Prevention Enhancement Protocols System
(PEPS) Preventing Problems Related to Alcohol
Availability: Environmental Approaches Practitioners' Guide
Third in the PEPS Series Prakash L.
Grover, Ph.D., Executive Editor
Department of
Health and Human Services Substance Abuse and Mental Health Services
Administration Center for Substance Abuse Prevention DHHS
Publication No. (SMA)99-3298.
The Prevention Enhancement Protocols System (PEPS) Series, initiated by the
Substance Abuse and Mental Health Services Administration's Center for Substance
Abuse Prevention (SAMHSA/CSAP), exists for three reasons. PEPS guides strive to
systematically evaluate research and practice evidence on substance abuse
prevention,
make recommendations for field use by those who implement intervention
programs, and
maximize the prevention efforts of State substance abuse prevention
agencies, practitioners, and local communities.
Prakash L. Grover, Ph.D., M.P.H., is the Program Director of PEPS and the
Executive Editor of the Guideline series for CSAP. Robert Bozzo serves as Team
Leader for the PEPS. Friedner D. Wittman, Ph.D., M.Arch., Chair of the Expert
Panel, played a major role in writing the Reference Guide. He contributed to the
volume beyond reasonable expectations from a Panel Chair. For this, CSAP and the
Executive Editor are deeply grateful. Several other members of the Expert Panel
also helped write the Reference Guide: Norman Giesbrecht, Ph.D.; Katherine
Kessler, M.S., L.M.F.C.C.; Michael Sparks; Ralph Hingson, Ph.D.; and Karen Bass.
From the PEPS staff, Mim Landry and Prakash Grover wrote the core sections on
analysis of evidence and recommendations for practice. Cheryl Droffner provided
the indispensable research assistance that serves as a foundation of such
documents. Donna Dean helped refine the Reference Guide and developed the
Practitioner's Guide and the Community Guide. Betsy Earp and Chip Moore, with
assistance from Sara Davidson, edited the document.
Exhaustive review of the documents was conducted by Robert W. Denniston, Mark
Weber, Tom Vischi, and Christine Quinn. Their comments vastly improved the
document.
The deliberations and recommendations of the Expert Panel in this guide do
not necessarily reflect the opinions, official policy, or position of
SAMHSA/CSAP, or the U.S. Department of Health and Human Services.
This publication was prepared for SAMHSA/CSAP, with substantial assistance
from Birch & Davis Associates, Inc. (Contract No. 277-92-1011). Lee Wilson
served as the Government Project Officer of the Prevention Technical Assistance
to States project under which this publication was produced.
For single copies of this document, contact SAMHSA' s National Clearinghouse
for Alcohol and Drug Information (NCADI), P.O. Box 2345, Rockville, MD
20847-2345, 1-800-729-6686, 301-468-2600, or TDD 1-800-487-4889; or visit the
website at http://ncadi.samhsa.gov/. The
documents are also available electronically from the National Institutes of
Health at http://text.nlm.nih.gov/ftrs/dbaccess/csap.
The Substance Abuse and Mental Health Services Administration's Center for
Substance Abuse Prevention, (SAMHSA/CSAP), is committed to enhancing a broad
range of effective prevention strategies that are planned and implemented by
State agencies as well as community-based organizations across the Nation.The
Prevention Enhancement Protocols System (PEPS) generates science-based documents
that can substantially improve planning and management of prevention programs,
consolidate and focus prevention interventions, and serve as the foundation for
potential prevention studies.
CSAP selected this topic, Preventing Problems Related to Alcohol
Availability: Environmental Approaches, because alcohol problems affect many
individuals and groups in our communities, and there is an emerging body of
evidence that these approaches can be highly effective. In fact, research and
practice strongly suggest that carefully planned management of alcohol
availability can reduce alcohol problems and enhance the quality of life for all
members of the community.
But many communities neglect to manage alcohol availability problems through
the State and local government entities that exist for that very purpose.
Through these PEPS documents, CSAP is providing State and local governments with
a strong foundation for addressing alcohol problems that affect the well-being
of communities, using balanced approaches involving education, regulation, and
local resources for managing alcohol availability, consistent with the norms and
values of the community.
PEPS designed this guide for broad use by State substance abuse agencies as
well as national, State, and local organizations that try to manage the problems
related to the availability of alcohol. It is intended as a practical guide for
those whose responsibility it is to consider the strengths and limitations of
specific interventions and to plan prevention initiatives. Using this Guide in
combination with other ongoing community efforts can result in a balanced,
effective program to addressing alcohol problems.
