Liability of commercial and social hosts for alcohol-related injuries: a national survey of accountability norms and judgments.

Legal standards for liability of commercial sellers and social providers of alcoholic beverages are affected by social norms concerning accountability and responsibility. Using a nationwide probability sample telephone survey of 7,021 U.S. residents, we conducted a randomized experiment in which each subject was asked to respond to multiple vignettes. The vignettes told stories of drinking situations, systematically varying dimensions concerning age of drinker, commercial versus social settings, amount of alcohol consumed, history of previous behavior, and seriousness of damage or injury following drinking. Analyses involved linear mixed (i.e., random effects) model regressions, using responses to vignettes as the outcome variable, controlling for a series of sociodemographic, behavioral, and attitudinal measures. Results showed that age of drinker (young), setting (bar), and previous behavior (history of irresponsibility) were most strongly associated with harsher judgments of civil liability. Citizens' multiple standards for assigning legal liability and implications for public policy are discussed.

Lowered legal blood alcohol limits for young drivers: effects on drinking, driving, and driving-after-drinking behaviors in 30 states.

OBJECTIVES: This study evaluated the effects on drinking and driving of lowered allowable blood alcohol concentration (BAC) limits for drivers younger than 21 years in 30 US states between 1984 and 1998. METHODS: Outcome measures were based on self-reports from a cross-sectional sample of more than 5000 high school seniors in 30 states surveyed before and after BAC limits were implemented in their states. RESULTS: Frequency of driving after any drinking and driving after 5 or more drinks declined 19% and 23%, respectively. Lower BAC limits did not affect overall amount of drinking or total number of miles driven. CONCLUSIONS: Significant beneficial effects of lowered youth BAC limits have appeared despite limited publicity and enforcement of the new laws.

Sociodemographic and individual predictors of alcohol policy attitudes: results from a US probability sample.

OBJECTIVE: Public views on alcohol policies have facilitated legislative change. Given limited resources, however, policy makers and prevention advocates cannot make haphazard attempts to mobilize public resources. This investigation reports sociodemographic and individual traits predicting attitudes on alcohol policies designed to reduce underage alcohol consumption. Previous studies have examined single-item measures of alcohol policy. We examined predictors of multi-item scales measuring five core dimensions of alcohol policy. METHODS: A survey of public attitudes on alcohol policies was administered to a US national probability sample of 7021 adults. RESULTS: Women, infrequent drinkers, and adults with greater knowledge about or concern for youth exhibited the greatest support across five alcohol policy scales. Older adults favored policies that restrict alcohol use in public places, whereas younger adults favored an increase in alcohol taxes to address underage alcohol use. CONCLUSIONS: Individual factors such as alcohol use frequency and concern for youth explained larger proportions of variance in alcohol policy attitudes than did sociodemographic factors. Consistent with previous research, political orientation, parental status, employment status, and marital status did not predict attitudes on alcohol policy.

Project ARM: alcohol risk management to prevent sales to underage and intoxicated patrons.

Clear policies and expectations are key to increasing responsible service of alcohol in licensed establishments. Few training programs focus exclusively on owners and managers of alcohol establishments to reduce the risk of alcohol service. Project ARM: Alcohol Risk Management is a one-on-one consultation program for owners and managers. Participants received information on risk level, policies to prevent illegal sales, legal issues, and staff communication. This nonrandomized demonstration project was implemented in five diverse bars. Two waves of underage and pseudo-intoxicated purchase attempts were conducted pre- and postintervention in the five intervention bars and nine matched control bars. Underage sales decreased by 11.5%, and sales to pseudo-intoxicated buyers decreased by 46%. Results were in the hypothesized direction but not statistically significant. A one-on-one, outlet-specific training program for owners and managers is a promising way to reduce illegal alcohol sales, particularly to obviously intoxicated individuals.

Public opinion on alcohol policies in the United States: results from a national survey.

We surveyed the U.S. non-institutionalized population age 18+ on opinions regarding 23 alcohol control policies (N = 7,021). The cooperation rate among contacted households was 70% and the overall response rate was 54%. Results showed high levels of public support for most alcohol control policies. Over 80% support restrictions on alcohol use in public places, such as parks, beaches, concert venues, and on college campuses. Eighty-two percent support increased alcohol taxes, provided the funds are used for treatment or prevention programs. Over 60% support alcohol advertising and promotion restrictions, such as banning billboard advertising, banning promotion at sporting events, or banning liquor and beer advertising on television. Multivariate regression analyses indicated significant relationships between alcohol policy opinions and a variety of sociodemographic, political orientation, and behavioral measures. However, the absolute differences in alcohol policy support across groups is small. There is a strong base of support for alcohol control policies in the U.S., and such support is found among whites and ethnics of color, young and old, rich and poor, and conservatives, moderates, and liberals.

