Strategies and outcomes in translating alcohol harm reduction research into practice: the Alcohol Linking Program

Harm associated with consumption of alcohol on licensed premises is an issue of community concern. Interventions to reinforce responsible sale of alcohol such as server training and accords between licensees, police and health advocates are well known. However, while generally supported by police and licensees as 'a good thing', evaluations demonstrating that they reduce alcohol-related harm are rare. Lack of enforcement is often an issue. This paper reports on system intervention to enhance police enforcement of liquor laws by providing data-based feedback to police and licensees about alcohol-related crime following drinking on specific licensed premises. The system has been shown to contribute to a reduction of alcohol-related crime and has been adopted into routine practice by NSW police state-wide. It is a good example of how research can be conducted in a way that bridges the gap between policy research and policy practice.

SIMON LENTON

Editor, Harm Reduction Digest     

The measurement of harmful outcomes following drinking on licensed premises

The relationships between five potential indicators of alcohol-related harm following drinking on licensed premises in Perth were explored. These were annual purchases made by individual licensees of 'high' (>=3.8%) and 'low' (<3.8%) alcohol content drinks, the number of times a particular licensed establishment is cited by drivers as the last place of drinking prior to failing a roadside breath-test (including after accidents) and the annual number of assaults occurring either on or in the vicinity of particular licensed premises. The study area selected was a central part of the Perth metropolitan area with 367 licensed premises serving a residential population of 400 000. Highly significant correlations were found between each of the five variables. The correlations involving purchases of low alcohol drinks, however, were small. When purchases of alcohol were controlled, significant, though lower, correlations, were still evident between the other three variables. This suggests that there are risk factors other than extent of alcohol sales which further research will need to identify, and that these indicators of harm can be of value in monitoring the impact of future intervention strategies.     

Police knowledge and attitudes regarding crime, the responsible service of alcohol and a proactive alcohol policing strategy

The purpose of this study was to investigate the pattern and predictors of police knowledge and attitudes regarding alcohol and crime, the responsible service of alcohol by licensees and proactive alcohol policing strategies. Operational police in the Hunter region of NSW, Australia who attended for duty on a selected weekday were invited to complete a questionnaire during their shift. Two hundred and ninety-eight police participated (77%). Police estimated that 60% of the incidents that they attend are related to the consumption of alcohol, with 44% of such incidents relating to alcohol consumed on licensed premises. Three-quarters of police were able to identify correctly responsible service components of the Liquor Act. A large proportion of police (93%) considered that alcohol servers are responsible for preventing intoxication and that trying to improve licensee serving practices is not a waste of police time (89%). Considerable support (67%) was shown for police using education rather than enforcement as a method for improving licensee responsible service practices. Strong support (92%) was shown for providing information to licensees about alcohol-related incidents associated with their premises. Only 55% of police reported having sufficient skills and 17% reported that sufficient police resources were used to enhance licensee alcohol service practices. The introduction of liquor legislation, with an explicit "responsible service of alcohol" emphasis, provides police with considerable opportunity to improve the serving practices of licensed premises and to reduce alcohol-related harm. The perception by police of a lack of skill, a low prioritization for alcohol policing, limited time availability and inadequate penalties may prevent the realization of these benefits. Enhanced police training and the development of alternative responsible service of alcohol policing strategies are needed if these benefits are to be achieved.     

The relationship between license type and alcohol-related problems attributed to licensed premises in Perth, Western Australia.

Drink-driving offenses, alcohol-related traffic accidents and number of assault charges were used as indicators of the degree of alcohol-related problems associated with individual licensed premises in the Perth Traffic Police region of Western Australia. These indicators were used to rank five main categories of licensed premises according to the levels of harm experienced by their customers while controlling for the amounts of alcohol sold in each category. Nightclubs, taverns and hotels emerged as "high-risk" in comparison with clubs and restaurants. The role of such factors as different customer characteristics, opening hours, types of entertainment, restrictions on clientele and provision of meals are discussed as possible explanations underlying this finding.     