Nelba Chavez, Ph.D. Administrator Substance Abuse
and Mental Health Services Administration
Karol Kumpfer, Ph.D. Director Center for Substance
Abuse Prevention Substance Abuse and Mental Health Services
Administration
This guide focuses on research and practice evidence for key environmental
approaches to the prevention of problems related to alcohol availability. It
evaluates the following six approaches:
Preventing Availability to Underage Youth
Raising Alcohol Taxes and Prices
Responsible Beverage Service
Changing the Conditions of Availability
Changing Hours and Days of Sale
Community-Based Prevention Approach
This practitioner's guide is intended to be brief and simple. It summarizes
much of the information in its parent document, Preventing Problems Related
to Alcohol Availability: Environmental Approaches-Reference Guide, and
highlights information that will be most useful to those directly involved in
planning and implementing prevention programs.
For much greater detail concerning the six prevention approaches, the
research and practice evidence for each approach, recommendations for practice,
and guides for program development, implementation, and evaluation, please see
the Reference Guide.
A separate brochure-length publication, Preventing Problems Related to
Alcohol Availability: Environmental Approaches-Community Guide, provides a
brief overview of substance abuse problems, outlines courses of action for
concerned citizens, and offers tips for becoming involved in community-centered
prevention.
Before developing guidelines for practitioners, the evidence that comes from
research and practice must be weighed. Several criteria are central to
determining whether information is strong enough to serve as the basis for
making recommendations.
The term research evidence refers to the research-based body of
knowledge for a specific prevention approach. This information is gathered from
scientific investigations that adopt various research designs but are all
rigorously conducted. When natural experiments are reviewed as evidence, it is
ensured that they are properly documented and analyzed.
design — an outline of the procedures to be followed in
scientific experimentation in order to reach valid conclusions.
The term practice evidence describes information gained from
prevention practice cases, which is generally presented in the form of
well-designed and -executed case studies that include documentation on program
implementation and procedures, as well as on process evaluation
effect — establishing, through comparison, a logical
relationship between conditions with and without the program or
intervention.
In each of the prevention approaches described in "Environmental Prevention
Strategies — What Works?," shaded boxes present information on levels of
evidence for the effect of intervention approaches. These boxes highlight the
consensus of the Expert Panel, whose members summarized the conclusions that can
reasonably be drawn after analyzing the evidence for each approach. The boxes
also indicate the strength of the level of cumulative evidence supporting the
conclusions.
The criteria for assigning levels of evidence are shown in the following
boxes. The first three categories apply to varying degrees of confirmation of
positive effect. The fourth category applies to evidence that a prevention
approach is ineffective.
1. Strong Level of Evidence
Application.
Practitioners can use the approach with the most assurance that the
approach can produce the effect specified in the evidence statement.
Here are the criteria for including evidence in this
category:
Consistent positive results of strong or medium effect from a series
of studies, including:
— At least three well-executed studies of experimental or
quasi-experimental design
OR
— Two well-executed
studies of experimental or quasi-experimental design and consistent
results from at least three case studies
The use of at least two different methodologies
Unambiguous time ordering of intervention and results
A plausible conceptual model ruling out or controlling for
alternative causal paths or explanations
2. Medium Level of Evidence
Application.
Although the number or rigor of the studies reviewed is limited, there is
substantial support for the approach's ability to produce the effect
specified in the evidence statement. Practitioners should exercise
discretion in applying the approach and in assessing the process and
outcomes.
Here are the criteria for including evidence in
this category:
Consistent positive results from a series of studies, including:
— At least two well-executed studies with experimental or
quasi-experimental designs
OR
— At least one
well-executed study and three prevention case studies showing
statistically significant or qualitatively clear effects
The use of at least two different methodologies
Unambiguous time ordering of intervention and results when so
measured
A plausible conceptual model, whether or not competing explanations
have been ruled out
3. Suggestive but Insufficient Evidence
Application. The approach has shown promise for the effect
specified, but it is not well documented. Practitioners should be cautious
about using this approach. However, if the approach fits the local
situation, practitioners may use it, paying special attention to its
systematic testing and documentation.
This category is
used to describe research and/or practice evidence that (1) is based on a
plausible conceptual model or on previous research and (2) is being
demonstrated in rigorous evaluation studies or appropriate intervention
programs currently in process.
Here are the conditions that lead
evidence to be included in this category:
The evidence, although limited, appears to support a conclusion, but
additional research is needed to fully support the conclusion.
This condition often applies to areas in which there has been little
study, such as those that are impractical to research or new areas of
study.
OR
The evidence is associated with equivocal results.
Effectiveness of the approach is supported in some studies but is not
supported in others.
4. Substantial Evidence of Ineffectiveness
Application. The approach has not demonstrated the intended
results or has shown negative findings for the effects specified.
Practitioners are advised not to use this approach at this time.
This category describes research and practice evidence
demonstrating that a prevention approach is not effective.
