Modifying Consumption of Alcohol Using Harm Reduction: the Role of Responsible Service of Alcohol

ABSTRACT - This paper reviews a variety of strategies designed to reduce the incidence of harms related to excess alcohol consumption by reducing the number of intoxicated people in situations where they may inflict harm on themselves or others in the community. Some non-clinical problems associated with excessive alcohol consumption are discussed in brief, highlighting the need for preventative strategies. Then, the psychology of harm reduction is explained and its application to the context of alcohol abuse. Finally, the concept of Aresponsible service of alcohol@ is analysed, describing work in progress to evaluate the effectiveness of this particular harm reduction strategy in Australia.

Citation:

Nevil Alexander and Nadine Henley (2001) ,"Modifying Consumption of Alcohol Using Harm Reduction: the Role of Responsible Service of Alcohol", in AP - Asia Pacific Advances in Consumer Research Volume 4, eds. Paula M. Tidwell and Thomas E. Muller, Provo, UT : Association for Consumer Research, Pages: 343-348.

Asia Pacific Advances in Consumer Research Volume 4, 2001      Pages 343-348

MODIFYING CONSUMPTION OF ALCOHOL USING HARM REDUCTION: THE ROLE OF RESPONSIBLE SERVICE OF ALCOHOL

Nevil Alexander, Edith Cowan University, Western Australia

Nadine Henley, Edith Cowan University, Western Australia

ABSTRACT -

This paper reviews a variety of strategies designed to reduce the incidence of harms related to excess alcohol consumption by reducing the number of intoxicated people in situations where they may inflict harm on themselves or others in the community. Some non-clinical problems associated with excessive alcohol consumption are discussed in brief, highlighting the need for preventative strategies. Then, the psychology of harm reduction is explained and its application to the context of alcohol abuse. Finally, the concept of "responsible service of alcohol" is analysed, describing work in progress to evaluate the effectiveness of this particular harm reduction strategy in Australia.

INTRODUCTION

News of a big success at work has arrived in the middle of Friday afternoon. Several work colleagues convince you to go for a few drinks at the close of business to celebrate the event. You meet them at a busy bar near work and each has a couple of drinks but someone suggests it’s too noisy to talk business and recommends another pub just around the corner. You all head off to the next 'watering hole’ and have another three or four drinks. A few members of your group leave but the rest, you included, are now looking for somewhere a bit more lively to kick up your heels. The next establishment is really humming. It’s crowded, noisy, a band is playing in one corner, and it’s difficult to get around the room without bumping into people. To have your order heard at the bar you have to raise your voice. Counting out the correct change while being jostled is a real juggling act. Little wonder that the server behind the bar didn’t notice that you were already a little tipsy. Each member of your group buys a 'shout’. While driving home you are involved in a traffic accident. The driver of the other car involved is seriously injured so the police attend the scene. A breath analysis is conducted and you are subsequently charged with drink driving and lose your licence.

Policy makers must ask the question: Who is responsible? Or, more constructively, who could have prevented this? You’re a mature adult and must be held responsible for your own actions. But are you solely responsible? You were under the influence of alcohol at the time you kept drinking. A person doesn’t get suddenly drunk. Your judgment was impaired by the first few drinks otherwise you wouldn’t have had the last few and the accident may not have happened. What about your friends? They bought the last few rounds and encouraged you to celebrate in style. Are they partly responsible? Could they have prevented the harm occurring? (Successful drink driving campaigns have been run on the basis of this, for example, "Mates don’t let their mates drink and drive".) They could have advocated caution but it’s risky to rely on them to do so when, like you, in this instance, their judgment was impaired.

What about the owner and licensee of the pub where you had the last drink before getting in your car to drive home? By law, he is responsible even though he wasn’t in the pub at the time. The serving staff at the last place you had a drink are also responsible by law, even though it may seem unreasonable to expect them to monitor how much each person in a crowded bar has consumed on the premises, and to evaluate how much a person may have consumed earlier at other premises.

This paper reviews a variety of strategies intended to limit the harm associated with excess alcohol consumption by reducing the number of intoxicated people in situations where they may inflict harm on themselves or others in the community. First, the problem of alcohol abuse is briefly discussed, highlighting the need for preventative strategies. Then, the psychology of harm reduction is explained and its application to the context of alcohol abuse. Finally, the concept of "responsible service of alcohol" as a use reduction intervention is analysed, describing work in progress to evaluate the effectiveness of this particular harm reduction strategy in Australia.