Alcohol prevention targeting licensed premises: a study of effects on violence

OBJECTIVE: This research studied the effects of a community alcohol prevention program on violent crimes. Starting in 1996, a 10-year multicomponent program based on community mobilization, training in responsible beverage service for servers and stricter enforcement of existing alcohol laws has been conducted in Stockholm, Sweden. The project has been led by an action group consisting of members from the hospitality industry and the authorities. METHOD: We used a time-series quasi-experimental design that included a control area. Data on police-reported violence during the period of January 1994 to September 2000 were analyzed through ARIMA modeling. RESULTS: During the intervention period, violent crimes decreased significantly by 29% in the intervention area, controlled for the development in the control area. CONCLUSIONS: The intervention seems to have been successful in reducing violent crimes. This effect is most likely due to a combination of various policy changes initiated by the project. The findings support the notion that community action projects working on a local basis can be effective in decreasing alcohol-related problems at licensed premises.     

Overserving at licensed premises in Stockholm: effects of a community action program

OBJECTIVE: The aim of this research was to study the sustainable effects of a community action program on alcohol service to intoxicated patrons at licensed premises. METHOD: Since 1996, the hospitality industry and authorities in Stockholm, Sweden, have been cooperating to reduce problems related to alcohol consumption at licensed premises. The intervention has included community mobilization, training in responsible beverage service (RBS) and enforcement. A pretest in 1996 and follow-ups in the 1999 and 2001 designs were used to study licensed premises in Stockholm. Male actors portraying intoxicated patrons visited the licensed premises and attempted to order beer. Observers were present at each visit. At the pretest, 92 licensed premises were visited, 47 in north central Stockholm and 45 in south central Stockholm. In 1999, 103 establishments were visited, 61 in north central Stockholm and 42 in south central Stockholm. At the latest follow-up in 2001, 100 licensed premises were visited, 56 in north central Stockholm and 44 in south central Stockholm. RESULTS: The results from the latest follow-up in 2001 showed a statistically significant improvement over those of earlier measures, with a refusal rate of 70% compared with 47% in 1999 and 5% in 1996. There were improvements in both study areas (i.e., north and south central Stockholm). CONCLUSIONS: There has been a significant improvement in the rate of refusal of alcohol service at licensed premises in Stockholm during the project period. The reason for this is probably a combination of the intervention efforts: community mobilization, RBS training and a more efficient monitoring of alcohol service by authorities.     

Patron care: Initial process evaluation of hospitality industry interventions

Preliminary data are presented on the impact of Patron Care, an innovative Australian approach to prevention and early intervention for alcohol-related problems. The emergence over the past decade of a range of factors affecting the viability of hospitality operations has created a heightened readiness by the industry to participate in the Patron Care Program. The paper describes the range of interventions conducted with regard to policies relating to licensed premises, promotions, and training of managers and servers. Basic indicators of penetration and impact are presented and discussed.     

Science,politics, and the play of chance in recent Australian drinking law changes

Regulating late‐night alcohol sales to prevent violence continues to be hotly debated in Australia. From July this year, Queensland required premises to stop serving alcohol (last drinks) by 3 am in entertainment precincts and by 2 am in the rest of the state. The Government made legislative provision for 1 am lockouts in entertainment precincts but at the time of writing has not committed to introducing them. Lockouts, also known as one‐way‐doors, permit patrons to remain drinking in premises until last drinks but deny entry to new patrons. In Newcastle, New South Wales, lockouts and earlier closing of licensed premises were introduced in 2008. Evidence that these produced large reductions in assault informed the 2014 Sydney restrictions that are currently under review. The global research evidence for last drinks regulations is compelling: trading extensions of as little as one h increase harm, and similarly modest restrictions reduce harm. In contrast, the effectiveness of lockouts, a phenomenon unique to Australasia, is uncertain. The Newcastle, Sydney and Queensland reforms are a stepwise progression in alcohol harm countermeasures, a welcome example of evidence‐based public policy. However, the aetiologies of these policy changes were complex. I present accounts of each and offer commentary on the interplay between scientific evidence, public health advocacy, politics, and chance occurrences that preceded these significant changes.     

