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4 Engaging the Business Sector A NEW DIRECTION IN ALCOHOL POLICY: COMPREHENSIVE SERVER INTERVENTION JAMES F. MOSHER, Medical Research Institute of San Francisco Perhaps the most significant contribution made by the report Alcohol and Public Policy: Beyond the Shadow of Prohibition (Moore and Ger- stein, 1981) is its delineation of new, alternative strategies for preventing alcohol-related problems. These strategies fall under three general cate- gories: (1) regulation of the supply of alcohol; (2) legal, educational, training, and mass media interventions aimed at changing harmful con- sumer drinking practices; and (3) environmental interventions. These approaches complement traditional individualized treatment and pre- vention programs by addressing alcohol-related problems at a com- munity and societal level. The panel noted, but perhaps without sufficient emphasis, that the design and implementation of prevention policies require a comprehen- sive approach that coordinates the three types of interventions. As stated in the report's conclusion (p. 116): We are convinced that the regulation of supply, legal and pedagogical approaches to drinking practices, and interventions in the environment mediating between drinking and certain of its consequences, represent valid approaches with prom- ise for sustained improvement. Each detailed element will fail or succeed only as it is implemented properly and thoroughly; tactics that are undertaken as 57
58 PREVENTION OF ALCOHOL PROBLEMS part of a broad and coordinated approach are more likely to be effective than ones undertaken in isolation. This is a critical point for the discussion of prevention-oriented regu- lations of the supply of alcoholic beverages. As the panel documents, current research offers only modest support for the proposition that supply regulations other than taxation and minimum-age drinking laws have a positive effect on the incidence of alcohol-related problems (p. 78): The effects of merchandising practices, outlet density, civil liability for servers, and so forth have not been established with reliability, in part because these control mechanisms are intrinsically very difficult to study. It is possible but as yet hypothetical that the cumulative effect of a number of changes in these areas of regulation has been substantial. Server intervention programs provide a case study on the need for a comprehensive approach to supply-oriented prevention programming, one that encompasses several complementary intervention strategies. Server intervention refers to the actions taken by servers of alcoholic beverages to reduce the likelihood that those being served will harm themselves or others. Servers include commercial vendors (persons or entities licensed to sell alcoholic beverages and their employees) and their noncommercial counterparts (social hosts and others such as fra- ternities and employers, who provide alcohol to specific groups in the course of special events). Server intervention, then, refers primarily to the regulation of the supply of alcoholic beverages by restricting the manner in which alcohol is made available for consumption. Yet the key to a successful server intervention program is the development and implementation of a multifaceted approach that includes legal and envi- ronmental interventions as well as training programs for servers. I would like to introduce the various elements of such a comprehen- sive program, describe existing programs, evaluate their strengths and weaknesses, and recommend future agendas for program development, including research priorities. (For more thorough discussions of these topics, see Mosher, 1979, 1982, 1983b.) The Key Components of Server Intervention Programs As previously noted, server intervention programs can be divided conceptually into three basic components: training, environmental, and legal. Strategies directed at drinkers to enlist their acceptance of pre- ventive actions taken by servers (mass media appeals, legal sanctions, educational programs, etc.âthe pedagogical approach to prevention
ENGAGING THE BUSINESS SECTOR 59 described by the panel), could be considered a fourth, complementary component. It is not discussed here, as it does not represent a central aspect of server intervention programs. The training component con- sists of educational programs directed at those who serve alcoholic beverages (either commercial servers or social hosts) and those who manage commercial alcohol outlets. The programs are designed to teach servers how to reduce the risk of intoxication among those who are served ("patrons" or "guests") and to prevent patrons or guests who do become intoxicated from causing harm to themselves or others. Many curricula have been developed throughout the country and typi- cally include sessions on the effects of alcohol on the body; signs of intoxication; legal responsibilities of