The Evolution of Research into Responsible Beverage Service as a Preventive Intervention

Prevention Research CenterPRCPacific Institute for Research and Evaluation

The Evolution of Research into The Evolution of Research into Responsible Beverage Service as Responsible Beverage Service as

a Preventive Interventiona Preventive Intervention

Bob SaltzBob SaltzPrevention Research CenterPrevention Research Center

Berkeley, CaliforniaBerkeley, California

Public Health ModelPublic Health ModelPublic Health ModelPublic Health Model

Individual

Alcohol Environment

Alcohol-Related Problems

Environmental InfluenceEnvironmental InfluenceEnvironmental InfluenceEnvironmental Influence

((3) Economic - Cost of alcohol, drugs, tobacco, or economic geography of availability

(1)Physical - Proximity of alcohol, drugs, tobacco outlets, places of publicuse

(2) Social - (2) Social - Family, peers and larger Family, peers and larger social networks, mediasocial networks, media

Evolving ConceptEvolving ConceptEvolving ConceptEvolving Concept

Server as referral agent – “Patron Care”Server as referral agent – “Patron Care”

Server Intervention - to reduce harm in Server Intervention - to reduce harm in case of intoxicationcase of intoxication

Responsible Beverage Service (RBS)Responsible Beverage Service (RBS)- to reduce likelihood of intoxication and - to reduce likelihood of intoxication and harmharm

Server as referral agent – “Patron Care”Server as referral agent – “Patron Care”

Server Intervention - to reduce harm in Server Intervention - to reduce harm in case of intoxicationcase of intoxication

Responsible Beverage Service (RBS)Responsible Beverage Service (RBS)- to reduce likelihood of intoxication and - to reduce likelihood of intoxication and harmharm

RationaleRationaleRationaleRationale

Historical & legal precedentsHistorical & legal precedents Potential impact may be highPotential impact may be high Very proximal to danger of harmVery proximal to danger of harm Minimizes reliance on drinker Minimizes reliance on drinker

judgment judgment Indirect evidence of potential efficacyIndirect evidence of potential efficacy

Historical & legal precedentsHistorical & legal precedents Potential impact may be highPotential impact may be high Very proximal to danger of harmVery proximal to danger of harm Minimizes reliance on drinker Minimizes reliance on drinker

judgment judgment Indirect evidence of potential efficacyIndirect evidence of potential efficacy

Effect of Allowing Liquor by the Drink onEffect of Allowing Liquor by the Drink onSingle Vehicle Nighttime Traffic Crashes Single Vehicle Nighttime Traffic Crashes Males 21 Years and Older in North CarolinaMales 21 Years and Older in North Carolina

Effect of Allowing Liquor by the Drink onEffect of Allowing Liquor by the Drink onSingle Vehicle Nighttime Traffic Crashes Single Vehicle Nighttime Traffic Crashes Males 21 Years and Older in North CarolinaMales 21 Years and Older in North Carolina

Month and YearMonth and Year

1/821/821/811/811/801/801/791/791/781/781/771/771/761/761/751/751/741/741/731/73

Nu

mb

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f A

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170170

150150

130130

110110

9090

7070

5050

Liquor by the drink Liquor by the drink begins November 1978begins November 1978

16% increase16% increase0% control counties0% control counties

Early Efficacy StudiesEarly Efficacy Studies

Can RBS reduce intoxicationCan RBS reduce intoxicationor harm?or harm?

TIPS EvaluationTIPS EvaluationTIPS EvaluationTIPS Evaluation

Commercial training programCommercial training program Six-hour trainingSix-hour training 17 Servers from 2 businesses17 Servers from 2 businesses Pseudopatrons consume drink every Pseudopatrons consume drink every

20 minutes20 minutes Outcome = Number of Interventions Outcome = Number of Interventions

plus BAC of pseudopatronsplus BAC of pseudopatrons

Commercial training programCommercial training program Six-hour trainingSix-hour training 17 Servers from 2 businesses17 Servers from 2 businesses Pseudopatrons consume drink every Pseudopatrons consume drink every

20 minutes20 minutes Outcome = Number of Interventions Outcome = Number of Interventions

plus BAC of pseudopatronsplus BAC of pseudopatrons

FindingsFindingsFindingsFindings

Trained servers intervened more Trained servers intervened more frequently, 3.24 vs. .75 at baselinefrequently, 3.24 vs. .75 at baseline