The objective of this paper is to explicate the link between an integrative framework for use reduction and harm reduction developed by MacCoun (1998), with elements of a model for responsible service of alcohol proposed by McKnight (1993). The paper then discusses the implementation and efficacy of some strategies aimed at delivering responsible alcohol service in licensed premises which, if successful have the potential to dramatically reduce the harms associated with alcohol consumption.

SIGNIFICANCE OF THE PROBLEM

Australia ranks fifteenth in the world on the basis of alcohol consumption per capita (White and Humeniuk 1993). This consumption rate converts to an average volume of 8.5 litres per annum of pure alcohol per person in Australia. While consumption levels of all alcoholic beverages except low-alcohol beers have been decreasing since the mid 1970s, health professionals still consider the rate to be unacceptably high. Excessive alcohol consumption is implicated in many of the ills confronting contemporary Australian society, including, but not limited to, traffic accidents.

The effect of alcohol as a contributing factor in road crashes and the attendant trauma have been the subject of high profile media coverage. The correlation between alcohol and road trauma in the mind of the general public has been achieved through almost continuous public education campaigns combined with rigorous enforcement of the law relating to driving under the influence of alcohol (DUI), in particular using Random Breath Testing.

Other negative impacts of excessive alcohol consumption have not been afforded the same level of public exposure and go largely unreported. Links between alcohol and violent crime have been well documented in the literature (Kevin 1992) but are reported infrequently in the popular press. For example, while it is not uncommon to find statistics linking road crashes and alcohol reported in newspapers, statistics linking assaults and alcohol are nowhere near as prevalent. Similarly the association between alcohol and crimes involving domestic violence, the destruction of property, or other forms of abusive behaviour is not as readily made. The costs associated with these crimes are borne not only by those individuals immediately affected as a consequence of them, but also by the community at large. Hospitalisation and other medical interventions, and lost productivity are examples of impacts that can be accurately measured and ascribed monetary value. Other impacts that can not be treated in purely financial terms include mental anguish, family breakdown, misappropriation of household income, and suicide.

Murdoch et al, (1990), cited by (White and Humeniuk 1993) contend that more than 50% of offenders involved in homicide, assault, domestic violence and rape, were under the influence of alcohol at the time the offence was committed. Alcohol is implicated in approximately one third of all motorist deaths in Australia and 45% of fatalities amongst adult and youth pedestrians (Alcohol and other drugs program 1998). Indeed it is estimated that there are 3700 alcohol related deaths each year in Australia and that the cost of alcohol related problems to the community totals $4.5 billion (Watts 1999). Young Western Australians are represented at disproportionately high levels in fatality, hospitalisation, and victim of abuse statistics. A paper prepared by the Health Department of Western Australia (Unwin 1997) reported that 14% of deaths, 21% of admissions and 11% of bed-days caused by alcohol were suffered by people between the ages of 20 and 29.

POSSIBLE SOLUTIONS TO THE PROBLEM

Eliminate Demand/Supply

One radical solution to the problem of alcohol abuse was tried in the United States last century: eliminate demand through Temperance campaigns and eliminate supply through law enforcement. Even if this option were considered politically palatable, which is highly unlikely, the historical evidence of the Prohibition era indicates that it would be an abject failure. We are unable currently to prevent the supply and use of illicit drugs without attempting to add a widely accepted drug to the list. Also, it is not only possible to consume a safe volume of alcohol but there is now a sizeable body o research to suggest that consumption of a moderate volume of alcohol may be beneficial from a health perspective.

Harm reduction

Harmful consequences of alcohol abuse are attributable to the volume of consumption rather than consumption per se. MacCoun (1998), writing on strategies for dealing with illicit drug use, stated the harm reduction equation as: "Total Harm=Average Harm per Use X Total Use" (p. 1202), where Total Use is related to the number of users and the amount each user consumes, and Average Harm per Use is a function of harms involving both users and non users. MacCoun’s (1998) model related specifically to the use of illicit drugs, but with minor modification can be applied to the abuse of alcohol.

Figure 1 shows how MacCoun’s (1998)model can be adapted to fit the circumstances unique to the reduction of harms associated with alcohol (MacCoun 1998). The adaptation of the model involves a change to the subheadings under Level of use. The original model of drug use listed 'prevalence (number of users)’ as a measure of use. This measure is not appropriate to the context of alcohol because alcohol can be consumed in quantities which do not result in harms. In figure 1 MacCoun’s 'Prevalence’ has been replaced with Individual consumption per episode. Harms associated with alcohol may result from excessive consumption during single drinking episodes as well as from excessive consumption over a protracted period. Links a and b depict the intended effects of harm-reduction and use-reduction policies. Harm reduction interventions include such things as modification to the physical environment in which consumption occurs, for example, fitting devices to vehicles and machinery that prevent operation if a breath sample indicates a prescribed alcohol level. Use reduction interventions on the other hand concentrate on the individual and seek to restrict the volume consumed during each drinking episode to levels that are less likely to result in harm to either the drinker or others. The premise is that if consumption cannot be eliminated we may be able to mitigate the harmful effects of consumption by reducing the volume consumed. Restricting consumption on licensed premises has, in recent times, come to be referred to as "responsible service of alcohol".