Here
are the conditions that lead evidence to be included in this category:
The absence of a statistically significant effect in a
majority of well-executed studies, including at least two quantitative
studies with sample sizes sufficient to test for the significance of the
effect
OR
The absence of a statistically significant negative effect in
a majority of well-executed studies, including at least two quantitative
studies with sample sizes sufficient to test for the significance of the
effect
All communities endure adverse health and social consequences related to
alcohol use and abuse. Many of these consequences are severe and expensive, such
as automobile-related injuries and fatalities, homicides and suicides, and
chronic health problems such as cirrhosis. Some of the most promising strategies
for these problems are community-based prevention activities that use
environmental approaches.
Reaching a single conclusion about a particular approach is difficult. No two
research studies or practice cases are the same, as they differ in the subjects
of evaluation and in the methods used. Conclusions from a single prevention
approach may justify more than one evidence statement since the approach may
have more than one desired result. Furthermore, evidence for a specific desired
result may show a complex pattern. For instance, studies may show that a
prevention approach has strong evidence for attaining a desired effect in
the short term but suggestive but insufficient evidence for sustaining
that effect over time.
Practitioners should evaluate the prevention approaches in this guide in
light of local circumstances; it may not be feasible to implement only
approaches with a strong level of evidence. In developing a program,
practitioners must consider local needs, interests, resources, and abilities —
as well as the level of evidence for a particular approach.
It takes prevention practitioners with great skill and dedication to develop
strong community-based programs. Despite the difficulty and complexity of the
challenges practitioners face, a growing body of research and practice evidence
has documented successful strategies that can change the social, political, and
economic contexts supporting alcohol availability.
The effective management of alcohol availability is a community
problem. The more available alcohol is in the environment, the more likely
it is that the community will have a higher alcohol consumption rate. A high
alcohol consumption rate has been found to be related to an increased number of
problems, such as the following:
Automobile-related injuries and deaths — Alcohol is a factor in 41
percent of traffic fatalities. Alcohol-related car crashes are the number one
killer of teens.
Homicides, manslaughters, and suicides — Alcohol is a factor in
more than 50 percent of homicides, 68 percent of manslaughters, and 33 percent
of suicides.
Head injuries — More than 50 percent of those who sustain head
injuries are drinking alcohol when injured.
Domestic accidents — Alcohol is a factor in 21 to 47 percent of
drownings, 35 to 63 percent of deaths due to falls, and 12 to 61 percent of
deaths due to fire.
High costs — In 1990, alcohol-related problems cost the Nation
$98.6 billion! That is a 40 percent rise between 1985 and 1990. Estimates for
the total lifetime cost for an individual with a severe head injury are as
high as $4.6 million.
Unprotected sex — Teens who drink are less likely to use condoms or
other methods to prevent pregnancy and sexually transmitted diseases.
These costly problems may strain community resources, including fire, police,
and ambulance crews; emergency department personnel and facilities; and the
court system. Therefore, prevention involves many community systems: health,
education, transportation, law, engineering, architecture, and public safety. It
takes the concerted effort of concerned citizens, community groups, businesses,
and officials from local and State agencies to develop and implement effective
strategies.
Although communities can largely manage these problems through State and
local government entities, many do not.
Efforts that focus solely on individual problem drinkers or on individual
outlets are not sufficient. Public health strategies must also prevent or reduce
problems related to availability through local laws, policies, and programs.
In practical terms, this means placing reasonable limitations on the retail
distribution of alcohol, on the operation of alcohol outlets, and on the
management of events at which alcohol is sold. This practitioner's guide
describes six prevention approaches that focus on limiting the availability of
alcohol in the community in order to help reduce alcohol-related
problems.
Communities that want to make an impact on the availability of alcohol
need to understand how alcohol is sold (made available) in the community; the
relationships between alcohol outlets and alcohol-related problems; and the
systems for managing alcohol availability.
Three forms of alcohol availability are of particular interest.
Retail availability — Commercial availability. Dimensions of
control include price, density of outlets, types of outlets, serving
practices, hours and days of sale, and one-day and short-term licenses. The
relationship between retail availability, consumption, and public health and
safety problems is the primary focus of this practitioner's guide.
Public availability — Public events and places. Public availability
is usually controlled by local jurisdictions, but the State Alcohol Beverage
Control (ABC) board may control availability at State-sponsored events or
locations.
Social availability — Social customs and traditions related to
alcohol use. Social availability is the product of community history, beliefs,
and cultures that shape the norms for drinking and social host practices at
private events. (This type of availability is not a direct focus of this
guide, but it does affect other forms of availability.)
To make an impact on alcohol availability, practitioners and community
leaders should have a common understanding of a few terms, the most important
of which are defined below. A full glossary is provided in appendix B.
Alcohol outlet — A place that sells alcoholic beverages to the
public or a select membership. Outlets vary throughout the United States
because of differences in State regulations and types of retail alcohol
licenses. Licenses are issued to applicants to sell alcohol for consumption
on, off, or both on and off their premises.
