Evidence-based
Strategies to Reduce
Alcohol-related Injuries
A REVIEW OF THE SCIENCE
Brenda Rooney, PhD,
Epidemiologist,
Gundersen Lutheran
What are
“evidence-based strategies”?

Strategies that based on data have been shown to
reduce risk in a community. Usually these have been
studied through tightly controlled research studies.

Strategies can include education, media campaigns, or
alcohol control policies.

Policies can affect how beverages are manufactured,
packaged, distributed, sold and consumed.

Policies can alter dimensions of the environment that
promotes overall consumption as well as hazardous
patterns of use.
Why should we consider
evidence-based strategies?
 They
will help us focus our energy on
those strategies that have been shown
to work in other communities.
Can we consider other
strategies too?
 Certainly!
 Every
community is unique. Strategies
need to be based on the unique assets
and problems within our community.
Applying the Public Health Model
Population/Host
(Age, Gender,
Race/Ethnicity)
Agent/Vehicle
(Content, Packaging
Warning Labels)
Environment
(Pricing/Taxation,
Regulations, Media)
Beer Keg Registration
What is it?

Beer kegs are marked with unique identification
numbers

The keg id number is recorded along with the
purchaser’s information

When a keg from which underage youth drink
alcohol is confiscated by the police, the
purchaser is fined for supplying alcohol to
underage persons.

Keg purchasers sign a statement promising not
to sell to underage persons.
Beer Keg Registration
Why it’s important

Kegs are often a main source of alcohol at teenage
parties. Kegs may encourage drinking greater quantities
of beer.

When police arrive at a party, people scatter. Without
keg tagging, there is no way to trace who purchased the
keg.

Adults who provide alcohol to underage youth may be
deterred only if they believe they will face legal or
financial consequences.

Keg registration works best if it covers a wide
geographic area.
Alcohol Warning Posters
- What is it?

Notices or signs located in alcohol establishments that provide information
related to the legal, social, and health consequences of alcohol use.

They may include:





Penalties and consequences of providing/selling alcohol to underage or
intoxicated persons
The legal penalties of underage possession and consumption
The establishment’s policies on checking IDs and refusing sales to intoxicated
persons
Risks of consuming alcohol while taking certain medications or before driving
A study in Arizona in 1992 one year after a state ordinance was passed,
showed that awareness of the sign and memory of the warning message
increased. Fenaughty 1993
Drink specials restrictions

Promotional drink specials may encourage
customers to consume a high volume of alcohol
in a short period of time.
 Research



3% decline in alcohol consumption after banning
happy hour in pubs in Ireland in 2003
Numerous studies have shown that consumption
increases because of drink specials.
Recent challenge in Madison
Price control/tax

Many studies have clearly established that
increases in alcohol taxes and increases in the
retail price of alcoholic beverages are
associated with:




Decreases in alcohol consumption
Decreases in alcohol-related traffic crashes
Decreases in violent crime
Youth are especially sensitive to changes in
price, which means that when prices rise, there
are greater reductions in consumption and
alcohol-related problems among youth than the
general adult population.
Toomey 1999, Chaloupka 1993, Grossman, 1994.
Price control/tax

States tax the sale of alcoholic beverages in one
of two ways.



Most states apply an excise tax on alcohol called
“gallonage taxes” that are based on the quantity of
beverage sold.
Some states apply a “percentage tax”, a tax based on
a percentage of the selling price.
3 basic taxes



Beer tax - $2/barrel (31 gallons)
Spirit tax - $3.36/gallon
Wine tax - $0.12-0.45/liter
Price control/tax
3rd lowest beer tax in the nation
 Beer tax hasn’t increase since 1969
 Special allowances for brewers




WI beer exported elsewhere is exempt from the WI
beer tax
Producers that brew less and 300,000 barrels pay
only half of the tax on the first 50,000 barrels
4th highest per capita beer consumption in the
nation
Applying the Public Health Model
Population/Host
(Age, Gender,
Race/Ethnicity)
Agent/Vehicle
(Content, Packaging
Warning Labels)
Environment
(Pricing/Taxation,
Regulations, Media)
Alcohol Use Restrictions
on Public Property - What is it?

Alcohol restrictions on public property control the
availability and use of alcohol at parks, beaches and
other public spaces.



Total ban
Restricted times or places
A range of polices may be implemented that:





Prohibit possession of an open container
Establish standard procedures for dealing with intoxicated
persons in public areas
Require regular monitoring of public areas
Require responsible serving practices at special events in park
shelters for special events (e.g. weddings)
Establish standard enforcement procedures
Alcohol Use Restrictions
on Public Property – Why it’s important

Underage drinking may occur in a variety of
unsupervised places including parks, beaches,
cemeteries or parking lots. It is easier to break up parties
in public areas if the community has a policy.

