Can training bar staff in responsible serving practices reduce alcohol-related harm?

A responsible service training programme aimed at reducing alcohol-related harm was implemented in a popular entertainment area over several months in 1992-93. Another popular entertainment area provided a control site. A number of evaluation measures were used: breath tests on 872 patrons from selected venues; drink driving data; risk assessments; the use of 'pseudo patrons'; and knowledge and attitude changes among trained bar staff (n = 88). Compared to control sites the intervention sites showed an immediate pre- to post-test reduction in patrons rated by researchers as extremely drunk and an eventual reduction from pre-test to follow-up in patrons with blood alcohol levels > = 0.08. There was also a small but significant increase in knowledge among bar staff. There was no significant reduction in patrons with blood alcohol levels > = 0.15 or in the number of drink driving offences from intervention sites during the study period. Pseudo drunk patrons were rarely refused service, identification was rarely checked and non-photographic identification was accepted on most occasions. The less than satisfactory outcome is attributed to poor implementation of the training and a lack of support among managers. The positive results from one venue, whose manager embraced the programme, served to highlight the importance of management support. It is suggested that mandatory training and routine enforcement of licensing laws are essential if the goals of responsible serving are to be met.

Pseudo-drunk-patron evaluation of bar-staff compliance with Western Australian liquor law.

Compliance of bar staff with the Western Australian liquor law prohibiting service to drunk patrons was assessed through the deployment of actors trained to behave in a drunken manner. The serving practices of 23 licensed premises (19 hotels and four nightclubs) were examined. During 120 visits to hotel and nightclub bars, more than 350 drink orders were placed by pairs of pseudo-drunk actors who ordered up to three drinks each on each visit. On placing these drink orders, pseudo-drunks were refused service by bar staff on only 12 occasions. The rate of refusal of service across all premises was 10 per cent of visits. Partial interventions by servers, such as offering food or low-alcohol or nonalcoholic drinks, occurred in only four instances of the 120 visits. Qualitative observations and results obtained from a separate study examining a subsample of the servers who trained in responsible service of alcohol are discussed.

Use of pseudo-patrons to assess compliance with laws regarding under-age drinking.

The extent to which door and bar staff of licensed premises responded to possibly under-age patrons was assessed through the use of research assistants (young pseudo-patrons) selected for having the appearance of being under 18 years old. A total of 156 visits were made to 13 licensed premises: 1. before delivery of a server training program, 2. immediately after training, and 3. after three months. Staff rarely checked the age and/or identification (ID) of the young pseudo-patrons before or after training. However, a significant interaction was found between the sex of the pseudo-patron and the type of premises. Door staff, who were predominantly at nightclubs, were more likely to check the ID of female pseudo-patrons and hotel bar staff were more likely to check the ID of males. In most cases, however, nonphotographic ID was accepted. While some strategies are suggested, the strongest and most effective measure to prevent under-age drinking will be a more rigorous enforcement of existing liquor laws.

Unravelling the preventive paradox for acute alcohol problems.

Kreitman's discussion of the preventive paradox in relation to the prevention of alcohol problems has had profound implications for alcohol policy and has generated considerable controversy [1]. It is argued here that although Kreitman should be credited with the important observation that alcohol-related harm is not confined to a few dependent drinkers, none the less an apparent paradox is not an ideal platform from which to recommend policy. Furthermore, Kreitman's own data and data from an Australian survey of drinking are used to demonstrate that a commonplace truth underlies his apparently paradoxical findings. It is shown that the preventive paradox disappears when consideration is given to the amount of alcohol consumed on either (i) the day of highest alcohol intake out of the last four, or (ii) the day on which acute alcohol-related harm occurred. Episodic heavy consumption by people whose average alcohol intake can be classified as 'low' or 'medium' risk contributes to the bulk of such experiences of harm. It is suggested that the importance of intoxication as a public health and safety issue has been neglected. This neglect is compounded when public education campaigns and prevention policy are only based on average rates of alcohol consumption. Advice regarding the low risk levels of consumption for different types of harm should form one component of a comprehensive harm reduction policy. Other elements of such a policy should include a variety of other measures of proven effectiveness in relation to reducing levels of intoxication and related problems.

Blood alcohol levels of patrons leaving licensed premises in Perth, Western Australia.