Alcohol outlet capacity — The serving capacity of one outlet or of
all outlets in a given area. On-sale capacity is calculated by the number of
seats in the outlet or the outlet's square footage. Off-sale capacity is
calculated by the number of linear feet of shelves devoted to alcohol sales or
the outlet's square footage.
Alcohol outlet density — The number of outlets licensed to sell
alcohol within a given geographic area.
On- or off-sale outlet — An on-sale outlet is licensed to sell
alcohol for consumption within, but not outside of, its establishment.
Examples include bars, taverns, clubs, and some restaurants. An off-sale
outlet is licensed to sell alcohol for consumption outside of, but not within,
its establishment. Examples include liquor stores, supermarkets, wine shops,
gas stations, and minimarkets.
Changes in alcohol control systems and in the availability of alcohol can
have a significant impact on the patterns and problems of alcohol consumption.
The key environmental factors that influence where, when, and how much people
drink are types of regulations, enforcement practices, outlet density, hours and
days of sale, and forms of retail outlet availability.
Today, management of alcohol availability is based on a system of State ABC
boards. State laws regarding the oversight of alcoholic beverages preempt those
of cities and counties. However, since the late 1970's, the States have
delegated varying degrees of power to local governments for retail licensing and
local enforcement.
alcohol management — ways in which a State plays a role
visà-vis the local authorities in controlling the distribution and marketing
of alcohol.
The ways in which States approach alcohol management can be divided roughly
into four categories: (1) Some States prohibit local control of alcohol
availability and marketing in virtually all circumstances. They are called
"control States." (2) Many States place primary authority at the State level but
allow local control through zoning ordinances and local police enforcement of
alcohol laws. (3) Some States provide concurrent State and local authority. (4)
Many States give primary authority to local jurisdictions, with only limited
State involvement. They are called "license
States."
Most local jurisdictions do not fully use their powers to prevent problems
related to alcohol availability. But this picture is changing as communities
begin to recognize the negative impact alcohol outlets can have. Communities
that might once have taken action only after problems arose are now taking
action to prevent problems from arising.
Cities and counties are beginning to put "alcohol elements" into their master
plans. They are also beginning to take stronger measures, such as these:
Writing zoning ordinances specifically to manage retail alcohol outlets.
These ordinances address such concerns as public decorum, litter, noise,
traffic, loitering, harassment, sale of alcohol to minors, underage drinking,
driving under the influence, alcohol-related crime and violence, and public
inebriation.
Imposing conditions on the sale and use of alcohol in public places and at
public events.
Setting policies regarding drinking at official public agencies'
activities and functions.
Enacting local ordinances (other than those tied to planning and zoning
ordinances) specifying how far away alcohol outlets must be from churches and
schools.
In an environmental prevention model, the focus on solving alcohol-related
problems shifts from an individual focus to an environmental focus.The logic is
that reducing alcohol availability will reduce alcohol consumption or modify the
conditions under which it is consumed, which will in turn reduce alcohol-related
problems such as violence, traffic injuries, and alcohol consumption by
minors.
Individual focus
Environmental focus
Individual behaviors
The relationship between the individual
Short-term program development
Individual participation in problem-solving
Policy and policy changes
The social, political, and economic and alcohol-related problems
contexts of alcohol-related problems
Long-term policy development
Collective action
As the PEPS Expert Panel evaluated research studies and practice cases, it
grouped the evidence into six prevention approaches. Each approach is presented
here in terms of its concept, the activities of the studies reviewed by PEPS,
the strength of the evidence supporting the approach, lessons learned from the
evidence, and recommendations for practice.
How do minors get their hands on alcohol? They get it from friends and family
members, they shoplift, and despite a minimum legal drinking age of 21 they buy
it directly from retail outlets such as convenience and grocery stores, service
stations, and minimarts. Enacting and enforcing laws prohibiting alcohol sales
to underage youth should reduce the likelihood that merchants will sell alcohol
to minors, who will in turn be less likely to try to buy it.
Merchants and minors often ignore the laws restricting alcohol sales to
minors. Community-based prevention efforts can educate and publicly support
merchants who comply with drinking age laws.
Levels of Evidence: Availability to
Youth
The research and practice evidence reviewed
indicates that it is possible to implement and enforce laws designed to
prevent alcohol availability to minors.
There is strong evidence that increasing the minimum
drinking age results in a decrease in traffic casualties.
There
is medium evidence that increasing the minimum drinking age
results in a decrease in consumption of alcohol and consequent alcohol
problems other than traffic casualties.
There is strong
evidence that there are substantial sales to minors and that there
is considerable potential for reduction of such sales.
There is
medium evidence that the level of enforcement affects the rates
of underage purchasing.
Most Americans who drink alcohol begin
in their early teens. Occasional intoxication for many begins during the
mid-teen years. Recurrent drinking to intoxication is quite common among
college students. It is clear that enforcement of minimum drinking age
laws decreases but does not eliminate underage drinking.