Alcohol consumption in unsupervised places may be
related to problems such as fighting, vandalism and
public disturbances.

Creating the policy is not enough. It must be enforced.

Its important to identify where the alcohol was purchased
so adult or commercial sources can also be targeted and
punished.
Alcohol Use Restrictions
on Public Property – The evidence
 Communities
that have increased
enforcement of existing public alcohol use
policies report a reduction in alcoholrelated problems.
Source: Cassady D, et al. Alcohol use at community
events: creating policies to prevent problems. San Diego
County Alcohol Program and Applied Communication
Technology, 1987.
Alcohol Restrictions
at Community Events - What is it?

Include policies that control the availability and
use of alcohol at public venues, such as
concerts, street fairs and sporting events. Such
restrictions can be implemented voluntarily by
event organizers or through local legislation.

Restrictions at these events can range from a
total ban on alcohol consumption to the posting
of warning posters that detail the risks
associated with consuming alcohol.
Alcohol Restrictions
at Community Events - What is it?

A wide variety of restrictions can be considered at community
events:











Establish non-drinking areas for families and youth
Establish designated drinking areas where underage youth are not
allowed; prohibit people from leaving these areas with alcoholic
beverages
Limit alcohol sponsorship
Have alcohol-free days/nights
Establish enforcement procedures for all policies
Require responsible beverage service training for alcohol sellers and
event coordinators
Require alcohol sellers to be at least 21 years old
Require a manager to be on duty at the alcohol booth at all times
Establish age identification checking procedures
Prohibit drinking by servers
Require signs indicating the illegality of providing alcohol to minors and
obviously intoxicated persons.
Alcohol Restrictions
at Community Events - What is it?

A wide variety of restrictions can be considered at
community events:








Establish procedures for handling intoxicated drinkers
Require that security staff be adequately trained
Ban alcohol consumption in parking lots and monitor the lots
Limit cup size to 12 ounces
Use cups for alcoholic beverages that are easily distinguishable
from non-alcoholic beverage cups
Limit number of servings per person per purchase to one or two
at a time.
Stop serving alcohol at least one hour before closing
Sell food and non-alcoholic drinks and provide free water.
Alcohol Restrictions
at Community Events –
Why it’s important



Underage youth may easily get alcohol by buying it or by having
friends over 21 buy it for them.
Individuals who are already intoxicated may easily get alcohol at
festivals and sporting events.
Alcohol use may fuel outbreaks of fighting and other forms of
disruptive behavior.



Policies such as discontinuing alcohol sales during the last half or final
hour of the event or limiting the number of servings per person can
reduce alcohol-related problems. Stadiums can prohibit the sale of
alcohol in the stands.
Alcohol consumption at community events may cause other types of
disturbance within the community (noise, traffic, litter, parking,
property damage and vandalism.)
Alcohol consumption at a community event increases the chances of
drinking and driving.
Alcohol Restrictions
at Community Events – The evidence
 One
study showed that youth were able to
purchase alcohol in 50% of attempts at
community festivals.
 This
same study showed that at 50
different festivals, individuals appearing
obviously intoxicated were able to buy
alcohol in 89% of attempts.

Source: Toomey TL et al. Illegal alcohol sales and use of alcohol
control policies at community festivals. Public Health Reports,
120:33-27, 2000
Public Intoxication Policies


The law allows police officers to cite intoxicated people
whom they believe constitute a danger or a public
nuisance.
Fines of up to $222 can be imposed, but those fines are
waived for first-time offenders if they complete a class
about binge drinking.



Disorderly conduct laws are less focused on education, nor does
it allow for warnings.
By Dec. 31, police had issued 156 warnings and 89 public
intoxication citations. Of the 156 people warned, 78 completed
the two-hour class.
Renewed for another year 4/1/08-3/31/08 at the 3/11/08
city council meeting.

Issues outside of La Crosse?
Social Host Liability
What is it?

Adults who serve or provide alcohol to minors or persons
who are obviously intoxicated can be held liable if the
person who was provided alcohol is killed or injured or
kills or injures another person.

In some states, social host liability is covered under
dram shop law.

Dram shop liability refers to a drinking establishment’s potential
financial liability for serving alcohol to an intoxicated or underage
person who later causes injury to a third party. (Dram shop law
normally covers commercial service and not private parties.)
Social Host Liability
Why it’s important

Social host liability laws deter parents and other adults
from hosting underage parties and purchasing/providing
alcohol for underage youth.