Policy evaluation research. Measuring the independent variables.

The purpose of this article is to evaluate the accuracy of three methods used to obtain policy data: (a) government agency surveys, (b) secondary sources, and (c) historical legal research. Changes in laws were identified for all 48 contiguous states for the period 1968 to 1994. Legal research is most accurate for well-established laws that have consistent legal descriptions across nearly all states. Laws that are recently enacted, adopted by only a few states, and treated in a legally inconsistent manner across states require a multistage data collection method to identify accurate policy change information.

Communities mobilizing for change on alcohol (CMCA): effects of a randomized trial on arrests and traffic crashes.

AIMS: We previously reported effects of the CMCA intervention in reducing social and commercial access to alcohol by youth, and reducing alcohol use by 18-20-year-olds. This paper reports on effects of CMCA on arrests and car crashes. DESIGN: CMCA was a group-randomized trial that implemented and evaluated a community-organizing effort to change community policies and practices to reduce youth access to alcohol. Seven Midwestern communities were randomly assigned to the intervention condition and eight communities were assigned to the control condition. INTERVENTION: For 2.5 years, a part-time community organizer worked in each of the seven intervention communities with local public officials, enforcement agencies, alcohol merchants, the media, schools and other community groups to reduce youth access to alcohol. MEASUREMENT: We collected annual arrest and quarterly traffic crash data for the years 1987-1995, providing a 6-year baseline and 3 years of data during the intervention. Data were stratified into two target age groups (15-17 and 18-20) and a control group (age 21 and over). Analyses used random-coefficient models because we had repeated observations for each unit of assignment in a group-randomized trial with heterogeneous trends across communities. FINDINGS: We observed net declines in the intervention communities for all arrest and traffic crash indicators. The decline was statistically significant for DUI arrests among 18-20-year-olds and approached significance for DUI arrests and disorderly conduct violations among 15-17-year-olds. CONCLUSIONS: Together with previously published results from this study, the results reported here suggest that a community-organizing approach to limit youth access to alcohol may be effective, at least for selected end-points and subgroups. We conclude that this approach may be useful, but that a longer intervention period is required to increase effectiveness.

Alcohol home delivery services: a source of alcohol for underage drinkers.

OBJECTIVE: This study describes the use of alcohol home delivery services by underage drinkers, and characteristics of grocery and liquor stores that deliver alcohol. The availability of alcohol home delivery services across the United States is also described. METHOD: Individuals surveyed were from 15 small- and medium-sized midwestern communities. Of all enrolled 12th graders, 83.5% (N = 4,487) responded, and of a randomly selected cohort of 18- to 20-year-olds, 93.9% (N = 1,721) responded. All grocery stores that sold alcohol and liquor stores in the corresponding communities were invited to participate in the study and 124 (92.5%) of those businesses completed surveys regarding outlet characteristics and practices. Data for the surveys were based on a nested cross-sectional design with individual respondents nested within the 15 communities. RESULTS: Purchases of delivered alcohol were made by 10% of 12th graders and 7.3% of 18- to 20-year-olds within the past year; 20.2% of outlets delivered alcohol. Using bivariate analyses, purchasing delivered alcohol was associated with male gender, high-risk drinking (drinking five or more drinks on an occasion), more recent and more frequent drinking. Providing delivery services was more common among outlets selling keg beer and/or single servings. Multivariate analyses revealed positive associations between purchasing delivered alcohol and male gender for the 12th graders, and high risk and more recent drinking for both the 12th graders and 18- to 20-year-olds. For outlets, selling keg beer was positively associated with providing delivery services. A separate survey indicated that home delivery services appear to be available in many areas of the country. CONCLUSIONS: Home delivery is a previously unidentified source of alcohol for underage drinkers that could be curtailed with effective alcohol policies.

Communities mobilizing for change on alcohol: outcomes from a randomized community trial.