The
enforcement efforts with the greatest immediate public health
significance are those that break the link between drinking and driving.
All the prevention approaches presented in this guide should
be considered in view of their suggested application in the Evidence Boxes
(pp. 2-3). However, local needs, interests, resources, and abilities — as well
as the level of evidence — must all be considered as practitioners develop
their programs.
Enhance enforcement. Laws that increase the minimum drinking age help
to decrease alcohol consumption, traffic casualties, and alcohol problems.
However, these laws are not uniformly enforced and are often poorly enforced.
Therefore, practitioners should focus on enforcement. Efforts can include
creating linkages among several groups: the State ABC board, the local police,
college administrations, and others that promote community values and support
strict enforcement of drinking-age laws.
Unite efforts. A high minimum drinking age is more effective when it
is complemented by adjunctive efforts such as implementing land use laws
consistent with the enforcement of drinking-age laws.
Be consistent. The enforcement of minimum drinking-age laws differs
among communities and is affected by many factors, such as the police
department's service level or workload, community priorities, and availability
of funds. Community laws and enforcement policies should be consistent with
local prevention messages.
Anticipate crises. The enforcement of minimum drinking-age laws is
often driven by tragedies and crises. Anticipate crises that could occur during
special events such as rock concerts, high school and college activities, and
holidays. Many fraternities and sororities have activities that revolve around
drinking alcohol. These activities often escape the scrutiny of community and
university law enforcement agencies and university administrations until a
tragedy occurs. Work to prevent such tragedies by gaining the support of
fraternities and sororities to change norms that promote heavy drinking. If the
local chapters will not cooperate, enlist the support of their national
organizations and their insurance companies.
Educate underage youth. Most young people harbor false beliefs about
alcohol and driving impairment. Many think it would take several alcoholic
drinks or many beers to impair their driving. Research shows that one or two
alcoholic drinks or four or five beers often produce blood alcohol
concentrations in excess of the legal limit. Even with low to moderate blood
alcohol concentrations, younger people are more likely to be in traffic crashes
when drinking alcohol. This message needs to be brought home to
teenagers.
When States add new taxes that raise the price of alcohol, researchers have
the chance to study how the increased cost affects purchase and consumption
rates. The assumption is that significant increases in price will make alcohol
less accessible, especially to youth. On the other hand, "two for the price of
one" or other happy-hour promotions are thought to increase the likelihood of
overconsumption.
Most of the studies reviewed in this approach were not planned interventions
developed by public health practitioners but, rather, the observations of
"natural experiments." Natural experiments are changes — such as new State taxes
on alcohol — that offer researchers an opportunity to compare behaviors before
and after the changes take effect. Some of the factors that researchers examined
in this prevention approach are changes in State and local taxes on alcohol;
minimum legal drinking age; retail prices of wine, beer, and distilled spirits;
and happy-hour drink discount policies.
Increased alcohol taxes are associated with a moderate decrease in alcohol
consumption, as well as alcohol-related problems, and can be an important aspect
of a prevention campaign. Some research even revealed that, among underage
youth, taxes that increased price were more effective in reducing consumption
than a minimum legal drinking age.
Levy local taxes. Where State laws allow, local taxes such as a
"nickel-a-drink" tax for on-site purchases may be an effective way of both
financing local alcohol prevention initiatives and dissuading purchase. Local
license fees may also be employed to increase alcohol prices.
default State taxes. Because the benefits of price increases resulting
from State alcohol taxes are likely to diminish as inflation erodes the real
value of the tax increase, the taxes can be defaulted so that the nominal tax
rates rise in step with prices. defaulting alcohol taxes to the consumer price
default is an effective way to maintain the public health gains of higher
taxes.
Seek allies in neighboring jurisdictions. Practitioners who are
considering promoting alcohol taxes should initiate discussions and possible
collaboration with neighboring jurisdictions. The benefits of State alcohol
taxes erode when the strategy is out of step with that of neighboring
jurisdictions. Cross-border shopping, cross-border drinking and driving, theft,
and black-market sales may result. When neighboring jurisdictions adopt
equivalent regulations, such problems greatly diminish.
Levels of Evidence:Taxes & Prices
The
research evidence reviewed indicates the following:
There is strong evidence that increases in alcohol
taxes result in a moderate decrease in alcohol consumption.
There is strong evidence that increases in alcohol taxes
result in a moderate decrease in alcohol-related problems such as
automobile crashes, cirrhosis mortality, and driving under the
influence.
There is medium evidence that increases in
alcohol taxes result in roughly equivalent reductions in consumption of
alcoholic beverages among all drinkers.
There is suggestive
but insufficient evidence that increases in alcohol taxes have a
strong effect on drinking initiation among youngsters.
