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Appendix I Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems 373

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TABLE I-1  Ratings of Policy-Relevant Strategies and Interventions 374 Breadth of Cross- Cost to Research National Implement Strategy or Intervention Effectiveness Support Testing or Sustain Comments Pricing and Taxation Generally evaluated in terms of how price changes affect population level alcohol consumption, alcohol-related problems and beverage preferences. Alcohol taxes +++ +++ +++ Low Increased taxes reduce alcohol consumption and harm. Effectiveness depends on government oversight and control of the total alcohol supply. Minimum price ? + + Low Logic based on price theory, but there is very little evidence of effectiveness. Competition regulations and trade policies may restrict implementation. Bans on price discounts ? + + Low Only weak studies in general populations of the effect of and promotions restrictions on consumption or harm; effectiveness depends on availability of alternative forms of cheap alcohol. Differential price by + + ++ Low Higher prices for distilled spirits shifts consumption to beverage lower alcohol content beverages resulting in less overall consumption. Evidence for the impact of tax breaks on low alcohol products is suggestive, but not comprehensive. Special or additional + + ++ Low Evidence that higher prices reduce consumption of alcopops taxation on alcopops by young drinkers without complete substitution; no studies and youth-oriented of impact on harms. beverages Regulating Physical A Generally evaluated in terms of how changes in availability vailability affect population level alcohol consumption and alcohol- related problems. Ban on sales +++ +++ ++ High Can reduce consumption and harm substantially, but often with adverse side-effects from black market, which is expensive to suppress. Ineffective without enforcement.

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Bans on drinking in ? + ++ Moderate Generally focused on young or marginalized high-risk public places drinkers; may displace harm without necessarily reducing it. Minimum legal purchase +++ +++ ++ Low Effective in reducing traffic fatalities and other harms with age minimal enforcement but enforcement substantially increases effectiveness and cost. Rationing ++ ++ ++ Moderate Effects greater on heavy drinkers. Government monopoly ++ +++ ++ Low Effective way to limit alcohol consumption and harm. Public of health and public order goals increase beneficial effects. retail sales Hours and days of sale ++ ++ +++ Low Effective where changes in trading hours meaningfully reduce restrictions alcohol availability or where problems such as late night violence are specifically related to hours of sale. Restrictions on density ++ +++ ++ Low Evidence for both consumption and problems. Changes to of outlets outlet numbers affect availability most in areas with low prior availability, but bunching of outlets into high-density entertainment districts may cause problems with public order and violence. Different availability by ++ ++ + Low Mostly tested for strengths of beer. alcohol strength Modifying the Drinking Generally evaluated in terms of how staff training, Environment enforcement, and legal liability affect alcohol-related violence and other harms. Staff training and house 0/+ +++ ++ Moderate Not all studies have found a significant effect of RBS training policies relating to and house policies; needs to be backed by enforcement for responsible beverage sustained effects. service (RBS) 375 continued

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TABLE I-1  Continued Policy-Relevant Strategies and Interventions Ratings of 376 Breadth of Cross- Cost to Research National Implement Strategy or Intervention Effectiveness Support Testing or Sustain Comments Staff and management ++ + ++ Moderate Evidence currently limited to one randomized control study training to better and supportive results from multi-component programs. manage aggression Enhanced enforcement ++ ++ ++ Moderate Sustained effects depend on making enhanced enforcement of on-premises laws and part of ongoing police practices. legal requirements Server liability ++ ++ + Low Effect stronger where efforts made to publicise liability. Research limited to the United States and Canada. Community action ++ ++ ++ Moderate Need commitment to long time frame; uncertain which projects to high components are responsible for effects. Voluntary codes of bar O ++ ++ Moderate Ineffective when strictly voluntary but may contribute to practice effects as part of community action projects. Late-night lockouts of O + + Low to Limited research and no studies have identified effective licensed premises moderate approaches. Drink-Driving Most research has focused on intervention effects on traffic Countermeasures accidents and recidivism after criminal sanctions. Sobriety checkpoints ++ +++ +++ Moderate Effects of police campaigns typically short-term. Effectiveness as a deterrent is proportional to frequency of implementation and high visibility. Random breath testing +++ ++ + Moderate Effectiveness depends on number of drivers directly affected and the extent of consistent and high-profile enforcement. Lowered BAC Limits +++ +++ ++ Low The lower the BAC legal limit, the more effective the policy. Very low BAC levels (“zero tolerance”) are effective for youth, and can be effective for adult drivers but BAC limits lower than 0.02 are difficult to enforce.