servers; methods for cutting off service to intoxicated patrons; methods for handling intoxicated patrons; management practices that support training recommendations; and alcoholism treatment. The environmental component involves where alcohol is being served and its relationship to other alcohol outlets; the location's interior and exterior design; and its relationship to transportation factilities, either public or private. These factors have been identified and researched only sporadically, although they are occasionally discussed as part of server training programs or as an overall prevention strategy for reduc- ing drunk driving. The legal component consists of three distinct bodies of state and local law. First, state and local regulation of commercial alcohol outlets (usually found in state and local alcoholic beverage control [ABC] codes) determine the ground rules by which such businesses operateâ who may sell, to whom and in what circumstances and locations, and what business practices must be followed. Second, many (but not all) states impose dram shop (civil) liability on commercial servers of alco- hol (and, in some cases, social hosts) if they serve obviously intoxicated or underage persons who subsequently cause harm to themselves or others. Finally, states set criminal sanctions on certain server practices (usually applicable to both commercial and noncommercial servers), most of which are also included in civil liability and ABC codes. Pro- hibitions on service to underage and obviously intoxicated persons are the most typical criminal provisions relevant to server intervention programs. Existing Server Intervention Programs Server intervention programs have been instituted on a limited, experimental basis in several states during the last five years. In general the programs have focused on the training component, targeted com-
60 PREVENTION OF ALCOHOL PROBLEMS mercial establishments, developed innovative curricula, and been well received by licensees and their employees. The brief description below of four existing server intervention programs offers a sampling of pro- gram designs now being implemented. Other programs exist in numerous sites, most of which rely primarily on a training or educational curriculum aimed at servers. For example, the New York State Division of Alcoholism and Alcohol Abuse is conducting educational seminars for commercial servers in cooperation with the New York State Restaurant Association; Mothers Against Drunk Drivers has instituted a similar seminar series in California, as has the Health Education Foundation in Washington, D.C. The S & A Restaurant Corporation has an in-house server training program used in its restaurants throughout the country. The California DUI Project The first comprehensive server training program, and the one most thoroughly studied, was conducted by the California ABC Department from 1977 to 1980. A detailed study was written in 1979 discussing the history and components of the program and offering recommendations for its continuation (Mosher and Wai- lack, 1979a). The DUI (driving under the influence) project had several innovative features. First, licenses were identified by the use of DUI arrest forms. Law enforcement personnel asked all DUI arrestees to indicate the location of their last drink. All licensees identified were tabulated, and if one location was listed three or more times ABC staff would contact the licensee and offer a training course. Participation was voluntary; after some initial suspicion, most licensees contacted did participate. In fact, by the end of the first year, after 540 training courses involving 5,720 server personnel, more requests for training were being received than could be conducted. In the second year, the course was conducted for those requesting it without use of the iden- tification process. The DUI project developed an innovative set of training materials which covered: (1) how to anticipate intoxicated patrons; (2) factors affecting intoxication; (3) effects of intoxication; (4) problems and rationalizations in cutting off service; (5) suggestions for when to cut off service; (6) suggestions for how to cut off service; (7) what to do after cutting off service; (8) myths about alcohol; (9) the drinking capac- ities of people by weight; (10) potentially effective house policies. Finally, the project included training sessions for the trainers. ABC personnel were hired as trainers, most of whom had no previous expe- rience in conducting educational workshops. Mosher and Wallack found that this design had both strengths and weaknesses. On one hand, it
