants, respectively, the densest areas elements, Available Family Income Index and touristic beds in Victoria (Australia) have 1.45 on-­premises and 0.45 off-­ per 1000 residents, by quartile. Barcelona, 2017–2018. premises per 1000 residents.13 Also in New Zealand, the *Densities per 1000 residents in 2016. reported highest density is 2.01 premises per 1000 resi- dents.30 Comparing ratios relative to population ignores the fact that Barcelona is a very compact city, so if we had in the street, which are difficult to capture using other compared ratios relative to the surface the differences methods.25 It is remarkable that the densities derived in with these studies would be even greater. 2015 for the pilot study covering only 20 census tracks but Establishments in Spain do not require a specific licence with observations in the morning, afternoon and night to sell alcohol (either in on-­premises or off-­premises), periods were fairly close to these estimates.15 Although allowing alcohol to be more ubiquitously available. we chose to perform the fieldwork on weekdays between There is evidence that tourism pressure in Barcelona has 16:00 and 20:00 to ensure that most on-­premises and off-­ favoured gentrification and the partial substitution of premises sales outlets would be open during data collec- traditional community trade for tourism-­oriented estab- tion, some pubs and nightclubs were closed at the time of lishments.17 20 This leads us to think that a greater supply the observation. Even though we included all the prem- of alcohol in the tourist areas could be an effect derived, ises regardless of whether they were open or closed, if at least partially, from the pressure of tourism. A higher some premises had no visible external signs while closed alcohol availability linked to tourism pressure could be a we may had some underestimation results, and this is a recent process as the city has evolved to become a major limitation of the study. However, as alcohol premises were tourist destination in a relatively short time. As a result, concentrated in central and touristic areas, the inclusion it now has to deal with the negative impacts of tourism of these unidentified outlets would have produced even on several aspects of city life, and this is one of the most stronger associations. Another potential limitation is the controversial current political issues.31 However, since the extrapolation of neighbourhood-­level data for the inde- provision of local food and drinks is also an attraction pendent contextual variables in the studied census tracts. factor for tourists, some areas may have increased tourism However, as neighbourhoods are relatively homogeneous pressure because they already had higher alcohol avail- areas, this should not produce biased results. As the study ability. Outside the city, the evolution of this process in is cross-­sectional in nature, there is no directionality in it, beach resorts has led to some areas becoming practically and of course no causality may be derived from the asso- a tourist ghetto, avoided by many local residents, but this ciations found. The question of whether tourism attracts is not the current situation in the city.27 Further, while outlets or outlets attract tourism cannot be answered with we expected socioeconomic level to strongly influence this observational study. alcohol availability,9 10 it seems to play now a minor role. We found that greater tourism pressure is now asso- In the city of Madrid, which has not undergone such a ciated with a greater density of alcohol outlets and rapid growth in tourism, socioeconomic level seems to be Puigcorbé S, et al. BMJ Open 2020;10:e037569. doi:10.1136/bmjopen-2020-037569 5 Open access Table 2 Poisson regression models with robust error variance of the census tracts density of alcohol premises and alcohol promotion elements with neighbourhood tourism pressure and with socioeconomic level (AFII), Barcelona, 2017–2018 IRRC (95% CI) P value IRRA (95% CI) P value Alcohol premises in general Low tourism pressure 1 1 Medium tourism pressure 1.31 (1.01–1.71) 0.045 1.30 (0.98–1.74) 0.07 High tourism pressure 2.52 (1.90–3.35) <0.001 2.50 (1.85–3.38) <0.001 Socioeconomic level (AFII) 1.00 (1.00–1.01) 0.064 1.00 (1.00–1.00) 0.911  On-­premises   Low tourism pressure 1 1   Medium tourism pressure 1.33 (1.00–1.77) 0.047 1.31 (0.95–1.79) 0.95   High tourism pressure 2.78 (2.06–3.77) <0.001 2.72 (1.96–3.76) <0.001   Socioeconomic level (AFII) 1.00 (1.00–1.01) 0.042 1.00 (1.00–1.00) 0.752  Off-­premises   Low tourism pressure 1 1   Medium tourism pressure 1.27 (0.91–1.77) 0.161 1.31 (0.92–1.86) 0.133   High tourism pressure 1.95 (1.37–2.76) <0.001 2.02 (1.38–2.95) <0.001   Socioeconomic level (AFII) 1.00 (1.00–1.00) 0.368 1.00 (1.00–1.00) 0.669 Advertising and promotion Low tourism pressure 1 1 Medium tourism pressure 1.20 (0.89–1.62) 0.237 1.18 (0.86–1.64) 0.308 High