Effectiveness of Interventions
and Alcohol Policies:
What Works, What Doesn’t
Thomas F. Babor
Alcohol, No Ordinary
Commodity: Research and
Public Policy
Sponsored by:
The World Health Organization
and
The Society for the Study of Addiction (UK)
The findings and conclusions represent the consensus views of its 15 authors,
none of whom received either direct or indirect support for their participation
from the sponsoring organizations or any other organization that might
represent a conflict of interest.
The Alcohol Public Policy Group
Co-authors
Thomas Babor
Raul Caetano
Sally Casswell
Griffith Edwards
Norman Giesbrecht
Kathryn Graham
Joel Grube
Paul Gruenewald
Linda Hill
Harold Holder
Ross Homel
Esa Österberg
Jürgen Rehm
Robin Room
Ingeborg Rossow
University of Connecticut (USA)
University of Texas (USA)
Massey University (New Zealand)
National Addiction Centre (United Kingdom)
University of Toronto (Canada)
Centre for Addiction and Mental Health (Canada)
University of California (USA)
University of California (USA)
University of Auckland (New Zealand)
University of California (USA)
Griffith University (Australia)
Institute for Social Research (Finland)
University of Toronto (Canada)
Stockholm University (Sweden)
National Institute for Alcohol and Drug
Research (Norway)
ALCOHOL: NO ORDINARY COMMODITY
•
The benefits connected with the production,
sale, and use of this commodity come at an
enormous cost to society.
•
Three important mechanisms explain alcohol’s
ability to cause medical, psychological, and
social harm:
1) physical toxicity
2) intoxication
3) dependence
Prevention Strategies
Reviewed and Evaluated
•
•
•
•
•
•
•
Regulating Physical Availability
Pricing and Taxation
Altering the Drinking Context
Education and Persuasion
Regulating Alcohol Promotion
Drinking-Driving Countermeasures
Treatment and Early Intervention
Ratings of 32 Policy-relevant Prevention
Strategies and Interventions
1) Evidence of Effectiveness – the quality of
scientific information
2) Breadth of Research Support – quantity and
consistency of the evidence
3) Tested Across Cultures, e.,g. countries, regions,
subgroups
4) Cost to Implement and Sustain – monetary and
other costs
aRating
Scale: 0, +, ++, +++, (?)
b Rating Scale: Low, Moderate, High
Evaluation Standards:
Other Considerations
• Target Group
– the general population of drinkers (and nondrinkers)
– high risk drinkers or vulnerable groups
– persons with harmful drinking and alcohol dependence
• Adverse side effects
– tax evasion
– criminal activity
– illicit production
• Population reach
– number of people affected by intervention
• Feasibility
– political considerations
– economic implications
– side effects
Taxation
Strategy or
Intervention
Alcohol
Taxes
Effectiveness
+++
XResearch Cultural
Support Testing
+++
+++
Cost
Low
Target
Group
General
Population
Pricing and Taxation
Evidence suggests that:
• People increase their drinking when prices are lowered,
and decrease their consumption when prices rise.
• Heavy or problem drinkers are no exception to this rule.
• Increased alcoholic beverage taxes and prices are related to
reductions in alcohol-related problems.
Alcohol taxes are thus an attractive instrument of alcohol
policy because they can be used both to generate direct
revenue and to reduce alcohol-related harm.
The most important downside to raising alcohol taxes is
smuggling and illegal in-country alcohol production.
Regulating Physical Availability
Strategy or
Intervention
Total ban on sales
XEffectiveness Research Cultural
Support Testing
+++
+++
++
Cost
Target Group
High
General
Population
High Risk
Group
General
Population
General
Population
Minimum legal
purchase age
Rationing
+++
+++
++
Low
++
++
++
High
Government
monopoly of retail
sales
Hours and days of
sale restrictions
Restrictions on
density of outlets
Server liability
+++
+++
++
Low
++
++
++
Low
++
+++
++
Low
+++
+
+
Low
Different
availability by
alcohol strength
++
++
+
Low
General
Population
General
Population
High Risk
Group
General
Population
Regulating the Alcohol Availability
•
•
•
Changes in availability can have large effects in
nations or communities where there is popular
support for these measures.
The cost of restricting alcohol availability is cheap
relative to the costs of health consequences related
to drinking, especially heavy drinking.
The most notable adverse effects of availability
restrictions include increases in informal market
activities (e.g., home production, illegal imports).
Modifying the Drinking Context
XStrategy or
Effective- Research Cultural
Intervention
ness
Support Testing
Outlet policy to not
+
+++
++
serve intoxicated
patrons
Training bar staff
+
+
+
and managers to
prevent and better
manage aggression
Voluntary codes of
O
+
+
bar practice
Enforcement of on++
+
++
premise
regulations and
legal requirements
Community
++
++
+
mobilization
Cost
Target Group
Moderate
High Risk
Group
Moderate
High Risk
Group
Low
High Risk
Group
High Risk
Group
High
High
General
Population
Modifying the Drinking Context
Many prevention measures seek to limit drinking in
the contexts or environments where alcohol is
typically sold and consumed (e.g., bars and
restaurants).