ENGAGING THE BUSINESS SECTOR 61 increased the communication between licensees and ABC field staff, which had many indirect benefits. In addition, the experience greatly broadened the interests and knowledge of the ABC trainers, thus responding to an identified problem in ABC policies (see Medicine in the Public Interest, 1979). On the other hand, the trainers lacked many of the skills necessary for conducting training sessions, and because of limited funding full-time efforts were not possible. Mosher and Wallack offered several recommendations, including integrating more effectively the enforcement and other legal aspects of the program, redesigning the training sessions, and conducting follow- ups. Despite its weaknesses, the DUI project offers an interesting and important first step in developing server intervention programs. The Madison, Wisconsin, Training Program On 1 August 1981 Madi- son, Wisconsin, enacted a local ordinance requiring that all commercial servers of alcohol participate in a Bartender Alcohol Awareness Train- ing Program as a condition of obtaining a local license. A local technical education organization has conducted the mandated training sessions pursuant to the local ordinance. The four sessions of training cover four major topics: city ordinances and state statutes; drunk driving laws and blood alcohol content; the effects of alcohol and other drugs and facts on alcoholism and treatment programs; and human relations, marketing, and responsibilities (Shold and Morgan, 1982). Shold and Morgan report that the program has gained much support from community enforce- ment personnel, alcohol-related programs, and community tavern leagues and associations. Pre- and post-test evaluations were conducted to determine whether those trained had gained an understanding of the training materials. The results showed very high rates of comprehension and new knowledge. No evaluation has been conducted on the imple- mentation of the training material or the outcome of implementation. Nevertheless, the Madison program is unique in this country in its use of the legal component. The Massachusetts Server Training and Intervention Program The efforts of a single educator have resulted in a server training and inter- vention program in Massachusetts (Peters, 1982). Peters has developed a curriculum focusing on the prevention role of bartenders. The mate- rials include information on alcohol and on bartenders' roles in policing, counseling, and supervising patrons. Peters has supplemented his train- ing efforts with legislative initiatives. Working throughout one Massa- chusetts city, he has succeeded in implementing changes in bar practices (including fewer happy hours, city wide training sessions, shifts in adver-
62 PREVENTION OF ALCOHOL PROBLEMS tising, and more active cutting off of intoxicated patrons) using both legal ordinances and voluntary compliance. Statewide legislation has been introduced to require server training as a condition of licensing. Although this is a promising program, very little has been written describing these activities, and no evaluation has been conducted. The Minnesota Community Program for Server Intervention The Uni- versity of Minnesota's Office of Alcohol and Other Drug Abuse Pro- gramming is developing a community-based prevention program for alcohol problems that has as one component server intervention strat- egies (Schaefer, 1982). Unlike the other programs reviewed here, the Minnesota program has not relied primarily on training sessions. Licen- sees have been contacted on individual and group bases, and various intervention techniques have been promoted. The program emphasizes voluntary action, including licensee-sponsored training sessions for employees (Schaefer, 1982). Legal strategies have also been proposed in one locality, and in an innovative approach, insurance companies have been contacted with an eye to possible reforms in dram shop liability policies. Weaknesses of Current Programs These programs represent a significant step in server intervention policyâthey are practical efforts to incorporate commercial alcohol establishments into a prevention effort. There are four major weak- nesses in their design, however, which must be addressed if effective programs are to be developed. First, most existing programs emphasize voluntary training of com- mercial servers without regard to environmental factors affecting server practices. For example, none of the programs provides any assessment of outlet design on servers' practices and patrons' drinking patterns. Many training curricula emphasize that servers should make unobtru- sive and comprehensive observations of patrons' activities. Yet the outlet may be designed such that adequate patron observation is difficult or impossible. Recent research suggests that drinking settings have an important impact on drinking behavior (e.g., Rosenbluth et al., 1978; Skog, 1979; Schaefer, 1981). Such variables as crowdedness, noise, availability of nonalcoholic beverages and food and of nondrinking activities that promote sociability may substantially reduce the need for interventions by bartenders and other employees. Voluntary training sessions for outlet personnel will have little impact on these factors.