There is
suggestive but insufficient evidence that happy-hour promotions
increase alcohol consumption.
The behavior of people who serve alcohol and the policies of drinking
establishments can influence the behavior of the patrons. For example, servers
may encourage heavy drinking; allow heavy drinking to continue ignored,
promoting intoxication; or foster problems associated with intoxication, such as
disruptive behavior, fights and resulting injuries, or driving while intoxicated
(DWI). Training servers and management to watch for and recognize the warning
signs of intoxication can help reduce the risk that patrons will become
intoxicated and harm themselves or others. It may be necessary to modify
management policies to discourage an atmosphere of "anything goes."
Establishing a State law requiring responsible server training
Enforcing a county law prohibiting alcohol service to intoxicated patrons
Establishing a State Liquor Control Board with comprehensive prevention
activities
Establishing a coalition of representatives from the hospitality industry
and the prevention field to promote and ensure responsible beverage service
Levels of Evidence: Responsible Beverage
Service
The research and practice evidence reviewed
indicates that it is possible to implement responsible beverage server
interventions:
There is strong evidence that server training and
policy interventions are effective in curbing illegal sales to
intoxicated and underage individuals when these interventions are
combined with enforcement activities.
There is medium
evidence that server training and policy interventions are effective
in improving some forms of server behavior, at least in the short term.
There is medium evidence that server training can lead to
more responsible service practices and management policies.
Server training programs differ in type, intensity, length, and focus.
There is no evidence that certain server training program characteristics are
associated with greater or lesser effectiveness.
Server training programs are more likely to exist when stakeholders
(people with a special interest in the problem) offer support, organization,
and interest.
States, counties, and other local jurisdictions are appropriate vehicles
for establishing server training programs.
Responsible beverage service programs are most likely to succeed when
servers and managers know that the law will be enforced or realize that they
assume significant liability if they serve intoxicated or underage
individuals.
Enforce the law. All States and most local jurisdictions have laws
regarding the sale of alcohol to underage and intoxicated individuals. These
laws should be enforced strictly and uniformly.
Target trouble spots. Focus on high-risk establishments and training
their staffs. High-risk establishments include the locations where arrested
drunk drivers purchased their last drink. Much of the information for such
training can be collected by police during arrests, by counselors during
hearings, or by those training drivers convicted of DWI.
Keep the legal burden on owners. The strongest incentive to stop
owners from serving intoxicated or underage individuals in their establishments
appears to be revocation of the establishment's alcohol license. Owners are also
concerned with preventing injuries for which they might have civil liability. In
a few States, this liability has, unfortunately, shifted from owner to server.
States and jurisdictions should try to keep — or even increase — the burden of
legal responsibility on the owners, not their employees.
Provide incentives. Drinking establishments often need incentives to
participate in responsible beverage service activities. Prevention approaches
should include incentives regarding license retention, legal liability,
reputation, etc. Practitioners can highlight such incentives through persuasive
statements such as these:
"You don't have to worry about losing your license to sell alcohol
if you never sell it to intoxicated or underage individuals."
"You
protect yourself from legal liability arising from the behavior of impaired
patrons if you never serve anyone to the point of intoxication."
"You'll be known as an establishment with a good reputation if you
help keep the community safe and healthy by doing your part to prevent alcohol
abuse, addiction, and alcohol-related problems."
Intervene early. Early intervention (to revoke alcohol licenses) is
more effective than waiting until the problems associated with a drinking
establishment have progressed to a late stage.
Close license loopholes. When the State or jurisdiction revokes a
license, the license should not be allowed to transfer to a new owner — often a
friend or relative. Potential new owners should have to apply formally for a new
license.
Avoid grandfather exceptions. Licenses should not transfer to a new
owner unless all restrictions that apply to new licenses apply to the purchase
of the existing business.
Help establish standards for beverage service activities. At this
point, there are no clear national standards. Certain national organizations and
State agencies are working to define what components are essential, optimal, and
effective. Server training should be understood as one component of responsible
hospitality, which encompasses the following actions:
Developing community norms on the principles and practices of responsible
hospitality
Instituting professional development programs that train management and
service staff in responsible hospitality
Providing information and training for organizers and volunteers at
community events
Developing guidelines for employers and social hosts
Consistently enforcing regulations governing the sale and serving of
alcoholic beverages
Creating positive incentives to recognize and reward businesses and events
that practice responsible hospitality
Be sure alternatives to alcohol are offered. Managers of sales
establishments often see food and nonalcoholic drinks as less desirable because
they are less profitable. Responsible beverage service programs should encourage
managers and servers to provide these products. Such services encourage the use
of designated sober drivers and reduce intoxication.
Provide continuous server training. There is significant turnover
among alcohol servers. As a result, continuous server training should be offered
for entrants into the business as well as for experienced servers, who can
benefit from refresher sessions.