Social host liability laws send a clear message to adults
that providing alcohol to underage youth is not
acceptable.

Social host liability laws may act as a strong deterrent if
providers believe that they will be sued if injury or death
occurs as a result of the provision of alcohol to an
obviously intoxicated person
Social Host Liability
The evidence

In an analysis of all 50 states, social host laws were
associated with reductions in drinking-driving and heavy
drinking.


Source: Goldberg. Social host liability for serving alcohol. Trial. March 31-33,
1992
As of 2002, 32 states in the US had social host liability
laws in place. In states that do not have host liability
laws, cities and communities have passed social host
liability ordinances. 18 cities in San Diego County in
California passed social host ordinances in 2004.

Source: www.madd.org
Minimum Age of Seller
Requirements – What is it?

Policies that require the server or clerks at
alcohol establishments be of a minimum age in
order to serve or sell alcohol.



In most states it is 18. It can be controlled at the local
level.
Younger employees may be allowed to stock coolers
with alcohol or clear beverages from tables.
Younger employees are more likely to sell to
underage youth and intoxicated patrons than
older employees.
Responsible Beverage Service
Training (Server Training)
- What is it?

Education of owners, managers, servers, and sellers at alcohol
establishments about strategies to avoid illegally selling alcohol to
youth or intoxicated patrons.











Helps managers and servers/sellers understand policies and the
consequences for failing to comply
Provides the necessary skills to comply with these policies
The importance of checking age id of customers
How to identify fake IDs and what to do if a fake ID is confiscated
How to recognize situations in which adults are buying alcohol for
underage youth
How to refuse sales to individuals who may supply alcohol to underage
youth
How to identify intoxicated customers
How to refuse service to underage youth and intoxicated customers.
Offer food with drinks
Delay service to rapid drinkers
Discourage intoxicated patrons from driving
Responsible Beverage Service
Training (Server Training)
- The evidence

Research in Minnesota shows that server and
management training reduced sales to youth by 11.5%
and to intoxicated buyers by 46%. Sources: Toomey 2001, Wagenaar 2005

In California, sales to intoxicated customers was cut in
half. Source: Salz, 1987.

Due to high staff turnover in many establishments,
owners and managers need to develop an on-going
system to train new employees

Requires good quality, face-to-face training with strong
and active management support.
Checking Age Identification
-What is it?


Age identification policies are written guidelines at stores, bars and
restaurants that provide employees instructions on checking IDs of
customers attempting to buy alcohol.
Although studies show that less than 15% of youth use fake IDs,
there are several sources of fake IDs including:






Alteration of one’s own ID
Use of someone else’s ID
Applying for another person’s ID using stolen information
Creating one’s own fake ID
Purchasing an ID from professional counterfeiters
Checking IDs decreases the potential liability a server or seller could
face for selling alcohol to an underage person.
Example
 Identification


Seizure – Newport, RI
When an establishment employee suspects an id
might be fake, he or she asks that person to wait until
a police officer arrives to investigate. Usually the
patron will abandon the fake ID and flee. If the
customer does wait the officer issues a citation and
the fine is up to $500.
In the first 3 months more than 400 fake IDs were
collected from 5 bars.
Compliance Checks
What is it?

A compliance check is a tool to identify alcohol
establishments that sell alcohol to underage
youth.
 The practice of compliance checks can be:



Mandated by a local ordinance
Voluntarily implemented by law enforcement or
licensing authorities
Compliance checks can be used for:


Enforcement
Education
Compliance Checks
Why it’s important

Alcohol licensees are informed that compliance checks
will occur at various times throughout the year and about
potential penalties for selling alcohol to underage youth.

While an enforcement agent waits outside the premises,
a person under age 21 attempts to purchase or order an
alcoholic beverage.