ENGAGING THE BUSINESS SECTOR 63 Also overlooked in the environmental component is the issue of location. Most importantly, what is the relationship of the outlet to transportation facilities? An effective server intervention program must be attentive to how patrons are traveling to and from the premises. Adequate alternatives to private automobiles are needed in case a patron becomes inebriated. Recent efforts have been made in some locales to provide free taxi, minibus, or public transportation services during peak drinking times such as holiday weekends. Such programs may provide a model for alternative transportation plans on a regular basis. At a minimum, outlets should develop a regular taxi program, ensuring immediate responses to requests for taxi service and regular reliance on taxis when a patron becomes intoxicated. A training course that suggests the use of taxis will have little impact if taxis are slow to respond or are unavailable. A second weakness of many (but not all) current programs, suggested by the first, is their relative inattention to the role of management. There is a tendency to focus merely on those in the front lineâbartenders, cocktail waitresses, and other employees actually in contact with the establishment's customers. An effective intervention program, how- ever, may require a number of reforms in management practices, includ- ing such variables as the number of employees on the job, the number of patrons allowed on the premises, the interior design, the commitment to alternative forms of transportation, the hours of operation, the use of promotional techniques, etc. Programs must not only address these issues in their training curricula, but they must also develop formats and approaches that will enlist management's commitment to a com- prehensive approach. Third, current programs underutilize the legal levers available for their implementation. The Madison program, which was instituted with a local ordinance requiring server training as a condition of operating a commercial establishment, provides a good example of the potential role of law in server intervention programs. But a much greater com- plementary role is needed. ABC codes establish the basic guidelines for server practices and license location and can, in conjunction with local regulations, provide a basis for implementing both the training and environmental aspects of a server intervention program. In addition to requiring server training, ABC codes should set standards for server and management practices that complement the training materials and should incorporate preventive environmental standards. For example, special license restrictions can be placed on premises that rely heavily on private auto travel (e.g., most sports stadiums) or that are targeted by those under the legal drinking age for purchases (e.g., convenience
64 PREVENTION OF ALCOHOL PROBLEMS stores). Licenses can be denied if the proposed location is ill-advised due to traffic patterns or if the proposed manner of sale tends to asso- ciate drinking with driving (e.g., licenses at gas stations). Such reforms require a major shift in current ABC policies and prior- ities. As a 1979 study conducted by Medicine in the Public Interest found, ABC laws lack a preventive focus and fail to define a coordi- nated, effective control system. In addition, ABC policy makers tend to have an extremely narrow vision of the role of ABC policies and do not coordinate their activities with other governmental officials charged with preventing alcohol-related problems. The role of the dram shop liability statutes and court case decisions, additional legal levers for implementing server intervention programs, has also been ignored. Commercial servers in more than 25 states may be held civilly liable for injuries caused by their intoxicated patrons (see Mosher, 1979, for a review). Unfortunately, current legal procedures have severely limited the potential impact of this legal doctrine on server intervention programs. First, the standard used for determining whether a commercial server should be found negligentâwhether the server has given alcohol to an "obviously intoxicated person"âis too vague. It does not offer practical guidance to the server for avoiding liability and is subject to adverse interpretations by juries, who tend to sympathize with victims. Second, insurance company policies often favor settle- ment of unjustified claims, making up the expenditures by increasing insurance premium rates. These factors combine to reduce a licensee's incentive to reform their server practices in order to avoid liability, as even the most responsible licensee is in danger of unjustified but suc- cessful legal actions. Instead, licensees often rely on insurance coverage for protection from financial harm, which converts dram shop laws into imperfect victim-compensation mechanisms (see Mosher, 1979, for a comprehensive analysis of current dram shop policies). These limitations could be corrected if liability were made contingent on a licensee's decision to take reasonable steps to prevent injuries to third parties. For example, a server who institutes a training program for employees, implements management practices that encourage com- pliance, and is attentive to environmental variables such as alternative transportation for intoxicated patrons could be protected as a matter of law from dram shop suits, assuming he or she could prove that the procedures were followed on a given occasion. Such a legal reform would provide a strong financial incentive for licensees to institute an effective server intervention program, particularly if insurance com- panies encourage action by basing their premiums on the existence of preventive policies. (For further discussion of the legal reform, see