Our adaptation of MacCoun’s (1993) model stipulates three levels of concern associated with use reduction interventions. These three levels require further explanation. Total quantity consumed refers to the total volume of alcohol consumed by a population during a given period. While studies linking a light to moderate alcohol intake to good health have been reported in the popular press, there is little disagreement with the contention that frequent heavy drinking is likely to result in health conditions requiring clinical intervention. The volume consumed by individuals rather than the average per capita determines the Shape of the consumption distribution. Those individuals who consume the largest quantities are at greatest risk of contracting associated health problems while individuals who drink far less than the average are at little to no risk. Individual consumption per episode is the primary focus of responsible service endeavours. Not only heavy drinkers, but also individuals who over the long term may be considered light to moderate consumers but who occasionally become intoxicated and involved in alcohol-related harms. While this adaptation of MacCoun’s model presents a framework for both harm and use reduction interventions it does not offer strategies for attaining those reductions. McKnight (1993) has identified a series of strategies including community awareness and the responsible service of alcohol. While the implementation of these strategies either individually or collectively is not specifically intended to affect the total quantity of alcohol consumed by a community, or the shape of the consumption distribution curve, together the range of strategies is intended to modify individual consumption per episode when appropriate.

RESPONSIBLE SERVICE OF ALCOHOL

One of the main goals of responsible service is to minimise the likelihood of individuals becoming intoxicated and so reduce the risk of intoxicated individuals causing harm to themselves or third parties (Saltz 1985). Responsible service is composed of the following elements, as illustrated in Figure 2 (McKnight 1993):

* Community awareness;

* Community leadership;

* Enforcement;

* Management;

* Training

These elements will be discussed separately.

Community Awareness

Community awareness is the public recognition of the nature and extent of harms associated with excessive alcohol consumption. The need to develop this awareness has been recognised in Western Australia. A three year campaign aimed at reducing the negative effects of alcohol has been initiated under the auspices of 'The Western Australian Host Responsibility Project’. The project is a collaborative undertaking by the Police Service of Western Australia, the Office of Racing, Gaming and Liquor, the Health Department of Western Australia, the Liquor Industry Council, the Western Australia Drug Abuse Strategy Office, the Office of Road Safety, and Healthway (Alcohol and other drugs program 1998). The first phase of the campaign is intended to increase awareness of the rights and responsibilities of both alcohol servers and customers. The campaign first came to public notice with the screening of television advertisements in April 1998. These advertisements were reinforced by coverage in other media at the same time. The advertising campaign was followed in May by point-of-sale materials assembled to reinforce the message of the advertisements. The campaign featured two advertisements: one was directed at staff and patrons of licensed outlets, and the other at social hosts. The message of the advertisement for licensed outlets sought to inform viewers that it is illegal to serve alcohol to intoxicated patrons. The patrons primarily targeted were those aged between 18 and 34. Approximately 70% of Western Australians in this age bracket drink weekly. As reported earlier, people aged between 20 and 29 account for 14% of deaths, 21% of admissions and 11% of bed-days in hospitals caused by alcohol. These figures far exceed this age group’s representation as a proportion of the population.

FIGURE 1

USE REDUCTION AND HARM REDUCTION: AN INTEGRATIVE FRAMEWORK [ADAPTED FROM MACCOUN (1998)]

FIGURE 2

ELEMENTS OF RESPONSIBLE ALCOHOL SERVICE. (MCKNIGHT 1993)

Evaluation of awareness of the advertisements has been conducted (Alcohol and other drugs program 1998) with the following results. When asked 'What if any, TV advertising about alcohol do you remember seeing in the past three months?’ 14% of 18-34 year olds recalled the ad without prompting. Response to the same question relating to radio resulted in a 5% spontaneous recall. Recall rates rose considerably when prompted: 81% recalled the TV ad, and 22% recalled the radio ad. More male bar patrons reported recognising the ad than female patrons. Correct message take-out from the advertisement was reported at 61% for the total sample and at 62% for bar patrons. Of respondents in the sample with correct message take-out 75% of bar patrons considered the ad had personal relevance compared to 54% of the entire sample. When asked about the convincingness of the message, 89% of bar patrons thought the message convincing compared to 90% from the entire sample. Importantly, 18% of respondents reported learning something about the rights and responsibilities of bar staff, 44% reported being 'much more accepting’ of bar staff if refused service when drunk, and 17% said the ad had made them aware that it is illegal to serve drunk customers. It could be reasonably claimed that community awareness of legalities has been heightened by the campaign.