OBJECTIVE: Communities Mobilizing for Change on Alcohol (CMCA) was a randomized 15-community trial of a community organizing intervention designed to reduce the accessibility of alcoholic beverages to youths under the legal drinking age. METHOD: Data were collected at baseline before random assignment of communities to intervention or control condition, and again at follow-up after a 2.5-year intervention. Data collection included in-school surveys of twelfth graders, telephone surveys of 18- to 20-year-olds and alcohol merchants, and direct testing of the propensity of alcohol outlets to sell to young buyers. Analyses were based on mixed-model regression, used the community as the unit of assignment, took into account the nesting of individual respondents or alcohol outlets within each community, and controlled for relevant covariates. RESULTS: Results show that the CMCA intervention significantly and favorably affected both the behavior of 18- to 20-year-olds (effect size = 0.76, p<.01) and the practices of on-sale alcohol establishments (effect size = 1.18, p<.05), may have favorably affected the practices of off-sale alcohol establishments (effect size = 0.32, p = .08), but had little effect on younger adolescents. Alcohol merchants appear to have increased age-identification checking and reduced propensity to sell to minors. Eighteen- to 20-year-olds reduced their propensity to provide alcohol to other teens and were less likely to try to buy alcohol, drink in a bar or consume alcohol. CONCLUSIONS: Community organizing is a useful intervention approach for mobilizing communities for institutional and policy change to improve the health of the population.

Intraclass correlations from a community-based alcohol prevention study: the effect of repeat observations on the same communities.

OBJECTIVE: School- and community-based alcohol prevention programs are often evaluated using a group-randomized trial (GRT) design with a single pretest and a single posttest survey. To size such studies properly, investigators need accurate estimates of the variance and intraclass correlation that will be operative in their analyses. Until recently, the only available estimates were based on cross-sectional analyses. A recent report suggests that values from cross-sectional analyses may overestimate the intraclass correlation operative in pretest-posttest analyses. The purpose of this article is to review these issues, present estimates of intraclass correlation for a variety of alcohol-related endpoints based on cross-sectional analyses and to compare those estimates to estimates based on pretest-posttest analyses. We will also show how these estimates can be used to establish optimal sample sizes for GRTs to evaluate school- and community-based alcohol prevention programs. METHOD: Data were collected from 18 to 20 year olds and high-school seniors as part of an alcohol prevention effort employing a group-randomized trial design with a single pretest and a single posttest survey. Data were analyzed via mixed-model regression methods to estimate components of variance. Those components were then used to compute the intraclass correlations operative in both cross-sectional analyses and in pretest-posttest analyses. RESULTS: Results indicate that intraclass correlations operative in pretest-posttest analyses are much smaller than are those operative in cross-sectional analyses. CONCLUSIONS: Our findings indicate that future alcohol-prevention studies employing a group-randomized trial design with a single pretest and single posttest survey may not need to be as large as previously suggested by intraclass correlation estimates based on cross-sectional data. This holds true even if they are analyzed to reflect the extra variation typical of group-randomized trials.

The value of interrupted time-series experiments for community intervention research.

Greater use of interrupted time-series experiments is advocated for community intervention research. Time-series designs enable the development of knowledge about the effects of community interventions and policies in circumstances in which randomized controlled trials are too expensive, premature, or simply impractical. The multiple baseline time-series design typically involves two or more communities that are repeatedly assessed, with the intervention introduced into one community at a time. It is particularly well suited to initial evaluations of community interventions and the refinement of those interventions. This paper describes the main features of multiple baseline designs and related repeated-measures time-series experiments, discusses the threats to internal validity in multiple baseline designs, and outlines techniques for statistical analyses of time-series data. Examples are given of the use of multiple baseline designs in evaluating community interventions and policy changes.

An evaluation of the general effect of the New Zealand graduated driver licensing system on motorcycle traffic crash hospitalisations.

In 1987, New Zealand introduced a comprehensive Graduated Driver Licensing System (GDLS) which was designed to allow new drivers to gain driving experience while being excluded from high risk situations. This study sought to evaluate the impact of the GDLS on motorcycle traffic crashes that resulted in serious injury. Injury crash data were obtained from the New Zealand Health Information Services national public hospital inpatient data files for the years 1978-1994, inclusive. Cases were disaggregated into three age groups, 15-19 years, 20-24 years, and 25 years or older, for which injury trends were obtained. In order to determine whether trends in motorcycle traffic crashes simply followed national trends in other injury events, two non-traffic comparison groups for the main target group (15-19 years) were included. Using time series analyses, the introduction of the GDLS was found to be closely followed by a significant reduction (22%) in motorcycle traffic crash hospitalizations for the 15-19 year age group. An examination of vehicle registration and driver licensure data suggests that the reduction in injury crashes may, largely, be attributable to an overall reduction in exposure to motorcycle riding.

Alcohol sales to pseudo-intoxicated bar patrons.