ENGAGING THE BUSINESS SECTOR 65 Mosher, 1979, and Stepnick, 1983. Stepnick analyzes the economic costs and benefits of a "responsible practices" defense to dram shop suits, concluding that there would be a significant economic benefit to society. The North Carolina legislature is now considering a bill that would institute a "responsible practices" law in that state; see Gover- nor's Task Force on Drunken Drivers, 1982.) Finally, the current server intervention programs have not conducted adequate evaluations. Both the California and the Madison programs did conduct pre- and post-tests to determine the comprehension of training materials. However, no program has attempted to determine whether the training materials have actually been implemented and, if so, what their impact is on patrons' drinking behavior. In the absence of such evaluations, the suggested practices remain in the realm of conjecture and common sense. As stated in the panel's report (p. 76): "At this time, in the absence of research data, the effectiveness of [dram shop] laws or variations therein is entirely a matter of anecdote, a priori speculation, and common sense argument." Future Agendas The discussion of the weaknesses of current programs provides the basis for setting future agendas, which should focus on research and evaluations. Experimental Training Programs Experimental programs are needed that offer the opportunity to evaluate the difficulties of implementing particular server interventions and their impact once implemented. Settings such as military bases, college campuses, and other isolated locations should be chosen initially to minimize the number of poten- tially confounding variables, and a variety of outcome and process measures, including statistical and observational data, should be used. Attention should be given both to the process of implementation as well as the outcome. As such evaluations are completed, programs can be redesigned and replicated in settings that are more difficult to evaluate. The programs should be limited, at least initially, to commercial settings. There are several reasons for such a priority. First, most dram shop laws and ABC regulations are themselves limited to licensed vendors and are not applicable to social hosts and other noncommercial servers. Second, because they are in the business of selling alcoholic beverages, commercial vendors have a special responsibility, reflected in existing laws and regulations, to take reasonable precautions in the operation of their businesses to protect the public from harm. Such
66 PREVENTION OF ALCOHOL PROBLEMS business responsibilities are common to other professions offering ser- vices to the public; the primary debate should not be the existence of that responsibility but rather its scope. Third, the limited available research suggests that a large portion of drunk drivers depart from commercial establishments. A 1973 report of a national roadside breath- testing survey found that 44 percent of those tested with blood alcohol levels of .10 or more were driving to, from, or between public eating and drinking places (Wolfe, 1974). Data from interviews of those arrested for drunk driving suggest similar findings (Yoder, 1975; Mosher and Wallack, 1979a). Finally, because server intervention is at an experi- mental stage, only a limited portion of the total spectrum of servers should be included in initial programs, research, and evaluations. Com- mercial establishments offer good settings for the conduct of research and evaluations; once particular commercial interventions are identified as effective, one can begin designing interventions for noncommercial settings, thus creating a ripple effect. Legal Research For server intervention programs to be effective, they need a comprehensive legal component. Current legal research is inad- equate to fulfill this task. Provisions affecting server practices found in ABC statutes and regulations need to be catalogued and analyzed, and dram shop cases need to be researched to determine the types of situ- ations most likely to lead to legal actions. As discussed in Mosher (1983b), existing research does not include any analyses of dram shop court cases other than those reaching the appeals court level. As a result there is no information on the prevalence of dram shop cases, their outcomes, the types of individuals and establishments involved, and the impact of insurance company practices. Environmental Research Policy decisions at state ABC departments seldom reflect the number or location of outlets or their interior and exterior design. Yet what little research exists suggests that these fac- tors could be the primary guide for community and ABC licensing and enforcement decisions (see Wittman, 1980,1982). Research should also include studies on the impact of various types of alcohol outlets (e.g., stadiums, nightclubs, gas stations, etc.) on drinking problems and on the drinking locations of drinking drivers. Findings should be used to inform and modify management and server training programs. Model Legislation Model ABC laws and dram shop legislation should be drafted and implemented on the basis of findings from research and evaluation. The impact of such legislation should be assessed as various