BAC for pseudopatrons was lower BAC for pseudopatrons was lower for trained servers (.059 vs. .10)for trained servers (.059 vs. .10)

Trained servers intervened more Trained servers intervened more frequently, 3.24 vs. .75 at baselinefrequently, 3.24 vs. .75 at baseline

BAC for pseudopatrons was lower BAC for pseudopatrons was lower for trained servers (.059 vs. .10)for trained servers (.059 vs. .10)

Navy Server StudyNavy Server StudyNavy Server StudyNavy Server Study

Revision in House PoliciesRevision in House Policies Sixteen-hour manager & server Sixteen-hour manager & server

trainingtraining One intervention and one One intervention and one

comparison sitecomparison site Outcome = Imputed BAC from self-Outcome = Imputed BAC from self-

reported and observed consumption reported and observed consumption datadata

Revision in House PoliciesRevision in House Policies Sixteen-hour manager & server Sixteen-hour manager & server

trainingtraining One intervention and one One intervention and one

comparison sitecomparison site Outcome = Imputed BAC from self-Outcome = Imputed BAC from self-

reported and observed consumption reported and observed consumption datadata


Proportion of intoxicated drinkers at Proportion of intoxicated drinkers at experimental Navy bar cut in half (e.g., experimental Navy bar cut in half (e.g., males dropped from 33% to 15%)males dropped from 33% to 15%)

No change at comparison siteNo change at comparison site No change in overall sales (more No change in overall sales (more

drinks to 1 and 2 drink orders)drinks to 1 and 2 drink orders)

Proportion of intoxicated drinkers at Proportion of intoxicated drinkers at experimental Navy bar cut in half (e.g., experimental Navy bar cut in half (e.g., males dropped from 33% to 15%)males dropped from 33% to 15%)

No change at comparison siteNo change at comparison site No change in overall sales (more No change in overall sales (more

drinks to 1 and 2 drink orders)drinks to 1 and 2 drink orders)

Thunder Bay, OntarioThunder Bay, OntarioThunder Bay, OntarioThunder Bay, Ontario

Manager and Server TrainingManager and Server Training Four intervention & 4 comparison Four intervention & 4 comparison

sitessites Expanded pseudopatron protocol Expanded pseudopatron protocol

with scenarioswith scenarios Outcome = Responsible Service Outcome = Responsible Service

ScoreScore

Manager and Server TrainingManager and Server Training Four intervention & 4 comparison Four intervention & 4 comparison

sitessites Expanded pseudopatron protocol Expanded pseudopatron protocol

with scenarioswith scenarios Outcome = Responsible Service Outcome = Responsible Service

ScoreScore


Trained servers scored higher in the Trained servers scored higher in the post-test while comparision sites did post-test while comparision sites did not change significantlynot change significantly

Trained servers scored higher in the Trained servers scored higher in the post-test while comparision sites did post-test while comparision sites did not change significantlynot change significantly

From Efficacy to EffectivenessFrom Efficacy to Effectiveness

What might effect adoption of What might effect adoption of RBS practices?RBS practices?

McKnight NHTSA StudyMcKnight NHTSA StudyMcKnight NHTSA StudyMcKnight NHTSA Study

100 Establishments in 8 cities100 Establishments in 8 cities Three-hour trainingThree-hour training 135 Comparison sites135 Comparison sites Pseudopatron protocolPseudopatron protocol Outcome = Server interventionOutcome = Server intervention

100 Establishments in 8 cities100 Establishments in 8 cities Three-hour trainingThree-hour training 135 Comparison sites135 Comparison sites Pseudopatron protocolPseudopatron protocol Outcome = Server interventionOutcome = Server intervention


Trained servers more likely to Trained servers more likely to intervene in some way, 27% vs. 14% intervene in some way, 27% vs. 14% at baselineat baseline

Outright refusal unchanged at 5%Outright refusal unchanged at 5%

Trained servers more likely to Trained servers more likely to intervene in some way, 27% vs. 14% intervene in some way, 27% vs. 14% at baselineat baseline

Outright refusal unchanged at 5%Outright refusal unchanged at 5%

Central California RBSCentral California RBSCentral California RBSCentral California RBS