OBJECTIVES: Many establishments serve alcoholic beverages to obviously intoxicated patrons despite laws against such sales. To guide the development of interventions to reduce these illegal alcohol sales, this study used actors feigning intoxication to determine whether servers recognized obvious signs of intoxication and to assess the tactics servers used when dealing with intoxicated patrons. METHODS: Male actors ages 30 to 50 acted out signs of obvious intoxication as they attempted to purchase alcoholic beverages. If served during the first attempt, these pseudo-intoxicated buyers made second purchase attempts during the same visit. Observers accompanied the actors; after each visit, actors and observers recorded the servers' behavior and comments. RESULTS: Alcoholic beverages were served to actors portraying intoxicated patrons at 68% of first purchase attempts and 53% of second purchase attempts (62% of a total of 106 purchase attempts). The most common refusal technique was a direct refusal (68% of refusals), made with either no excuse or with reference to the actors' apparent intoxication level. Servers' second most commonly used refusal technique was offering alcohol-free beverages, such as coffee or water (18% of refusals). CONCLUSIONS: Further research is needed to determine why servers who recognize intoxication serve alcoholic beverages and what training, outlet policies, and external pressures are needed to reduce illegal alcohol sales to obviously intoxicated patrons.

Policy options for prevention: the case of alcohol.

Reducing the availability of alcohol through alcohol control policies such as excise taxes and the minimum legal drinking age has been effective in reducing a wide range of alcohol-related problems, including traffic crashes, liver cirrhosis, and violence. Alcohol control policies may be classified into two overlapping categories--public and institutional policies. Some policies such as alcohol server training may be either mandated by governmental jurisdictions or voluntarily adopted by individual institutions, which include alcohol retail establishments, other businesses, worksites, schools, colleges/universities, law enforcement agencies, religious institutions, insurance agencies, and alcohol producers. Public policies may be mandated by national, state/provincial, or local governments to regulate where, when, and how alcohol is sold and consumed. This paper describes the wide array of public and institutional policies available to reduce alcohol-related problems. Summaries of research evaluating specific alcohol control policies are provided when available.

Qualitative assessment of training programs for alcohol servers and establishment managers.

OBJECTIVE: In an attempt to reduce the societal burden associated with alcohol-related problems such as underage drinking and drunk driving, some local communities and state governments mandate training programs for employees of establishments that serve or sell alcoholic beverages. This study was designed to assess the available training programs for employees and managers and to identify states that either mandate training programs or encourage them by reducing establishments' legal liability. METHODS: Training programs were identified through the Internet, key informants, and the research literature. Three researchers independently rated each of 22 local and national programs across 10 categories. In addition, the authors surveyed alcoholic beverage control agencies and legislative research bureaus in the 50 U.S. states. RESULTS: The results show that training programs are not standardized and vary widely in content, use of behavior change methods, and production quality. Most programs targeted waitstaff and bartenders. Only one program exclusively targeted owners and managers. CONCLUSIONS: National standards must be developed for training programs for servers, managers, and owners.

Dose-effect relations for early local pulmonary injury after irradiation for malignant lymphoma and breast cancer.

PURPOSE: To quantify the influence of treatment- and patient-related factors on the severity of early local pulmonary injury and to establish whether regional differences are present for local dose-effect relations for early radiation-induced pulmonary injury. METHODS: Forty-two patients with malignant lymphoma and 40 breast cancer patients were examined prior to and 3 months after radiotherapy. The lymphoma patients were irradiated with mantle fields to an average dose of 38 Gy and the breast cancer patients were irradiated with internal mammary node fields with or without tangential breast fields to an average dose of 50 Gy. Dose-effect relations for local perfusion, ventilation and density changes were determined using correlated single photon emission computed tomography (SPECT) and CT data. A multivariate analysis was performed to study the influence of irradiated volume, chemotherapy (CMF and MOPP/ABV), smoking, age and gender. In addition, dose-effect relations for different regions in the lung were determined. RESULTS: A similar and almost linear increase of early functional changes as a function of radiation dose was observed for perfusion and ventilation, whereas the shape of the dose-effect relation and the magnitude of early structural changes were different for density. For the three end-points studied, regional differences in radiosensitivity could not be demonstrated. For the posterior lung region compared to the anterior lung region, however, a difference was observed, which could be attributed to a gravity-related effect in the measuring procedure. Local structural changes (density) were significantly smaller for smokers (P = 0.002) and young patients (P = 0.007), whereas the CMF chemotherapy regimen given after radiotherapy (P = 0.017) significantly increased the amount of functional changes (perfusion). The magnitude of local pulmonary changes was independent of the irradiated volume, the MOPP/ABV chemotherapy regimen and gender. CONCLUSION: The dose-effect relations for early radiation-induced local pulmonary changes were independent of the irradiated volume, MOPP/ABV, gender and lung region. CMF, smoking and age influenced the magnitude of early pulmonary changes and should be taken into account in dose-escalation protocols.