If the alcohol establishment sells alcohol to the young
person, the enforcement agent issues a citation to the
seller/server or the establishment

Because compliance checks can be used to hold the
owner and seller accountable, it encourages the licensee
to adequately train, supervise and back up their
employee.
Compliance Checks
The evidence

Several studies show that in communities where there is
little or no enforcement, youth can buy alcohol without
showing their IDs in 45-50% of their attempted
purchases.
Two studies from the mid 1990’s found that after
compliance checks were conducted, sales to underage
patrons reduced from 60-80% to 25-30%. Lewis 1996, Preusser, 1994
In a large study in Minnesota, sales to youth were
reduced immediately by 17% in alcohol establishments
that experienced a check. Wagenaar, 2005
Nationally, 66% of adults are in favor of compliance
check policies. Wagenaar, 2000
Forster 1994



A.C.E.
• Operational January 2005
• Three officers assigned
• Hours of operation 7pm – 3am
•Focused enforcement on alcohol violations
• Developed SOP’s on large party containment and dispersal &
compliance checks
•Dual purpose: (1) Aggressive enforcement of alcohol related
violations (2) Provide alcohol education
Covert Compliance Checks
Compliant rate:
2005 – 64%
2006 – 71%
2007 – 79%
149 establishments were checked in June 2007;
118 passed.
La Crosse Police Department
Responsible Beverage
Serving
Identifying ID’s
License Requirements
Signs of Intoxication
Quantifiable results from aggressive enforcement:
Year
Underage Citations Issued
10+ @ one location
2005
1,350
18
2006
1,186
11
2007 (Jan – July)
654 (1,116 projected)
Summary Report:
38% reduction in underage citations issued
12% reduction in incidents where 10 or more citation
were issued at one location
Alcohol Sponsorship Restrictions

Control of alcohol-related sponsors at community events.

Sponsors provide financial support for the event in return
for promotions and advertisements at the event.

Restrictions can be by a local ordinance, state law or can
be implemented voluntarily by a business, event or
organization.

Promotions may send the message that alcohol is
needed to have fun or to excel in athletics
Alcohol Sponsorship Restrictions
-An Example
 In
Oakland, California, the annual Cinco
de Mayo festival was not previously
associated with drinking, but in the 1980s
there was an onslaught of nationwide
advertising. A group in Oakland called
Hispanos Unidos organized people in the
community to find non-alcohol sponsors
for their festival.
Sobriety Checkpoints

The US uses selective breath testing checkpoints in
which law enforcement official must have reason to
suspect that a driver who is stopped has been drinking
before a breath test can be administered
 Some European countries use random breath testing in
which all drivers are stopped and given breath tests.
 Use of sobriety checkpoints have been determined to be
legal by the US Supreme Court
 The research:



Based on 11 studies (Guide to Community Preventive Services, 2004)
Selective breath testing checkpoints are effective in reducing
fatal and non-fatal injury crashes by 20%
$6 - $23 Return on Investment
Decrease the number
of outlets per capita

Alcohol outlet density refers to the number of alcohol
merchants available to a particular population or in a
particular area
 Affects the availability of alcohol, its presence as part of
the community culture, and the strain on local
enforcement agencies.
 Several studies found the more outlets, the higher
drinking and driving and riding with impaired drivers, and
higher alcohol-related fatalities.
 La Crosse liquor license per capita as a county isn’t as
high as some counties, but issue may be the
concentration of liquor licenses in certain areas
(downtown)
 Community statistics from census:
Applying the Public Health Model
Population/Host
(Age, Gender,
Race/Ethnicity)
Agent/Vehicle
(Content, Packaging
Warning Labels)
Environment
(Pricing/Taxation,
Regulations, Media)
Blood Alcohol Concentration Laws
 As
of July 2004, all states have passed a
0.08 BAC which established the legal level
of intoxication for drunk driving
 The research:



A review of 9 studies
Following implementation of the laws, the
median decrease in fatal alcohol-related
motor vehicle crashes was 7%
Estimates of the number of lives that could be
saved ranged from 400 to 600 lives per year.
(Guide to Community Preventive Services, 2004)
Minimum drinking age

Minimum legal drinking age laws specify an age
below which the purchase of public consumption
of alcoholic beverages is illegal. In all states in
the US the legal age is 21.
 Minimum bar entry age in WI?
 The Research:


A Review of 33 studies
Raising the drinking age was effective at reducing the
fatal injury crashes by 17% and fatal and non-fatal
injury crashes combined by 15%.
(Guide to Community Preventive Services, 2004)
Mass Media Campaigns

Typically carried out in conjunction with other
programs and policies
 Where adequate local resources can support a
mass media campaign that is carefully planned,
well executed and attains adequate audience
exposure, and is supported by other prevention
activities, mass media campaigns can be
effective in reducing alcohol-impaired driving.
 Research:


8 studies (Guide to Community Preventive Services, 2004)
13% reduction in crashes
Restriction on Advertisement

Includes any policies that limit advertising of alcoholic
beverages particularly advertising that exposes young
people to alcohol messages. Can include:





Banning ads on buses, billboards, supermarket carts, bus
shelters, schools
Banning or limiting advertising and sponsorship at community
events such as festivals, parties, concerts and sporting events
Restricting alcohol advertising in newspapers, TV, or radio
Restricting the size and placement of window advertisements in
liquor and convenience stores
Setting a maximum for the percentage of total advertising space
that alcohol ads can cover
Restriction on Advertisement
An Example
 Oakland,
California adopted a strict
ordinance prohibiting alcohol ads on
billboards in residential areas and near
schools. The ordinance also banned
alcohol advertising within 3 blocks of rec
centers, churches, and licensed day care
facilities.
Alcohol Education to Youth
 Peer-to-peer
 Expert
led
 Middle school
 High school
 College
Alcohol Education to Youth
 School-based
instructional programs
 Peer organizations
 Social “norming” campaigns
School-based instructional
programs

Many school-based programs exist- teach about
the health consequences of alcohol use and role
model how to avoid behavior
 Only a few are evidence-based.


E.g., Project Northland
Research:


5 studies on school-based intervention effectiveness
suggest small benefits for preventing drinking and
driving
4 studies suggest small benefits to decreased
likelihood of riding with drinking drivers.
Peer-based programs

Many peer-based programs exist


E.g., Students Against Destructive Decisions
Research:



2 studies on peer-led programs have produced some
beneficial effects, but neither study found that their
presence was associated with a significant decrease
in drinking and driving or riding with drinking drivers.
Too much variability in programs to easily study
Community/culture specific
Social Norming programs

Social norming campaigns attempt to correct
students’ tendencies to overestimate the alcohol
consumption of peers, thus reducing the
perceived pressures to consume excessive
quantities of alcohol.
 Research:



2 studies on social norming.
One found at 25% reduction in the number of drivers
with a positive BAC and 50% reduction in BAC about
.08%
One found a self-reported increase in use of
designated drivers and decrease in drinking and
driving.
Social Norms Approach





Relies on hopeful tactics
Highlights protective behaviors
Uses media to expose solutions
Uses policy to reward behavior change
Results in partnerships working
effectively for health and safety.
Protective practices, policies, and places are norms of the
population and are reinforced with methods derived from the
population.
Michael Haines, Northern Ill Univ
When asked, “How do you protect
yourself and others when drinking at a
party or social event?” Students
replied:
• Set a limit and stick to it
• Avoid drinking games
• Abstain for the night
• Count your drinks
• Pace yourself to one drink per hour
• Drink a look-alike drink
Results of Social Norms:
Reductions in Heavy Drinking at
Universities

44% Northern Illinois University
 40% Hobart and Wm Smith Colleges
 28% University of Arizona
 23% Florida State University
 23% Rowan State University
 20% Western Washington University
 20% University of Virginia
 18% Michigan State University
© Michael Haines 2006
Increasing the penalty
for underage drinkers
 Limited
research/evidence with increased
penalties
 May achieve the same results by applying
restrictions on licensing

Graduated drivers’ license laws
Increasing the penalty/lowering
the BAC limits for
Young or inexperienced drivers

In the US, the lower BAC laws apply to all
drivers under the age of 21. The illegal BAC
level varies by state from any BAC to 0.02% (WI
is 0.00)
 The Research:

6 studies have reviewed the impact of a lower BAC
level for young or inexperienced drivers: (Guide to Community
Preventive Services, 2004)


Fatal crashes declined by 9-24%
Injury crashes declined by 4-17%
Alternate activities for youth
 Makes
intuitive sense
 Alternative activity needs to be seen to
youth as a “true alternative.”
 Research needed on the effectiveness of
alternative activities.
Designated Driver Promotion
Programs

Programs use mass media and other communication
channels to promote designated driver use
 May commonly use incentives like free soft drinks, food
or free admission.
 Most commonly inform customers with a display in a bar.
 Research:



13% increase in “always” selecting a designated driver but not
change in self-reported alcohol impaired driving or riding with an
alcohol-impaired driver.
Incentive program increased the number of designated drivers
per night (+0.9)
6% decrease in self-reported drinking and driving
In the 1st six years of the program, over 280,000 people have utilized the
“Safe Ride” program. The program was developed by the University of
Wisconsin – La Crosse Student Association in cooperation with the City’s
Mass Transit Authority. The program is currently administered by the
La Crosse Tri-Campus Group and financed through student tuition fees.
The program has been a model for other college communities throughout
the state.
Operation River Watch is
a grass roots initiative
utilizing community
volunteers to patrol
Riverside Park, creating a
safer environment and
increasing public
awareness on the dangers
of binge drinking.