Two Communities (Santa Cruz & Two Communities (Santa Cruz & Monterey, CA)Monterey, CA)

Three commercial businesses in Three commercial businesses in each communityeach community

Compared 2 trainings with 1 Compared 2 trainings with 1 comparisoncomparison

Outcome = Observed consumptionOutcome = Observed consumption

Two Communities (Santa Cruz & Two Communities (Santa Cruz & Monterey, CA)Monterey, CA)

Three commercial businesses in Three commercial businesses in each communityeach community

Compared 2 trainings with 1 Compared 2 trainings with 1 comparisoncomparison

Outcome = Observed consumptionOutcome = Observed consumption


RBS programs reduced likelihood of RBS programs reduced likelihood of impairment and intoxication in one of impairment and intoxication in one of two communities two communities

No difference between RBS No difference between RBS programsprograms

RBS programs reduced likelihood of RBS programs reduced likelihood of impairment and intoxication in one of impairment and intoxication in one of two communities two communities

No difference between RBS No difference between RBS programsprograms

Probability of Impairment and IntoxicationProbability of Impairment and IntoxicationFollowing Alcohol Beverage Server TrainingFollowing Alcohol Beverage Server Training

Santa Cruz, CASanta Cruz, CA

Probability of Impairment and IntoxicationProbability of Impairment and IntoxicationFollowing Alcohol Beverage Server TrainingFollowing Alcohol Beverage Server Training

Santa Cruz, CASanta Cruz, CA

0000

10101010

20202020

30303030

40404040

50505050

PretestPretestPretestPretest PosttestPosttestPosttestPosttest

T = T = Server Training SiteServer Training Site, C = , C = Comparison SiteComparison Site

T = T = Server Training SiteServer Training Site, C = , C = Comparison SiteComparison Site

Pre

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Pro

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ImpairmentImpairmentImpairmentImpairment

IntoxicationIntoxicationIntoxicationIntoxication

Oregon Server Training LawOregon Server Training LawOregon Server Training LawOregon Server Training Law

Training mandated for all servers of Training mandated for all servers of alcoholic beveragesalcoholic beverages

Outcome = Single-vehicle night-time Outcome = Single-vehicle night-time crashescrashes

ARIMA model to control for other ARIMA model to control for other influencesinfluences

Training mandated for all servers of Training mandated for all servers of alcoholic beveragesalcoholic beverages

Outcome = Single-vehicle night-time Outcome = Single-vehicle night-time crashescrashes

ARIMA model to control for other ARIMA model to control for other influencesinfluences


23% reduction in crashes net of other 23% reduction in crashes net of other influencesinfluences

23% reduction in crashes net of other 23% reduction in crashes net of other influencesinfluences

Texas Liability LawTexas Liability LawTexas Liability LawTexas Liability Law

Established through case lawEstablished through case law

Court ruling heavily publicizedCourt ruling heavily publicized

Time series analysis over 10 yr Time series analysis over 10 yr periodperiod

Outcome = SVN crashesOutcome = SVN crashes

Established through case lawEstablished through case law

Court ruling heavily publicizedCourt ruling heavily publicized

Time series analysis over 10 yr Time series analysis over 10 yr periodperiod

Outcome = SVN crashesOutcome = SVN crashes


First case produced a reduction in First case produced a reduction in SVN crashes of 6.5% net of other SVN crashes of 6.5% net of other influences influences

Second case reduced crashes an Second case reduced crashes an additional 5.3% net of other additional 5.3% net of other influencesinfluences

First case produced a reduction in First case produced a reduction in SVN crashes of 6.5% net of other SVN crashes of 6.5% net of other influences influences

Second case reduced crashes an Second case reduced crashes an additional 5.3% net of other additional 5.3% net of other influencesinfluences

Freo Respects YouFreo Respects YouFreo Respects YouFreo Respects You

50 Establishments in Freemantle, WA50 Establishments in Freemantle, WA Comparison communityComparison community Training supported by media Training supported by media

campaigncampaign Included risk assessmentIncluded risk assessment Outcomes included service to Outcomes included service to

pseudopatrons and BAC of patronspseudopatrons and BAC of patrons

50 Establishments in Freemantle, WA50 Establishments in Freemantle, WA Comparison communityComparison community Training supported by media Training supported by media

campaigncampaign Included risk assessmentIncluded risk assessment Outcomes included service to Outcomes included service to

pseudopatrons and BAC of patronspseudopatrons and BAC of patrons


Low participation and challenges to Low participation and challenges to program fidelityprogram fidelity