Alcohol availability is associated with social, civic, and health problems
and can be modified through government and community actions. These actions
include two distinct dimensions:
Controlling outlet density and restricting days and hours of alcohol sales
Restricting availability of alcohol at sporting and recreational events,
as well as at special locations such as parks and other publicly owned
facilities
While both aspects of this prevention approach are important, substantially
more research is needed on the second (i.e., restricting availability at special
events and locations).
The studies reviewed in this approach evaluated outcomes of "natural
experiments," including changes in legislation regarding alcohol sales
restrictions and regional differences in laws that allowed comparison between
regions. Some of the changes involved the following activities:
Eliminating State and provincial monopolies and privatizing retail alcohol
sales and wholesale alcohol sales and distribution
Changing a State law to remove off-sale restrictions on the sale of wine
and beer near campuses
Comparing differences in county-level prohibitions and State and local
laws, regulations, and policies pertaining to: liquor sales, distribution
methods, minimum legal age for purchase, and licensing of off- and on-premises
alcohol outlets
Comparing differences in county and city ordinances that range from
liberal to rigid control over outlet density
Instituting a law permitting grocery stores to sell table wine products
The following activities were examined in studies and practice cases
concerning alcohol availability at special events and locations:
Provincial regulations permitting the sale of beer at sporting events
Use of alcohol at city-owned recreational properties
Municipal policies regulating alcohol sales at specially licensed social
and recreational events in city-owned or -managed facilities
Community policies that establish alcohol rationing, prohibit public
drinking, and disallow congregating at parking lots and campgrounds
Levels of Evidence: Conditions of
Availability
The research evidence reviewed indicates
that it is possible to implement efforts that result in changes in alcohol
availability.
There is medium evidence that an increase in the
number of outlets per capita increases rates of alcohol consumption and
alcohol-related problems.
The research and practice evidence
reviewed indicates that it is possible to pass legislation regulating the
sale and consumption of alcohol at special events and locations.
There is suggestive but insufficient evidence that
controlling alcohol availability and training servers in sporting arenas
and at special events reduces the number of intoxicated persons and the
rate of abusive incidents involving intoxication.
Alcohol consumption levels and the rates of alcohol-related problems tend
to increase when a greater density of outlets and increased hours of sale
increase the availability of alcohol.
Although there is a clear relationship among alcohol outlets, high poverty
rates, and violence, the location and density of outlets are themselves
related to community power. For example, zoning laws often keep liquor stores
and high-risk businesses out of affluent neighborhoods.
The following lessons pertain to the regulation of alcohol availability at
special events and locations:
A wide range of restrictions can be placed on special events, including
restrictions on operating hours, noise levels, general location of event,
location of alcohol sales or places of consumption (such as beer gardens),
advertising of alcohol, alcohol sponsors, age of servers, quantity of sales,
size of containers, and condition of the customers.
Alcohol sales can be discontinued before an event is over, giving patrons
some time between their last drink and driving home. For example, alcohol
sales can be discontinued at the end of the third quarter of a football game.
Sales of food and nonalcoholic beverages can be required during and after
alcohol sales are cut off.
The following recommendations of the Expert Panel address general issues such
as geographic spacing of outlets and community compatibility.
Collect data on outlet density. When communities perceive problems
related to outlet density, it is important that they initiate a data
collection effort using individuals with skills in data collection and
analysis. Important information that should be gathered includes police
activities, citizen complaints, and State licensing complaints.
Become aware of licensing laws and processes. Community prevention
groups should become involved in issues such as density and spacing. They also
need to become aware of licensing laws and ways in which citizens can become
involved in the law-changing process. Laws are not changed unless there is
involvement and activity on the part of those who are affected; often, it is
the community that makes the difference.
Consider neighborhood compatibility. A specific outlet may be
incompatible with the surrounding area. For instance, an outlet may be
incompatible with other businesses or local residents — perhaps due to
late-night entertainment or hours of closing. The Expert Panel recommends that
all new applicants be interviewed by representatives of local residents and
businesses and be able to demonstrate to the city or licensing body that the
immediate neighborhood does not object to the business.
The following Expert Panel recommendations regarding regulations at special
events and locations address general issues such as alcohol control activities
at community events.
Plan ahead. Introduce discussions about alcohol control activities,
providing nonalcoholic beverages, and alcohol safety provisions early in the
planning stages of community-sponsored festivals, street fairs, and other
special events.
Train servers. Make sure that the people who will serve alcoholic
beverages at special events receive server training, understand relevant laws
and policies, and know the guidelines for resolving problems.
Disseminate rules. Develop simple guidelines for alcohol activities
before special events and publicize them through signs, brochures, and
printing of rules on tickets.
Use physical visual aids to separate drinking adults from nondrinking
ones. Providing nondrinking "family areas" decreases alcohol-related
incidents. This approach also attracts family customers who may otherwise stop
attending functions because they object to incidents of drunken rowdiness.