The effects of community policies to reduce youth access to tobacco.

OBJECTIVES: This study tested the hypothesis that adoption and implementation of local policies regarding youth access to tobacco can affect adolescent smoking. METHODS: A randomized community trial was conducted in 14 Minnesota communities. Seven intervention communities participated in a 32-month community-organizing effort to mobilize citizens and activate the community. The goal was to change ordinances, merchant policies and practices, and enforcement practices to reduce youth access to tobacco. Outcome measures were derived from surveys of students before and after the intervention and from tobacco purchase attempts in all retail outlets in the communities. Data analyses used mixed-model regression to account for the clustering within communities and to adjust for covariates. RESULTS: Each intervention community passed a comprehensive youth access ordinance. Intervention communities showed less pronounced increases in adolescent daily smoking relative to control communities. Tobacco purchase success declined somewhat more in intervention than control communities during the study period, but this difference was not statistically significant. CONCLUSIONS: This study provides compelling evidence that policies designed to reduce youth access to tobacco can have a significant effect on adolescent smoking rates.

Social settings and situations of underage drinking.

OBJECTIVE: Social settings and situations of underage drinking were described for students from 15 communities in Minnesota and Wisconsin. Reports of their last drinking event, including setting, number of persons drinking with them, number of those persons under age 21, and whom they were with, were examined. The role of these variables in the prediction of having five or more drinks on one occasion was assessed. METHOD: Ninth graders (n = 2,269) and 12th graders (n = 2,377) who reported using alcohol in the last 30 days were included in the sample from a nested cross-sectional survey design. Bivariate analyses were performed between the situational variables and gender, number of older siblings and drinking behavior. Chi-square statistics were divided by an estimate of the design effect and multivariate analyses used mixed-model regression to correct for the nesting of individuals within communities. RESULTS: Situations and settings of drinking differed according to age and drinking behavior. Twelfth graders were less likely to drink with parents or other adults than 9th graders and more likely to drink in someone else's home, and in large groups where nearly everyone was underage. Persons reporting having five or more drinks on one occasion in the last 2 weeks were more likely to report drinking with peers, in large groups of underage persons and away from home. CONCLUSIONS: Interventions to reduce use of alcohol by youth must focus on the context in which the drinking is taking place in addition to other factors. Policy or educational interventions that seek to alter the situations and settings of underage drinking may be effective in reducing consumption of alcohol in adolescents.

Prediction of overall pulmonary function loss in relation to the 3-D dose distribution for patients with breast cancer and malignant lymphoma.

PURPOSE: To predict the changes in pulmonary function tests (PFTs) 3-4 months after radiotherapy based on the three-dimensional (3-D) dose distribution and taking into account patient- and treatment-related factors. METHODS: For 81 patients with malignant lymphoma and breast cancer, PFTs (VA, VC, FEV1 and TL,COc) were performed prior to and 3-4 months after irradiation and dose-effect relations for early changes in local perfusion, ventilation and air-filled fraction were determined using correlated CT and SPECT data. The 3-D dose distribution of each patient was converted into four different dose-volume parameters, i.e. the mean dose in the lung and three overall response parameters (ORPs, which represent the average local injury over the complete lung). ORPs were determined using the dose-effect relations for early changes in local perfusion, ventilation and air-filled fraction. Correlation coefficients were calculated between these dose-volume parameters and the changes in PFTs. In addition, the impact of the variables chemotherapy (MOPP/ABV and CMF), tamoxifen, smoking, age and gender on the relation between the mean lung dose and the relative changes in PFTs following radiotherapy was studied using multiple regression analysis. RESULTS: The mean lung dose proved to be the easiest parameter to predict the reduction in PFTs 3-4 months following radiotherapy. For all patients the relation between the mean lung dose and the changes in PFTs could be described with one regression line through the origin and a slope of 1% reduction in PFT for each increase of 1 Gy in mean lung dose. Smoking and CMF chemotherapy influenced the reduction in PFTs significantly for VA and TL,COc, respectively. Patients treated with MOPP/ABV prior to radiotherapy had lower pre-radiotherapy PFTs than other patient groups, but did not show further deterioration after radiotherapy (at 3-4 months). CONCLUSIONS: The relative reduction in VA, VC, FEV1 and TL,COc 3-4 months after radiotherapy for breast cancer and malignant lymphoma can be estimated before radiotherapy based on the mean lung dose of each individual patient and taking into account the use of chemotherapy and smoking habits of the patient.