Outright refusal low (10%) with no Outright refusal low (10%) with no difference across communitiesdifference across communities

Lower patron BACs in intervention Lower patron BACs in intervention communitycommunity

Low participation and challenges to Low participation and challenges to program fidelityprogram fidelity

Outright refusal low (10%) with no Outright refusal low (10%) with no difference across communitiesdifference across communities

Lower patron BACs in intervention Lower patron BACs in intervention communitycommunity

Community TrialsCommunity TrialsCommunity TrialsCommunity Trials

RBS part of comprehensive community-RBS part of comprehensive community-level prevention intervention to reduce level prevention intervention to reduce injuries and deaths related to alcoholinjuries and deaths related to alcohol

Combined voluntary training and Combined voluntary training and limited but publicized enforcement limited but publicized enforcement campaigncampaign

Outcome = Refusal to drinking Outcome = Refusal to drinking pseudopatron (drink every 20 minutes)pseudopatron (drink every 20 minutes)

RBS part of comprehensive community-RBS part of comprehensive community-level prevention intervention to reduce level prevention intervention to reduce injuries and deaths related to alcoholinjuries and deaths related to alcohol

Combined voluntary training and Combined voluntary training and limited but publicized enforcement limited but publicized enforcement campaigncampaign

Outcome = Refusal to drinking Outcome = Refusal to drinking pseudopatron (drink every 20 minutes)pseudopatron (drink every 20 minutes)

Alcohol-involved Trauma at the Community Level: Alcohol-involved Trauma at the Community Level: Conceptual ModelConceptual Model

MOBILIZATIONMOBILIZATIONMOBILIZATIONMOBILIZATION DRINKING AND DRIVINGDRINKING AND DRIVINGDRINKING AND DRIVINGDRINKING AND DRIVING

UNDERAGE DRINKINGUNDERAGE DRINKINGUNDERAGE DRINKINGUNDERAGE DRINKING

ALCOHOL ACCESSALCOHOL ACCESSALCOHOL ACCESSALCOHOL ACCESS

RESPONSIBLE BEVERAGE RESPONSIBLE BEVERAGE SERVICESERVICE

RESPONSIBLE BEVERAGE RESPONSIBLE BEVERAGE SERVICESERVICE

Non-Traffic Risk ActivitiesNon-Traffic Risk Activities

Local News about AlcoholLocal News about AlcoholProblems & EnforcementProblems & Enforcement

Retail Alcohol Retail Alcohol AvailabilityAvailability

(On and Off-premise)(On and Off-premise)Alcohol IntoxicationAlcohol Intoxication or Impairmentor Impairment

Alcohol-involvedAlcohol-involvedInjury and DeathInjury and Death

(Traffic and Other)(Traffic and Other)

Driving afterDriving afterDrinkingDrinking

Perceived Perceived Risk of ArrestRisk of Arrest

Local LawLocal LawEnforcementEnforcement

Social Access Social Access to Alcoholto Alcohol

Alcohol Alcohol Serving and Serving and

Sales PracticesSales Practices

Local Regulation Local Regulation of Alcoholof Alcohol

(Density, Hours (Density, Hours of Sale)of Sale)


Refusal rates of servers to drinking Refusal rates of servers to drinking pseudopatrons were lowpseudopatrons were low

Observed differences not significantObserved differences not significant

Refusal rates of servers to drinking Refusal rates of servers to drinking pseudopatrons were lowpseudopatrons were low

Observed differences not significantObserved differences not significant

Enforcement of Serving LawsEnforcement of Serving LawsEnforcement of Serving LawsEnforcement of Serving Laws

Washtenaw County, MIWashtenaw County, MI Warning notices to employees observed Warning notices to employees observed

(by plainclothes officers) serving to (by plainclothes officers) serving to obviously intoxicated customersobviously intoxicated customers

Comparison siteComparison site Outcomes = refusal to serve Outcomes = refusal to serve

pseudopatron, and proportion of arrested pseudopatron, and proportion of arrested DUI cases that drove from a licensed DUI cases that drove from a licensed premisepremise