Community Leadership

If implementation of responsible service is to work, the community must demonstrate a desire for it to succeed. This requires leadership by advocacy groups, the liquor industry and governments. Local accords have assumed this role. Local accords are cooperative agreements, usually between local government, the police, licensees from the area, and an advocacy group such as the state health department. While such agreements have been trialed in other countries (Canada, Britain, New Zealand) the only rigorous investigations measuring their effectiveness have been conducted in Australia. Unfortunately these evaluations fail to demonstrate that accords are having the desired outcomes (Hawks et al 1998; Homel et al 1997; Stockwell et al 1993). The success of accords is dependent on the commitment of all parties to their maintenance. One criticism levelled by police is that licensees are simply signed-up members, paying lip service to the ideals and objectives of the accord. One of the problems identified by the evaluation of the Fremantle accord was the perception by licensees that they were being disadvantaged by their adherence to the accord relative to their competitors who were not signatories (Hawks et al 1998).

Enforcement

McKnight (1993, p.81) holds the view that "Rigorous enforcement of alcohol laws shows that a community is serious about seeing its laws observed." Responsibility for enforcing the liquor act and other laws regulating the sale and consumption of alcohol rests with the police and liquor licensing authorities. The role of law enforcement can be effectively complemented by the use of highly publicised media campaigns, often using controversial shock tactics, such as the Victorian TAC campaigns. However, media campaigns may inadvertently serve to distract public attention from the fundamental role of law enforcement, especially as many campaigns are not based on legal requirements (eg., "Respect Yourself" and "Fatigue Kills"). There is a public perception that the police only enter licensed premises when they are called on to attend disturbances. The liquor licensing authorities also have a role to play in ensuring laws are adhered to. It is their responsibility to enforce laws and, in some cases, impose a penalty on those who break the law. In Western Australia, the number of prosecutions and disciplinary hearings undertaken against those considered to have supplied alcohol to intoxicated persons on licensed premises is negligible compared to the number of drivers arrested for drunk driving who have cited a licensed establishment as the place of their last drink. One strategy, involving more community awareness, would be to raise public awareness of such prosecutions as a means of highlighting the law and the intention of authorities to safeguard the community by enforcing it. The Liquor Licensing Board of Ontario, Canada, for example, publishes the names of all establishments cited for breaches of that province’s liquor laws (www.llbo.gov.on.ca). As part of the restructuring of the Western Australian Police Service, what was previously known as the liquor licensing squad has been disbanded. The role that this squad once played has now been devolved to local area police as part of the 'Delta program’.

Management

The evaluation of the 'Freo’ Respects You’ project identified the lack of commitment by management as a major impediment to the provision of responsible service. In May 1998 the Liquor Licensing Division of the Western Australian Department of Racing, Gaming and Liquor made it mandatory for licensees and approved managers of licensed premises to undertake training in the responsible service of alcohol to be granted approval as a licensee or manager. The objective of this mandatory training was to have licensees and managers promote responsible service and consumption of alcoholin their establishments by setting and maintaining standards of service and conduct. Another objective was that licensees and managers would pass the training they underwent on to their staff. As yet no evaluation of the efficacy of the training has occurred. Currently there are two providers of this training in WA. They are the Western Australian Hotels Association, and Aragon and Associates. We are attempting to conduct an evaluation of the training, in part by measuring what impact the training of licensees and managers is having on the frequency of service being continued to intoxicated patrons. One intended method is to establish whether there is a measurable difference in the probability of intoxicated patrons continuing to be served in establishments at which personnel have undergone the mandatory training. Originally, the study was to involve a comparative assessment using two variables. The first was to assess change to the frequency of intoxicated patrons being served on a longitudinal basis using an evaluation pre-training, immediately post-training, and three months post-training. The second variable involved comparing establishments at which personnel underwent the training, with matched control sites at which the training was not undertaken. This phase of the data collection was to be conducted by 'pseudo drunk patrons’. Researchers trained to act drunk were to attempt to enter both intervention and control site and, while feigning a moderate degree of drunkenness, try to purchase an alcoholic drink. If successful, they would increase the level of apparent drunkenness while trying to purchase a second drink. If they were again successful, they were to repeat the exercise, this time feigning quite an advanced level of intoxication. Considering the safety of the researchers who would have to drive home, they were instructed not to consume the third drink but to leave the premises and complete their evaluations. This method of data collection has been used for a number of studies (Gliksman et al 1993; Hawks et al 1998; McKnight 1991; Rydon et al 1996; Stockwell et al 1993) and has proven to be reliable. Queries raised relating to the ethics of this method of data collection were answered by demonstrating that the pseudo drunks would not be presenting bar staff with a situation uncommon to their everyday work environment.