Gender,intoxication and the developing brain: Problematisations of drinking among young adults in Australian alcohol policy

In this article, we draw on recent scholarly work in the poststructuralist analysis of policy to consider how policy itself functions as a key site in the constitution of alcohol ‘problems’, and the political implications of these problematisations. We do this by examining Australian alcohol policy as it relates to young adults (18–24 years old). Our critical analysis focuses on three national alcohol policies (1990, 2001 and 2006) and two Victorian state alcohol policies (2008 and 2013), which together span a 25-year period. We argue that Australian alcohol policies have conspicuously ignored young adult men, despite their ongoing over-representation in the statistical ‘evidence base’ on alcohol-related harm, while increasingly problematising alcohol consumption amongst other population subgroups. We also identify the development of a new problem representation in Australian alcohol policy, that of ‘intoxication’ as the leading cause of alcohol-related harm and rising hospital admissions, and argue that changes in the classification and diagnosis of intoxication may have contributed to its prioritisation and problematisation in alcohol policy at the expense of other forms of harm. Finally, we draw attention to how preliminary and inconclusive research on the purported association between binge drinking and brain development in those under 25 years old has been mobilised prematurely to support calls to increase the legal purchasing age from 18 to 21 years. Our critical analysis of the treatment of these three issues – gender, intoxication, and brain development – is intended to highlight the ways in which policy functions as a key site in the constitution of alcohol ‘problems’.     

Responsible alcohol service: lessons from evaluations of server training and policing initiatives

Responsible alcohol service programmes have evolved in many countries alongside a general increase in the availability of alcohol and a greater focus on the prevention of alcohol-related road crashes. They also recognize the reality that a great deal of high-risk drinking and preventable harm occurs in and around licensed premises or as drinkers make their way home. Early US efficacy studies of programmes which trained managers and barstaff to limit customers' levels of intoxication and prevent drink driving showed promise. Studies of effectiveness of these programmes in the wider community, and in the absence of the enforcement of liquor laws, found little benefit. The data will be interpreted as suggesting that, in reality, skills deficits in the serving of alcohol are not a significant problem compared with the motivational issue for a commercial operation of abiding by laws that are rarely enforced and which are perceived as risking the goodwill of their best customers. Australian, UK and US experiences with liquor law enforcement by police will be discussed along with outcomes from the Australian invention of Alcohol Accords, informal agreements between police, licensees and local councils to trade responsibly. It will be concluded that the major task involved in lifting standards of service and preventing harm is to institutionalize legal and regulatory procedures which impact most on licensed premises. A number of strategies are suggested also for creating a political and social climate which supports the responsible service of alcohol and thereby supports the enactment and enforcement of appropriate liquor laws.     

Experience of harm from others’ drinking and support for stricter alcohol policies: Analysis of the Australian National Drug Strategy Household Survey

BackgroundPrevious research indicates that those who have experienced alcohol-related harm from others are more likely to support stricter alcohol control policies. This study investigates the association between types of harm experienced because of others’ drinking and support for stricter alcohol control policies.MethodsData from 20,570 Australians aged 18 and over who completed the 2013 National Drug Strategy Household Survey was used. Questions about experience of alcohol-related harm from others – being put in fear and abuse (verbal or physical) – were asked. Support for stricter alcohol control policies was quantified by a mean policy support score across 18 alcohol policy questions.ResultsTwenty seven percent of respondents reported harm from someone’s drinking. Respondents who were put in fear had a higher level of support for stricter alcohol control policies than respondents who were not harmed (p < 0.001), regardless of whether they were abused or not. Conversely, respondents who experienced abuse but were not put in fear did not significantly differ in their support for stricter policies from those who experienced no harm.ConclusionIt is the apprehension of harm (i.e. having been put in fear), and not the experience of harm itself (i.e. abuse), which is related to people’s support for stricter alcohol policies. These findings suggest that perceiving others’ intoxication as dangerous to oneself may motivate support for stricter alcohol policies.     

Alcohol consumption in the Arab region: What do we know,why does it matter,and what are the policy implications for youth harm reduction?