Washtenaw County, MIWashtenaw County, MI Warning notices to employees observed Warning notices to employees observed

(by plainclothes officers) serving to (by plainclothes officers) serving to obviously intoxicated customersobviously intoxicated customers

Comparison siteComparison site Outcomes = refusal to serve Outcomes = refusal to serve

pseudopatron, and proportion of arrested pseudopatron, and proportion of arrested DUI cases that drove from a licensed DUI cases that drove from a licensed premisepremise


Outright refusals increased from 16% Outright refusals increased from 16% to 53%to 53%

Proportion of DUI from businesses Proportion of DUI from businesses dropped from 32% to 23%dropped from 32% to 23%

Outright refusals increased from 16% Outright refusals increased from 16% to 53%to 53%

Proportion of DUI from businesses Proportion of DUI from businesses dropped from 32% to 23%dropped from 32% to 23%

Surfer’s ParadiseSurfer’s ParadiseSurfer’s ParadiseSurfer’s Paradise

Case study – pre/post comparisonCase study – pre/post comparison Australia’s Gold CoastAustralia’s Gold Coast Targeted alcohol-related violence and Targeted alcohol-related violence and

general disordergeneral disorder Community mobilizationCommunity mobilization

Risk assessmentsRisk assessmentsEnforcement of license lawsEnforcement of license lawsStaff trainingStaff trainingEliminated price promotionsEliminated price promotions

Outcome = observed assaults & Outcome = observed assaults & intoxicationintoxication

Case study – pre/post comparisonCase study – pre/post comparison Australia’s Gold CoastAustralia’s Gold Coast Targeted alcohol-related violence and Targeted alcohol-related violence and

general disordergeneral disorder Community mobilizationCommunity mobilization

Risk assessmentsRisk assessmentsEnforcement of license lawsEnforcement of license lawsStaff trainingStaff trainingEliminated price promotionsEliminated price promotions

Outcome = observed assaults & Outcome = observed assaults & intoxicationintoxication


Note: weak design…Note: weak design…

Assaults dropped from 9.8 per 100 Assaults dropped from 9.8 per 100 hrs. of observation to 4.7hrs. of observation to 4.7

Lower frequency of observed Lower frequency of observed intoxicationintoxication

Note: weak design…Note: weak design…

Assaults dropped from 9.8 per 100 Assaults dropped from 9.8 per 100 hrs. of observation to 4.7hrs. of observation to 4.7

Lower frequency of observed Lower frequency of observed intoxicationintoxication

Primary ConclusionsPrimary ConclusionsPrimary ConclusionsPrimary Conclusions

RBS RBS cancan significantly reduce alcohol significantly reduce alcohol impairment and intoxicationimpairment and intoxication

Training alone seems unpromising, Training alone seems unpromising, but Oregon results argue otherwisebut Oregon results argue otherwise

RBS RBS cancan significantly reduce alcohol significantly reduce alcohol impairment and intoxicationimpairment and intoxication

Training alone seems unpromising, Training alone seems unpromising, but Oregon results argue otherwisebut Oregon results argue otherwise

Responsible Service

Practices

Reduced Intoxication

Reduced Harm

Fairly ConfidentFairly ConfidentFairly ConfidentFairly Confident

What We What We Don’tDon’t Know… Know…What We What We Don’tDon’t Know… Know…

What What kindskinds of harm RBS can reduce of harm RBS can reduce

What combination of incentives will What combination of incentives will reliably change serving practicesreliably change serving practices

What combination of incentives will What combination of incentives will reduce harm most cost-effectively reduce harm most cost-effectively

What What kindskinds of harm RBS can reduce of harm RBS can reduce

What combination of incentives will What combination of incentives will reliably change serving practicesreliably change serving practices

What combination of incentives will What combination of incentives will reduce harm most cost-effectively reduce harm most cost-effectively

Responsible Service

Reduced Intoxication

Reduced Harms?

?

What We Don’t KnowWhat We Don’t KnowWhat We Don’t KnowWhat We Don’t Know

• Training (skills)

• Community Pressure

• Enforcement

• Insurance

• Liability Law

• Violence• DUI• Injuries

FINFIN

Documents

The Evolution of Research into Responsible Beverage Service as a Preventive Intervention