The most effective options involve:
• enforcement of serving regulations
• increasing the legal liability of bar staff and
owners for the actions of those they serve.
Responsible Beverage Service
(RBS) programs
• Focus on attitudes, knowledge, skills, and
practices of persons involved in serving alcoholic
beverages on licensed premises
• If supported by actual changes in the serving
policies of licensed establishments and reinforced
by local police, RBS training can reduce heavy
consumption and high risk drinking
Community Mobilization
• Raise public awareness of problems associated with onpremise drinking in licensed establishments
• Develop specific solutions to problems
• Pressure owners to recognize that they have a
responsibility to the community in terms of such barrelated issues as noise level and patron behavior
• Can be highly successful at reducing aggression and other
problems related to drinking in licensed premises, but the
long-term sustainability of these efforts remains to be
demonstrated.
Drinking-Driving Countermeasures
Strategy or
Intervention
Sobriety check
points
Random breath
testing (RBT)
Lowered BAC
Limits
Administrative
license
suspension
Low BAC for
young drivers
(“zero
tolerance”)
Graduated
licensing for
novice drivers
Designated
drivers and ride
services
Effectiveness
++
Research
Support
+++
XCultural
Testing
+++
+++
++
+
Moderate
+++
+++
++
Low
++
++
++
Moderate
+++
++
+
Low
High Risk
Group
++
++
++
Low
High Risk
Group
O
+
+
Moderate
High Risk
Group
Cost
Target Group
Moderate
General
Population
General
Population
General
Population
Harmful
Drinkers
Drinking-Driving
Countermeasures
• Consistently produce long-term problem
reductions of between 5% and 30%.
• Deterrence-based approaches, using innovations
such as Random Breath Testing, yield few arrests
but substantial accident reductions.
• The persistent delinquency of some impaired
drivers should not detract from the enormous
achievements of recent decades.
Random Breath Testing (RBT)
• Motorists are stopped at random by police and
required to take a preliminary breath test, even if
they are in no way suspected of having committed
an offence or been involved in an accident.
• Highly visible, non-selective testing can have a
sustained effect in reducing drinking-driving and
the associated crashes, injuries, and deaths.
BAC Limits
• When combined with enforcement, national and
state laws lowering the legal limit of the driver’s
blood alcohol concentration (BAC) have been a
successful way to reduce drinking-driving.
• The evidence indicates that setting a reasonably
low level of BAC (e.g., .08) significantly reduces
alcohol-related driving fatalities.
Young drivers
• Adolescents aged between 16-20 years are at higher risk
for alcohol-involved crashes as a result of their limited
driving experience and their tendency to experiment with
heavy or binge drinking.
• Traditional countermeasures such as driver training and
school-based education programs are either ineffective or
have yielded mixed results.
• One effective measure is the use of graduated licensing for
novice drivers, which limits the time and other conditions
of driving during the first few years of licensing.
Treatment programs as an
alternative to punishment
• Evidence from some countries supports the
effectiveness of comprehensive treatment
including counseling or therapy plus license
suspension in reducing recidivism.
• Successful programs are well structured, go
beyond information provision to address alcohol
abuse, are conducted for more than ten weeks, and
have rules of attendance enforced by a court.
Education and Persuasion
Strategy or
Intervention
Alcohol
education in
schools
College
student
education
Public service
messages
Warning
labels
Effectiveness
O
XResearch Cultural
Support Testing
+++
++
O
+
+
O
+++
++
O
+
+
Cost
High
High
Target
Group
High Risk
Group
High Risk
Group
Moderate General
Population
Low
General
Population
Education and Persuasion Strategies
• School-based alcohol education programs have been found to increase
knowledge and change attitudes toward alcohol and other substances,
but actual substance use remains unaffected.
• Approaches that address values clarification, self-esteem, general
social skills, and “alternatives” approaches that provide activities
inconsistent with alcohol use (e.g., sports) are equally ineffective.
• Programs that include both resistance skills training and normative
education (which attempts to correct adolescents’ tendency to
overestimate the number of their peers who drink) have modest effects
that are short-lived unless accompanied by ongoing booster sessions.
• Programs that include both individual-level education and family- or
community-level interventions may not be sufficient to delay the
initiation of drinking, or to sustain a small reduction in drinking
beyond the operation of the program.
Education and Persuasion Strategies
Public service announcements (PSAs)
• Messages prepared by nongovernmental
organizations, health agencies, and media
organizations that deal with responsible drinking,
the hazards of drinking-driving, and related topics.
• Despite their good intentions, PSAs are an
ineffective antidote to the high-quality prodrinking messages that appear much more
frequently as paid advertisements in the mass
media.
Education and Persuasion Strategies
Counter-advertising
• Disseminating information about a product, its
effects, and the industry that promotes it, in order
to decrease its appeal and use.