ENGAGING THE BUSINESS SECTOR 67 provisions are enacted using a "natural experiment" methodology simi- lar to that used in minimum-age drinking studies (e.g., Wagenaar, 1982). Conclusion Server intervention has received considerable public attention in the past two years, and several programs have come into existence during that time. Groups recommending implementation of at least some aspect of server intervention programs include the Presidential Task Force on Drunk Driving, Mothers Against Drunk Drivers, the National Highway Traffic Safety Administration, several state task forces on drunk driv- ing, and numerous scholars (e.g., Mosher, 1979; Beauchamp, 1980; Bonnie, 1981; Reed, 1981). Legal interventions are now being consid- ered in several states, including Connecticut, Massachusetts, Califor- nia, South Dakota, and North Carolina. Industry groups have become interested in developing in-house programs, and several such programs are now in place in various locales (see, e.g., Peters, 1982; Schaefer, 1982; Waring and Spier, 1982). Even the Health Education Foundation, an organization often opposed to legal interventions as a means to prevent alcohol-related problems, is developing a server training cur- riculum and has recommended dram shop laws as a means for imple- mentation. As support for server intervention spreads, the demand for additional programs will undoubtedly increase. This enthusiasm needs to be tem- pered to reflect the major tasks that must be completed before effective programs are possible. State ABC departments, insurance companies, enforcement agencies, private industry, citizen support groups, researchers, evaluators, educational specialists, and local community organizations need to focus on the difficult research and implementation problems and to coordinate their activities. The federal government, through the National Institute on Alcohol Abuse and Alcoholism (NIAAA), needs to take the lead in this process, providing financial resources for the necessary research and evaluation studies, offering technical assistance to interested groups, acting as an information clear- inghouse, and ensuring that duplication of effort is minimized. Server intervention programs offer strong support for two of the panel's major conclusionsâthat control of the supply of alcoholic bev- erages is one viable strategy for preventing drinking problems, and that comprehensive programs encompassing a variety of interventions are needed. The promise embodied in the panel's report, however, can become a reality only if there is both careful planning by policy makers and a strong commitment for change among the many affected groups and individuals in our society.
68 PREVENTION OF ALCOHOL PROBLEMS THE ROLE OF THE STATE ALCOHOL AUTHORITY JOHN F. VASALLO, JR., State of New Jersey The main role of state liquor administrators and ABC boards, com- missions, divisions, etc., is to apply and enforce the law. Unfortunately most of us are limited in what we can do because of budget restrictions; none of us has enough money. In New Jersey I have only 15 undercover agents to handle almost 8 million people, and funds are even being cut from that. We cannot attract people to this field with the monies that can be paid. The approach we have to take is to support good practice in the industry that supplies, wholesales, and serves alcoholic beverages. We cannot regulate and control the industry to such a degree that no abuses flow from it. The primary responsibility of a regulator is to ensure that the regulations do not harm those who are regulated. Of course the welfare of the entire people is the underlying reason for any government regulation at all. A state regulator must be concerned with the public interest, but the rights of those who are regulated must be balanced with it. Rules must be set down for the growth and welfare of the industry as well as the benefit of the general public. Where they conflict, the needs of the general public must come first. A good analogy: to the alcohol beverage industry, the role of a state administrator is like that of a father. A father guides and sets rules to ensure a child's greatest growth and achievement of potential within the confines of those rules and at the same time to provide a benefit to society as a whole. The same applies to regulating the alcohol beverage industry. Guidelines may be set down, but if they are too stringent, licensees will find ways to get around them. Rules and regulations must be realistic. Because those regulated sometimes get out of line, it is necessary to discipline them, much as it is necessary to discipline a child. It is done, however, with the intent of bringing them back into line and correcting them rather than punishing them, as a stable alcohol beverage industry is the ultimate goal. The fatherly role consists of trying to guide the licensees along the lines that the legislature has set down, protecting them, promoting their interests, but at the same time paddling their backsides when they get out of hand. That may sound a little facetious or a little farfetched, but that is the job that has to be done. I consider myself fortunate to regulate the system of distribution in New Jersey because that system is quite limited. Since licensees have to obtain consumption licenses with full privileges for the sale of all