Alcohol is a recognized global risk factor for many diseases and injury types and a major contributor to disability and death. While cost-effective interventions do exist, many countries lack a comprehensive national alcohol harm reduction policy. The Arab world includes 22 diverse countries stretching from North Africa to Western Asia having varying dispositions with regards to alcohol sale and consumption. Epidemiological data is scattered and the picture on alcohol consumption remains blurry. This paper presents the findings of an extensive review conducted on all 22 Arab countries, specifically describing: (1) the density and methodology of alcohol-related peer-reviewed publications over the last two decades (1993–2013); (2) the epidemiology of alcohol consumption given all available data; and (3) the current status of policies in the region. Our search revealed a strikingly low number of alcohol-related peer-reviewed published studies – a total of 81 publications across 22 countries and two decades. Most studies are based on clinical or student samples. Where data is available, age of onset is low and drinking is frequent, in the absence of any available or enforced harm reduction policies. We submit that countries in the Arab region can be divided into four categories by alcohol ban and published data. One category includes countries where alcohol is not banned but data is absent, suggesting an ostrich-like response to a controversial behavior, or reflecting a weak research infrastructure and/or policy landscape. Evidence-informed recommendations and future directions for policy and research are discussed and tailored to countries’ current stance on alcohol legislation and consumption. Given the particular vulnerability of youth to uptake of alcohol as well as the resulting short and long term consequences, the paper concludes by focusing on the implications of the findings for youth alcohol harm reduction.     

Approaches to preventing alcohol-related problems: the experience of New Zealand and Australia

New Zealand and Australia have experienced similarities in their drinking cultures and patterns since colonization. This paper briefly reviews those experiences and looks at the approaches both countries have taken in dealing with alcohol-related problems. Over 10 years ago Australia developed a national strategy embracing a harm reduction approach and more recently New Zealand embarked upon a similar process. As well as examining the development of these, other initiatives are examined. These include approaches to licensing of alcohol sales, taxation, alcohol promotion, control of drinking on licensed premises, drinking and driving intervention, community action, initiatives by Maori and Aboriginal people and efforts to educate the individual drinker.     

The new policy mix: Alcohol,harm minimisation,and determined drunkenness in contemporary society

This paper reflects on the relationship between harm reduction, demand reduction, and supply reduction (collectively, harm minimisation) in relation to the individual, socio-economic, and legal regulation of alcohol, focusing on changing consumption patterns of youths and young adults in the UK. Firstly, harm reduction and practices of self-regulation are considered within the British context of an apparent culture of intoxication, with evidence of determined drunkenness amongst young people that builds upon a longstanding tradition of northern European drinking characterised by weekday restraint and weekend excess. Secondly, demand reduction and the predominant public health programme of recommended sensible drinking levels are discussed in relation to the credibility gap between such messages and contemporary alcohol-related attitudes and behaviours. Thirdly, looking at supply, recent legislative changes and broader developments in the alcohol industry are explored. They counterbalance economic deregulation of licensed leisure with the increased criminalisation of some drinkers. In order to produce the most effective policy mix, individualised models of harm reduction and demand reduction need to be located within broader, culturally appropriate, and context-specific policies that consider the socio-economic, political, and environmental factors influencing harm, demand, and supply.     

Public perceptions of responsibility and liability in the licensed drinking environment

This study reports the results of a survey conducted in Perth (Western Australia) to assess public perceptions of the concepts of server responsibility and server liability. Eleven hundred and sixty persons aged 16 and over were asked if they thought licensees and barstaff should be held partly responsible when someone becomes intoxicated on licensed premises, or licensees and barstaff should be partly liable for injuries caused by an intoxicated person after leaving licensed premises. Results indicate that, on average, few people agreed to either proposition, despite an overwhelming majority believing that continuing to serve an intoxicated person increases the risk of an accident. However, when analysed by category of respondent, non-drinkers and persons aged over 30 were significantly more likely to agree with licensees and barstaff being partly responsible for someone becoming intoxicated, and for them to be partly liable in the case of an accident involving an intoxicated customer. The results of this survey indicate the need for education programmes to convince the public that excessive alcohol consumption and the resulting harm is not merely the responsibility of the individuals concerned, but is also the responsibility of those groups and individuals involved in the promotion, marketing and sale of alcohol. We suggest that such education campaigns might best be targeted at those groups where least support was found, young drinkers (18-24 years) and the servers of alcohol.     