• Tactics include health-warning labels on product
packaging, such as those that explain that alcohol
may cause birth defects when consumed during
pregnancy.
• Although a significant proportion of the
population reports seeing these warning labels,
research indicates that exposure produces no
change in drinking behavior per se.
Summary: Education and
Persuasion Strategies
• The impact of education and persuasion programs tends to
be small at best.
• When positive effects are found, they do not persist.
• Among the hundreds of studies, only two show significant
lasting effects (after 3 years), and the significance of these
is questionable when reanalyzed (Foxcroft et al. 2003).
• The time is past for arguments on behalf of substituting
education for other, more effective approaches.
• If educational approaches are to be used, they should be
implemented within the framework of broader
environmental interventions that address availability of
alcohol.
Regulating Alcohol Promotion
Strategy or EffectiveIntervention
ness
Advertising
+
bans
Advertising
?
content controls
Research
Support
+
XCultural
Testing
++
O
O
Cost
Low
Moderate
Target
Group
General
Population
General
Population
Regulating alcohol promotion
• The marketing of alcohol is a global industry.
• Alcohol brands are advertised through television, radio,
print, point-of-sale promotions, and the Internet.
• Exposure to repeated high-level alcohol promotion
inculcates pro-drinking attitudes and increases the
likelihood of heavier drinking.
• Alcohol advertising predisposes minors to drinking well
before legal age of purchase.
• Advertising has been found to promote and reinforce
perceptions of drinking as positive, glamorous, and
relatively risk-free.
Regulating alcohol promotion
Legislation restricting alcohol advertising
• A well-established precaution used by
governments throughout the world, despite
opposition from the alcoholic beverage industry.
• Findings suggest that while the restrictions have
not achieved a major reduction in drinking and
related harms in the short-term, countries with
greater restrictions on advertising have less
drinking and fewer alcohol-related problems
(Saffer, 1991).
Regulating alcohol promotion
Industry Self-regulation Codes
• Self-regulation tends to be fragile and largely
ineffective.
• These codes may work best where the media,
advertising, and alcohol industries are all
involved, and an independent body has powers to
approve or veto advertisements, rule on
complaints, and impose sanctions.
• Few countries currently have all these
components.
Treatment and Early Intervention
Strategy or
Intervention
Brief
intervention
with at-risk
drinkers
Alcohol
problems
treatment
Mutual
help/selfhelp
attendance
Mandatory
treatment of
repeat
drinkingdrivers
Effectiveness
++
Research
Support
+++
XCultural
Testing
+++
+
+++
+++
High
Harmful
Drinkers
+
+
++
Low
Harmful
Drinkers
+
++
+
Moderate
Harmful
Drinkers
Cost
Moderate
Target
Group
High Risk
Group
Treatment and Early Intervention Services
• In general, exposure to any treatment is
associated with significant reductions in
alcohol use and related problems, regardless
of the type of intervention used.
• Regarding specific treatment modalities, the
weight of evidence suggests that behavioral
treatments are likely to be more effective
than insight-oriented therapies
Brief interventions
• Consist of one to three sessions of counseling or
advice delivered in general medical settings.
• Randomized controlled trials (conducted in a
variety of settings) indicate that clinically
significant changes in drinking behavior and
related problems can follow from brief
interventions with non-alcoholic heavy drinkers.
Best Practices
• Minimum legal
purchase age
• Government
monopoly of retail
sales
• Restriction on hours or
days of sale
• Outlet density
restrictions
• Alcohol taxes
• Sobriety check points
• Lowered BAC limits
• Administrative license
suspension
• Graduated licensing
for novice drivers
• Brief interventions for
hazardous drinkers
Least Effective Practices
• Voluntary codes of bar
practice
• Promoting alcoholfree activities
• Alcohol education in
schools
• College student
education
• Public service
messages
• Warning labels
• Designated drivers and
ride services
Evolving Views of Alcohol Policy: Optimism
• Opportunities for effective, evidence-based
alcohol policies are more available than ever to
better serve the public good.
• Alcohol policies that limit access to alcoholic
beverages, increase the price of alcohol, and
enforce laws and regulations through deterrence,
are likely to reduce the harm linked to specific
drinking patterns and per capita consumption.
• Alcohol problems can be minimized or prevented
using a coordinated, systematic policy response.
CONCLUSIONS
• The difference between good and bad alcohol policy is not
an abstraction, but very often a matter of life and death.
• Research has the capacity to indicate which strategies are
likely to succeed in their public health intentions, and
which are likely to be less effective or even useless,
diversionary, and a waste of resources.
• Opportunities for evidence-based alcohol policies that
better serve the public good are more available than ever.
• There are still too many instances of policy vacuums filled
by unevaluated or ineffective strategies and interventions.
• Because alcohol is no ordinary commodity, the public has
a right to expect a more enlightened, evidence-based
approach to alcohol policy.