Approximately one year prior to the intended commencement of the study both training providers agreed to cooperate with the researchers by supplying the names of the establishments represented by attendees at up-coming training sessions. These establishments would then be matched with control establishments based on a range of criteria. In the interim, there was a change in upper management personnel within one of the trainer organisations. The new management withdrew support for the study citing 'Professionalism and commercial confidentiality’ as reasons. We viewed this as unfortunate but reasoned that the research could proceed with no dilution of reliability, using the information supplied by the remaining training provider. However the support of this provider too was subsequently withdrawn after discussions with their competitor. Perhaps there was a perception that the results of the research would be unfavourable to vested interests in the industry. This attitude does nothing to improve standards in the industry and simultaneously obscures the good work of the many licensed premises operators who are abiding by the law and serving alcohol in a responsible manner. In addition, even a negative evaluation of the training would provide useful information, which could be used to improve the effectiveness of the strategy of responsible service of alcohol. While the evaluation research will proceed by alternative methods, the problem encountered serves to highlight the necessity for all aspects of the industry, the licensees, managers, and industry bodies, to make a real commitment to both designing and evaluating such training programs if the current law is to have the intended effect.

Training

Server training has bee made a condition of employment in positions which involve the service of alcohol in a number of jurisdictions of the United States of America but not in Australia. Nevertheless, numerous people have attended such training courses either as a component of their studies at TAFE or an equivalent private trainer. Others have received in-house training either from their employers or consultant trainers brought in by their employers. Still other servers have received the training as a component of accord agreements. Where training has been provided in the execution of research that evaluates the efficacy of accords there has, in some instances, been a notable improvement to responsible service immediately post training. However this improvement has been short lived.(Hauritz et al 1998; Krass and Flaherty 1994). The demonstrable commitment of management to the implementation and maintenance of responsible serving practices is essential if responsible server training is to be converted into responsible server practices in the work place.

Clearly the adoption of one single element is unlikely to result in reducing the level of alcohol use and more specifically individual consumption per drinking episode. However it is plausible that a community’s implementation of the full raft of strategies proposed by McKnight will significantly progress the ideal of alcohol use and harm reduction espoused in MacCoun’s framework.

DISCUSSION

Our adaptation of MacCoun’s (1998) model (Figure 1) stipulates three levels of concern associated with use reduction interventions: Total quantity consumed, Shape of the consumption distribution and Individual consumption per episode. The objective of responsible service in licensed venues primarily deals with this last intention. It could be justifiably argued in most circumstances that it is not the obligation of licensees to restrict the total supply of alcohol to the community. However, they do have a responsibility, both under the law and morally, to restrict supply to individuals considered to be at risk of harming either themselves or others.

A major impediment to responsible service of alcohol seems to be the belief of operators of licensed premises that responsible service will result in a negative effect on profitability. However, it is feasible for licensees to prevent intoxication on their premises and at the same time increase the volume of their sales and revenue. One way is to increase the number of patrons drinking at moderate levels. Another way is to increase the frequency of visits by patrons who consume at moderate levels. Both of these are more likely to happen if there are no drunken patrons present. While we are not aware of research into the impact responsible service has on bottom line profitability, there is anecdotal evidence to suggest that providing a safe, friendly, hassle free venue devoid of drunks is a profitable exercise because it encourages more non-hardened drinkers to frequent the establishment. Promoting low alcohol drinks not only prevents customers from becoming intoxicated, it also means they can spend more per drinking session!

The success of responsible service programs is reliant upon the contribution and commitment of numerous parties to each of the elements identified. Both the supply side and the demand side of the consumption equation must be addressed in concert. Providing incentives for licensees, training for servers, and penalties to recalcitrants will not render the desired effects if bar staff are met with a barrage of abuse from intoxicated customer because they are refused service. While it is important to make those engaged in the liquor industry aware of their rights and responsibilities it is also important to address the need to educate the consuming public of their need to comply with those rights and responsibilities. 'The efficacy of harm reduction depends on behavioural responses to policy interventions.’ (MacCoun, 1998, p. 1202.).

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