Hand-stamping adults or giving them identification bands as they enter special
events helps to enforce no-sales-to-minors laws.
Educate promoters. Alcohol-related problems at sporting events,
rock concerts, and other large special events can be categorized into two
types. The first type includes unpleasant behavior, rowdiness, fights, and
personal and property damage that occurs at the site before and during the
event. The second type includes arrests for DWI, driving casualties, street
fights, and other incidents that occur after and away from the event site,
often on the way home. Promoters are more likely to pay attention to the first
type. Fewer promoters adequately address the second type. Prevention
practitioners can sensitize promoters to the second type of problems and the
promoters' potential contribution in reducing them.
Address the need for a balance of interests. Permitting and
controlling alcohol use at sporting and special events involves balancing
several needs and concerns. Alcohol sales are a substantial source of profit
for stadium owners, sports teams, and catering companies. If alcohol-related
problems become numerous and severe, however, attendance may suffer and
liability issues can arise. Community interests can influence private profit
interests, helping all concerned to work together to achieve an acceptable
balance.
Level of Evidence: Hours and Days of
Sale
The research evidence reviewed indicates that, in
relation to changes in the days and hours of alcohol sales:
There is medium evidence that expanding the hours or
days of alcohol sales increases the rates of alcohol consumption and
alcohol-related problems.
Governments often influence the availability of alcohol by specifying the
hours of sale at specific sites and by allowing sales only on certain days.
Although seldom designed for prevention purposes, such changes are natural
experiments that provide opportunities to examine the effects on overall alcohol
sales and patterns of consumption.
The studies reviewed evaluated outcomes of natural experiments resulting from
changed alcohol sales laws. These changes included the following:
Increasing, decreasing, or shifting the hours during which taverns can
sell alcohol
Prohibiting Saturday sales at wine and spirits shops
Most of the research in this area reflects recent experience with extending
rather than reducing hours or days of sale and is based on research conducted
outside the United States.
Alcohol consumption levels and rates of alcohol-related problems tend to
increase when the hours and days of sale increase.
Reducing availability is difficult in an era when consumer convenience is
such a high priority. Even though one experiment (in Norway) demonstrated
clear positive results from Saturday closing, the political support was
lacking to continue or extend the closing.
Know the law. It's important for communities to be familiar with State
and local laws regarding hours and days of operation.
Be alert for chances to make the case for limited availability.
Knowing the law will enable communities to recognize and take advantage of
opportunities to exercise control.
Be alert to seemingly minor or innocuous changes in availability.
Proposals to extend hours or days of sale should be evaluated in light of the
fact that it is nearly impossible to reverse such changes.
Community-based initiatives to change local laws, regulations, or policies
offer a powerful resource for decreasing alcohol availability and the
accompanying alcohol-related problems. (This approach combines the most
promising elements of the other five approaches.)
Launching a comprehensive prevention program that included mass media
programming, a school-based education program, parent education, community
organizing, and health policy development components
Developing a community coalition of merchants, police officers, and
community organizations
Organizing a public education campaign led by a local council on
alcoholism and drug abuse in concert with the hospitality industry and
community-based prevention groups
Setting up a coalition that included a city planning committee, the city
council, and other city agencies working in concert with a university-based
prevention institute
The following are lessons learned and conclusions that can be drawn from the
research and practice evidence reviewed for this approach.
Community-based activities to control alcohol availability can lead to the
development of other alcohol-related prevention activities.
Community-based activities to control alcohol availability can be used to
enhance the effectiveness of prevention programs aimed at reducing drinking by
individuals.
Ad hoc coalitions can result in the establishment of permanent entities
for maintaining policy changes on alcohol availability and developing other
prevention activities.
Community organizing initiatives can be combined with mass media campaigns
to increase coverage of and debate on alcohol availability issues and proposed
changes in local laws, regulations, or policies.
Levels of Evidence: Community-Based
Approach
The research and practice evidence reviewed
indicates that community-based approaches can produce coalitions that
include multiple partners and address diverse issues:
There is strong evidence that community-based
prevention activities can result in decreases in alcohol consumption.
There is suggestive but insufficient evidence that these
programs can diminish driving after drinking, traffic death and injury,
and speeding.
community based prevention — a prevention approach that
relies on several interventions in concert, involving various sections of the
community, drawing on multiple local resources to address a community
problem.
It is important to note that, to be effective, coalitions need the
participation of the retail and wholesale beverage industries.
Use multiple, integrated strategies. Multicomponent,
community-based strategies are more effective than single-component
strategies. The individual components of a multicomponent strategy strengthen,
complement, and support one another. Multicomponent strategies create an
additive effect that is greater than the sum of the individual components.
Also, in the undesirable event of one component having to be eliminated, the
remaining components may continue to exert a significant preventive effect.
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