Contextual determinants of alcohol consumption changes and preventive alcohol policies: a 12-country European study in progress

Beginning with France in the 1950s, alcohol consumption has decreased in Southern European countries with few or no preventive alcohol policy measures being implemented, while alcohol consumption has been increasing in Northern European countries where historically more restrictive alcohol control policies were in place, even though more recently they were loosened. At the same time, Central and Eastern Europe have shown an intermediate behavior. We propose that country-specific changes in alcohol consumption between 1960 and 2008 are explained by a combination of a number of factors: (1) preventive alcohol policies and (2) social, cultural, economic, and demographic determinants. This article describes the methodology of a research study designed to understand the complex interactions that have occurred throughout Europe over the past five decades. These include changes in alcohol consumption, drinking patterns and alcohol-related harm, and the actual determinants of such changes.     

A “leap in the dark?” Lessons for the United Kingdom from past extensions of bar opening hours

The Licensing Act of 2003 for England and Wales paves the way for 24-hour opening of licensed premises. Senior members of the United Kingdom Government have claimed that the pressure of rigid closing times contributes to the rising problem of binge-drinking and associated harm in the UK. Removing set opening times it is hoped will reduce these problems. These plans have been widely criticised. Moreover, international evidence suggests this may not be the case. Studies from Europe, Iceland, Australia and North America have indicated that extending trading hours may not only fail to reduce alcohol-related problems but might increase them. Evidence exists of licensing liberalisation being followed by rises in alcohol consumption, violent crime, traffic accidents, illicit drug use as well as extra public health and tourism costs.     

Contextual Determinants of Alcohol Consumption Changes and Preventive Alcohol Policies: A 12-Country European Study in Progress

Beginning with France in the 1950s, alcohol consumption has decreased in Southern European countries with few or no preventive alcohol policy measures being implemented, while alcohol consumption has been increasing in Northern European countries where historically more restrictive alcohol control policies were in place, even though more recently they were loosened. At the same time, Central and Eastern Europe have shown an intermediate behavior. We propose that country-specific changes in alcohol consumption between 1960 and are explained by a combination of a number of factors: (1) preventive alcohol policies and (2) social, cultural, economic, and demographic determinants. This article describes the methodology of a research study designed to understand the complex interactions that have occurred throughout Europe over the past five decades. These include changes in alcohol consumption, drinking patterns and alcohol-related harm, and the actual determinants of such changes.     

Key stakeholder perspectives of drink restrictions in Newcastle,Australia

Background: The problems associated with alcohol consumption in or around licensed premises in the nighttime economy are extensive. One intervention designed to address these problems is drink restrictions. The aim of the current study is to gain different key stakeholder perspectives on drink restriction interventions, including their ability to reduce alcohol-related harms.

Method: This study involves an analysis of key stakeholder perspectives on the introduction of drink restrictions. Interviews were conducted with 23?key stakeholders, including venue licencees, security, and police from Newcastle, Australia. Drink restrictions, including limits on shots and number of drinks, were part of a mandatory set of interventions, which were implemented as a result of legislative change in New South Wales. As such, key stakeholders were able to provide insight into the implementation and practicality of the restrictions. All interviews were analyzed using thematic analysis.

Results: Overall, key stakeholders were mixed in their support for drink restrictions, particularly because of the issues associated with customer preloading and practicality of enforcement. Stakeholders remained unconvinced of the impact of the restrictions on reducing harm.

Conclusions: Key stakeholders believe that drink restrictions would almost certainly be more likely to reduce alcohol-related harm in the nighttime economy as part of a larger intervention. However, it is unclear how much impact they have as a standalone harm reduction measure.     

Home drinking – Is this the target of the new alcohol strategy?

In the foreword to the third alcohol strategy for England and Wales, Prime Minister David Cameron is clear that this is a response to the problems caused by binge drinking. This is within the context of alcohol consumption in England and Wales having fallen steadily for a number of years and a shift to more drinking at home, which until recently has largely been seen as non-problematic. Despite being portrayed as a response to binge drinking, the main headline that accompanied the strategy was the proposal to introduce minimum unit pricing. The main effect of this will be to narrow the price of alcohol purchased in supermarkets compared to licensed premises. This article suggests that policy makers may now be more receptive to the arguments that suggest they should now be considering alcohol-related general population harms. Despite the fact that the strategy has been presented as a response to binge drinking, there is also a focus on the cost of general population harms.