We aimed to determine the alcohol consumption, blood alcohol levels (BALs) and subsequent driving of patrons leaving 15 hotels and taverns in Perth, Western Australia. Of the 414 patrons approached by interviewers on Friday and Saturday evenings, 307 (74 per cent) consented to take part. Self-reported alcohol consumption, driving intentions, perceived levels of fitness to drive and demographic information were collected using an interviewer-administered questionnaire. Observations of subsequent driving were recorded and BALs were measured by breath-alcohol meter. The patrons surveyed were predominantly male (76 per cent) and aged between 18 and 35 (87 per cent). Average reported alcohol consumption was 7.6 standard drinks for males and 4.9 drinks for females, around double the daily amount recommended by the National Health and Medical Research Council. Further, 23 per cent of the sample had consumed more than 10 drinks (male) and 6 drinks (female). With respect to BALs, 37 per cent of patrons exceeded the drink-drive limit then in force of 0.087 and 56 per cent exceeded 0.05. Of greater concern, 23 per cent who were over the 0.08 legal limit were subsequently observed to drive even though they had been informed of their BAL and legal status with respect to driving. The results suggest that most young patrons drinking in Perth metropolitan hotels and taverns consume alcohol on such occasions in excess of limits currently recommended by health authorities and attain blood alcohol levels dangerous for driving. This is likely to remain unchanged without public debate as to the responsibility of licensees in serving a potentially harmful psychotropic drug and effective enforcement of liquor licensing laws.

High risk drinking settings: the association of serving and promotional practices with harmful drinking.

A household survey of 1160 Western Australian adults was used as a basis for exploring drinkers' reports about the settings in which they drank alcohol and their experiences of alcohol related harm. Of the 873 drinkers identified, 7.9% had experienced some form of acute alcohol related harm over the previous 3 months. Violent incidents were the most common of these and drink-driving offences the least. Such harm was significantly more likely among drinkers who variously drank 'heavily', were male, single, under 25 years of age and/or who drank on licensed premises. Regression analyses revealed that even when demographic characteristics of the drinkers were controlled for licensed premises were significantly more likely to be the settings used prior to harm occurring. Bar staff continuing to serve 'obviously intoxicated' customers was the most powerful predictor of harm. Premises which offered discounted drinks or permitted crowding also tended to be those where intoxication was permitted but these variables were not directly associated with an increased risk of harm. These findings lend further weight to the view that prevention efforts should focus on licensed drinking environments and, in particular, the practice of continuing to serve obviously intoxicated customers.

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.

Public support for the prevention of alcohol-related problems.

Support for a number of strategies and policies for the prevention of alcohol related harm was ascertained as part of a larger survey of public attitudes and behaviours in a representative sample of the Perth metropolitan area. Support for these policies varied, but was generally positive, with young male drinkers the least supportive. The greatest degree of support was found for a variety of training strategies for licensees and barstaff, while a number of restrictive practices, such as reduced trading hours and the banning of the sale of beer in jugs, were less popular. Those who had recently worked in the alcohol trade were less likely than the general population to be supportive of these policies. This effect could not be completely explained by their generally being younger and drinkers. It is concluded that governments generally have a mandate to introduce certain policies and practices into the licensed drinking environment, but that the resistance of the alcohol trade to such measures may need to be overcome if they are to be successfully introduced.

Levels of drunkenness of customers leaving licensed premises in Perth, Western Australia: a comparison of high and low 'risk' premises.

A measure of the risk of licensed premises having customers involved in road traffic accidents and drink-driving offences was utilised in order to identify seven 'High Risk' and eight 'Low Risk' premises in metropolitan Perth, Western Australia. This measure, or 'Risk Ratio', was defined as the ratio of incidents of alcohol-related harm to an estimate of on-premises alcohol sales for a particular establishment. A study was conducted to test the hypothesis that a High Risk status would be associated with greater levels of customer intoxication. Interviews concerning drinking behaviour and breathalyser readings were collected from 74.2% of 414 customers exiting from the chosen premises between 8 p.m. and midnight on Friday and Saturday nights. High Risk premises had three times more customers whose readings were in excess of 0.15 mg/ml (p less than 0.01). The proportion of customers with BAL's above 0.15 correlated strongly with the premises' Risk Ratio (r = 0.63, p less than 0.01). There were also significantly more patrons from High than from Low Risk establishments who were rated as appearing moderately or severely intoxicated but refused to be interviewed or breath-tested. It is argued that these results support the need for strategies which aim to reduce very high levels of intoxication on licensed premises in order to reduce alcohol-related accidents, injuries and offences.

Detection of alcohol-related problems in general practice.

While primary care has considerable potential as a site for detecting and intervening for alcohol-related problems, few doctors currently identify these problems. The judgments of eight primary care physicians about alcohol-related problems in 371 of their patients were compared with the patients' responses to the Short Michigan Alcoholism Screening Test (SMAST) and the CAGE. The CAGE classified 11.4% of the patients as alcoholics and the SMAST identified 23.9% as probable alcoholics. However, the doctors identified only a small proportion (7.0%) of their patients as having any level of alcohol-related problem. The doctors did not identify 65.0% of CAGE-defined alcoholics and 82.3% of those patients classified by the SMAST as probable alcoholics. The discrepancy between primary care physician's judgments and the SMAST and CAGE may be attributable to the doctor's failure to identify patients with alcohol-related problems. An alternative explanation is that the SMAST and CAGE are inappropriate screening tools for use in Australian primary care. The findings are discussed in terms of the implications for training doctors and for the development of better measures of alcohol-related problems for use within a primary care context.