ENGAGING THE BUSINESS SECTOR 69 types of alcoholic beverages, and those licenses are limited according to the population of municipalities, availability of beer and wine in restaurants or food stores is not widespread. Some food stores have purchased retail consumption licenses, but they must have their beer/ wine/liquor department completely separated from the general shelves of the supermarket. One of the primary reasons that the system in New Jersey has worked very well and should continue to work well is that the licensees have such a large investment. Generally it costs quite a bit to purchase a liquor license, and there is a sizable annual fee. There is also equity in the license; it can be resold for a substantially appreciated sum. Licen- sees do not want to risk losing this investment. Their lives and busi- nesses are centered around their license; it is one of their most valuable assets and will be protected. Consequently they take more precautions than would otherwise be expected in order to keep that license from being threatened. In other states outlets that sell only beer and wine, whether by the drink or by the bottle, are primarily in the restaurant or food business. The beer and wine activity is secondary and does not matter as much to them; it is only a small part of their profits. If the privilege is lost, the business is not lost. Consequently there is not as great an interest in devoting the time and effort necessary to ensure that violations do not occur and that the distribution of alcohol takes place properly and lawfully. Using this paternalistic approach, we try to create a certain atmo- sphere through regulations and enforcement. We try to get the licensees to take pride in what they are doing, to take precautions, to value their license and privilege, to respect it, and to respect what they are adding to the economy. These licensees are very important to the economy of the state. A tremendous number of people are employed as either a direct or an indirect result of alcoholic beverage activity. Many restau- rants would not be able to offer employment to as many waiters and waitresses if they did not serve alcoholic beverages: the sale of alcoholic beverages can be a high gross-profit item, which can absorb the costs of serving food and providing an enjoyable atmosphere. It is also impor- tant to tourism; in addition, many people in New Jersey are employed in the glass bottle industry, on which the alcohol beverage industry depends. The overall economic effect of the industry is great; therefore we don't want to adversely affect the situation and cause unemployment or other hardships to the general public. In other words, in regulating alcoholic beverages, especially when trying to control their supply and
70 PREVENTION OF ALCOHOL PROBLEMS distribution, we must keep in mind that cutting down the quantity is going to have many adverse effects. It is thus necessary to view the broad picture. Some negative serving practices occur among those who have not been in the industry for long. The fight for the dollar leads to practices such as "two drinks for the price of one." I notice this practice through- out the country, but the New Jersey Administrative Code (13:2-23- 16(a)2) prohibits giving anything of value conditioned on the purchase of an alcoholic beverage, and on the basis of this regulation I do not allow two-for-one. Certain licensees do not like this. They are permitted happy hour specials with drinks at half-price, but selling drinks at half- price could cut down on total cash flow since certain people may order only one drink. These licensees do not want to diminish their revenue; they would rather pour a few more ounces of alcohol. Our feeling, however, is that an enticement must be a genuine bargain and not something disguised. A person should not have to be served a double amount of alcohol in order to get the benefit of the "bargain." The big difficulty with two-for-one and other specials that increase the amount of consumption is that the tolerance or capacity of the patron is not known at the time of serving the drink. By the time the person finishes two drinks, that tolerance level may have been passed, even though it might not be a presumptive intoxication level when measuring blood alcohol content. The blood alcohol level at which people feel the effects of alcoholic beverages varies, and the tolerance of alcoholics is generally much higher than that of nondrinkers or occa- sional social drinkers. This is also why we do not condone the practice of supplying more than one drink at a time. This type of thing leads to alcohol problems. I am also critical of happy hour promotions that run far longer than an hour, sometimes an entire day: I saw a sign in one restaurant that read: "Happy Hours: Sunday through Saturday." Placing controls on these practices or trying to get licensees to curtail these practices vol- untarily is an effective way of regulating the supply of alcohol. It is much better to obtain voluntary cooperation from licensees than to try to force them to do something they do not want to do. Coercion fosters attempts to get around the regulation. For example, when we took initial steps with certain licensees to curtail two-for-one practices, rather than giving two drinks in two glasses, they doubled the size of the glass during the time of the promotion. Patrons then did not realize how much alcohol they were getting. Another approach that is sometimes suggested is controlling the amount of alcohol that may be put in a shot, but this is really not satisfactory,