tourism pressure 2.33 (1.69–3.22) <0.001 2.30 (1.64–3.23) <0.001 Socioeconomic level (AFII) 1.00 (1.00–1.01) 0.088 1.00 (1.00–1.00) 0.841  Advertising and promotion in public places   Low tourism pressure 1 1   Medium tourism pressure 0.97 (0.52–1.81) 0.916 0.94 (0.48–1.85) 0.868   High tourism pressure 1.18 (0.60–2.33) 0.623 1.15 (0.55–2.43) 0.707   Socioeconomic level (AFII) 1.00 (1.00–1.00) 0.711 1.00 (1.00–1.00) 0.819  Premises with alcohol advertising and promotion elements   Low tourism pressure 1 1   Medium tourism pressure 1.21 (0.90–1.63) 0.202 1.19 (0.86–1.64) 0.229   High tourism pressure 2.51 (1.83–3.44) <0.001 2.44 (1.75–3.41) <0.001   Socioeconomic level (AFII) 1.00 (1.00–1.00) 0.064 1.00 (1.00–1.00) 0.735 AFII, Available Family Income Index; IRRA, adjusted incidence rate ratio ; IRRC, crude incidence rate ratio. the leading factor explaining the distribution of alcohol and of trivialisation of the consequences of alcohol use elements,10 but this is not the case now in Barcelona. The both for residents and temporary visitors.32 33 Of course, current picture may reflect changes caused by expanding contextual factors related to alcohol culture and formal tourism pressure in the city in recent years, driven by the and informal regulations may be relevant and result in growth in tourist apartments displayed in Airbnb and variations across countries.3 4 Traditional direct adver- similar platforms. tising seems to have evolved into a more subtle range of Overall, it seems that tourism is shaping cities in many alcohol marketing elements. Most elements that promote ways. Probably its influence in gentrification and its impact alcohol in the city are not plain advertising, but rather on housing is a major effect, but also its impact in the items placed in alcohol premises with logos or brands local fabric of trade, including those aspects determining (such as parasols, ashtrays or napkin holders).6 Repeated alcohol availability and promotion urban elements. The exposure to these elements is known to favour positive strong association found between tourism and these attitudes towards it (or greater preference for it), what is elements in the urban environments may contribute at known as the ‘mere exposure’ effect.34 This is one of the least partially to the process of drinking normalisation mechanisms through which advertising and marketing 6 Puigcorbé S, et al. BMJ Open 2020;10:e037569. doi:10.1136/bmjopen-2020-037569 Open access techniques succeed, even when the target audience of its authorities. This map is provided without any warranty of any kind, either does not pay direct attention to the messages: simply express or implied. perceiving a product or brand can affect behaviour and Competing interests None declared. decisions.35 In fact, this advertising has been shown to Patient consent for publication Not required. increase drinking rates in target groups (mainly young Provenance and peer review Not commissioned; externally peer reviewed. people) in different countries.36–38 Therefore, a dense Data availability statement Data are available upon reasonable request, such as alcohol urban environment can induce more drinking by collaborative research, at ​mbosquep@​uoc.​edu. local residents, since a higher density of alcohol elements Open access This is an open access article distributed in accordance with the could act as advertising.39–41 Exploring whether this influ- Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which ence exists and its magnitude is a suggestive research to permits others to distribute, remix, adapt, build upon this work non-­commercially, and license their derivative works on different terms, provided the original work is undertake in the process to disentangle the many factors properly cited, appropriate credit is given, any changes made indicated, and the use influencing the harmful use of alcohol, which will require is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/. the contribution of different disciplines. Having docu- mented urban alcohol environmental factors, we intend ORCID iD Marina Bosque-­Prous http://​orcid.​org/​0000-​0002-​8830-​8880 to analyse this relation further in future studies, using both qualitative and quantitative methods. REFERENCES 1 Alwan A, Armstrong T, Bettcher D, et al. Global status report: on CONCLUSIONS noncommunicable diseases 2010. Lisbon, Portugal: World Health We observed a relationship between tourism pressure Organization, 2011. 2 GBD 2016 Alcohol Collaborators. Alcohol use and burden for 195 and density of alcohol outlets and alcohol advertising countries and territories, 1990-2016: a systematic analysis for the and promotion elements in Barcelona, which may influ- global burden of disease study 2016. Lancet 2018;392:1015–35. ence alcohol use by the population. Future studies on 3 Babor TF, Caetano R, Casswell S, et al. 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