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Administrative license ++ ++ ++ Moderate When punishment is swift, effectiveness is increased. Effective suspension in countries where it is applied consistently. Target population: high-risk drinkers. Low BAC for young +++ ++ + Low Clear evidence of effectiveness for those below the legal drivers (“zero drinking or alcohol purchase age. tolerance”) Graduated licensing for ++ ++ ++ Low Can be used to incorporate lower BAC limits and licensing novice drivers restrictions within one strategy. Some studies note that “zero tolerance” provisions are responsible for this effect. Designated drivers and O + + Moderate Effective in getting impaired drinkers not to drive but do not ride services affect alcohol-related accidents, perhaps because these services account for a relatively small percent of drivers. Severity of punishment 0/+ ++ ++ Moderate Mixed evidence concerning mandatory or tougher sanctions for drink-driving convictions. Effects decay over time unless accompanied by renewed enforcement or media publicity. Restrictions on Better quality studies evaluate impact in terms of youth Marketing drinking and attitudes. Impact also studied in terms of ability to limit youth exposure to marketing campaigns. Legal restrictions on Strong evidence of dose-response effect of exposure on young exposure +/++ +++ ++ Low peoples’ drinking, but mixed evidence from ecological on per capita consumption; advertising bans or restrictions may shift marketing activities into less regulated media (e.g., Internet). Legal restrictions on Evidence that advertising content affects consumption but no content ? O O Low evidence of the impact of content restrictions as embodied in industry self-regulation codes. Alcohol industry’s Industry voluntary self-regulation codes of practice are voluntary self-regulation O ++ ++ Low ineffective in limiting exposure of young persons to alcohol codes marketing, nor do they prevent objectionable content from being aired. 377 continued

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Continued TABLE I-1  Ratings of Policy-Relevant Strategies and Interventions 378 Breadth of Cross- Cost to Research National Implement Strategy or Intervention Effectiveness Support Testing or Sustain Comments Education and Impact generally evaluated in terms of knowledge and Persuasion attitudes; effect on onset of drinking and drinking problems is equivocal or minimal. Target population is young drinkers unless otherwise noted. Classroom education 0 +++ ++ Moderate May increase knowledge and change attitudes but has no long-term effect on drinking. College student 0 + + Moderate May increase knowledge and change attitudes but has no education — universal effect on drinking. Brief interventions with + + + High Brief motivational interventions can impact drinking high-risk students behaviour. Mass media campaigns, 0 +++ ++ Moderate No evidence of impact of messages to the drinker about including drink-driving limiting drinking; messages to strengthen policy support campaigns untested. Warning labels and signs 0 + + Low Raise public awareness, but do not change drinking behaviour. Social marketing 0 ++ + Moderate Raises public awareness but alcohol specific campaigns do not to high change behaviour. Treatment and Early Usually evaluated in terms of days or months of abstinence, Intervention reduced intensity and volume of drinking, and improvements in health and life functioning. Target population is harmful and dependent drinkers, unless otherwise noted. Brief intervention with +++ +++ +++ Moderate Can be effective but most primary care practitioners at-risk drinkers lack training and time to conduct screening and brief interventions.

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Mutual help/self-help ++ ++ ++ Low A feasible, cost-effective complement or alternative to formal attendance treatment in many countries. Mandatory treatment + ++ + Moderate Punitive and coercive approaches have time-limited effects, of drink-driving repeat and sometimes distract attention from more effective offenders interventions. Medical and social 0 ++ ++ High Safe and effective for treating withdrawal syndrome but detoxification have little effect on long-term alcohol consumption unless combined with other therapies. Talk therapies ++ +++ ++ Moderate A variety of theoretically-based therapies to treat persons with alcohol dependence in outpatient and residential settings. Population reach is low because most countries have limited treatment facilities. Pharmaceutical therapies + ++ ++ Moderate Consistent evidence for a modest improvement over talk therapies and clinical management only for naltrexone. The following rating scale was used to evaluate effectiveness   0 Evidence indicates a lack of effectiveness   + Evidence for limited effectiveness   ++ Evidence for moderate effectiveness   +++ Evidence of a high degree of effectiveness   ? No controlled studies have been undertaken or there is insufficient evidence upon which to make a judgment SOURCE: Reprinted from Babor, T. F., R. Caetano, S. Casswell, G. Edwards, N. Giesbrecht, K. Graham, J. Grube, L. Hill, H. Holder, R. Homel, M. Livingston, E. Osterberg, J. Rehm, R. Room, and I. Rossow. 2010. Alcohol: No ordinary commodity: Research and public policy. Oxford, UK: Oxford University Press. 379

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