Evidence-based Strategies to Reduce Alcohol-related Injuries A REVIEW OF THE SCIENCE

1. Evidence-based Strategies to ReduceAlcohol-related InjuriesA REVIEW OF THE SCIENCE Brenda Rooney, PhD, Epidemiologist, Gundersen Lutheran

2. 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.

3. 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.

4. 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.

5. Applying the Public Health Model Population/Host (Age, Gender, Race/Ethnicity) Environment (Pricing/Taxation, Regulations, Media) Agent/Vehicle (Content, Packaging Warning Labels)

6. Beer Keg RegistrationWhat 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.

7. Beer Keg RegistrationWhy 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.

8. 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

9. 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

10. 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.

11. 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

12. 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

13. Applying the Public Health Model Population/Host (Age, Gender, Race/Ethnicity) Environment (Pricing/Taxation, Regulations, Media) Agent/Vehicle (Content, Packaging Warning Labels)

14. 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

15. 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.

16. Alcohol Use Restrictions on Public Property – The evidence • Communities that have increased enforcement of existing public alcohol use policies report a reduction in alcohol-related 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.

17. 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.

19. 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.

20. 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.

21. 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.

22. 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

23. 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?

24. Social Host LiabilityWhat 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.)

25. Social Host LiabilityWhy 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

26. Social Host LiabilityThe 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

27. 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.

28. 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

29. 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.

30. 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.

31. 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.

32. Compliance ChecksWhat 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

33. Compliance ChecksWhy 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.

34. Compliance ChecksThe 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. Forster 1994 • 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

35. 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

36. Covert Compliance Checks Compliant rate: 2005 – 64% 2006 – 71% 2007 – 79% 149 establishments were checked in June 2007; 118 passed.

37. Responsible Beverage Serving Identifying ID’s License Requirements Signs of Intoxication La Crosse Police Department

38. 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

39. 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

40. 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.

41. 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

42. 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:

44. Applying the Public Health Model Population/Host (Age, Gender, Race/Ethnicity) Environment (Pricing/Taxation, Regulations, Media) Agent/Vehicle (Content, Packaging Warning Labels)

45. 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 (Guide to Community Preventive Services, 2004) • 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.

46. 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 (Guide to Community Preventive Services, 2004) • Raising the drinking age was effective at reducing the fatal injury crashes by 17% and fatal and non-fatal injury crashes combined by 15%.

47. 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

48. 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

49. Restriction on AdvertisementAn 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.

50. Alcohol Education to Youth • Peer-to-peer • Expert led • Middle school • High school • College