ENGAGING THE BUSINESS SECTOR 71 as alcohol comes in different proofs. That strategy would require reg- ulating the size of the shot in proportion to the volume of alcoholic content. Another development involves the type of alcohol available. The laws we work with in many cases go back to the 1930s, and they do not cover all present circumstances. I have noticed recently on the shelves a 190-proof grain alcohol, sold in small bottles as miniatures. If we cannot encourage licensees to get rid of these voluntarily, then we will take other steps to get rid of them. Educational and instructional programs for licensees can be very effective, but I feel strongly that they can only be successful on a voluntary level. Attempts at instruction of licensees in New Jersey on a voluntary basis have been somewhat successful. I think there is an interest on the part of licensees who are serious about their business and have some stake in learning what they can do to avoid problems. Licensees are keenly aware of these problems, especially if they are subject to dram shop liability. THE CORPORATE ROLE IN PREVENTING ALCOHOL ABUSE ROGER THOMSON, S & A Restaurant Corporation My firm, the S & A Restaurant Corporation, has approximately 300 licensed restaurants nationwide. Some are in the state of New Jersey, from where John Vassalloâmy "father," whom I have just metâhails, and where we have indeed been paddled. We are as concerned as everyone else about people dying on the roads, and we are trying to take an active stance to deal effectively with this situation. We are spending a great deal of time, money, and effort to educate our employ- ees and our patrons on the sharing of responsibility. We do not force anyone to enter our restaurants; but once they do, we have a respon- sibility to attempt to see that they do not get intoxicated. This does not, however, absolve patrons of their responsibility not to get intoxicated. Responsibility should be a shared burden and that concept should carry over to dram shop liability, which is a complex field. Nationwide we have posted notices in some of our restaurants to remind our customers that they have a responsibility, and we will refuse to serve them if we think they are not taking this responsibility. We also have blood alcohol content charts posted in some restrooms and telephone booths. If we think that somebody may be drinking too much,
72 PREVENTION OF ALCOHOL PROBLEMS we may serve them protein- and fat-rich foods that absorb alcohol more quickly. We may also place on our new menus a nonalcoholic beverage section that receives top billing. We have game areas that allow people to feel that they do not have to sit and drink first to enjoy a meal, and we are initiating other diversions for people who choose not to drink alcohol. Where we have been able to strike deals with taxi companies, our restaurants have a hot line to the taxi company: Just pick up the phone, which is a direct line, and we pay for the cab to take home a patron who has had too much to drink. To educate our staff, we invite the local police and the local alcohol councils to speak to our employees frequently. In our newspaper, which goes to all our restaurants, there is often an article on some aspect of alcohol. We help our employees recognize the signs of intoxication and we give them support to cut an intoxicated person off. On the com- munity level, we funnel money into various school systems to produce posters on responsibility and alcohol. We work with Mothers Against Drunk Drivers and other groups on various local issues. We are trying to be responsible. I think the vast majority of restaurants is very concerned about this situation and is trying to be responsive to the problems. Our efforts to be responsive should be shared by those who patronize our facilities, and all reasonable steps should be taken to ensure this sharing of responsibility. COMMENTS ON THE INTERSECTION OF PUBLIC AND PRIVATE SECTORS HENRY KING, United States Brewers Association There is a restaurant in Washington named Mel Krupin's, a famous political and press hangout, which will not permit patrons to get intox- icated. They know how much you drink and they just stop you. I have been eating there 4 nights a week for 10 years, and I have never seen an intoxicated person in the restaurant, though I have seen people stopped from coming in. This place has a great reputation for being aware of the problem. It does not put signs in the men's room saying, "Drink in moderation." The employees are trained, and you cannot get in without being observed.
ENGAGING THE BUSINESS SECTOR 73 ROBERT REYNOLDS, County of San Diego The issue here is not whether isolated restaurateurs have these poli- cies but whether as a matter of public policy this kind of training should be a prerequisite for licensing. Consumer action might be effective in developing server training programs in many more establishments that serve alcoholic beverages. SHEILA BLUME, National Council on Alcoholism In New York State, the Division of Alcoholism and Alcohol Abuse has started a pilot program of bartender and server training. The divi- sion's executive deputy, counsel, and executive assistant met with the restaurant owners' representatives, who identified escalating liability insurance as one of their biggest problems. By putting the two groups' resources together, a training package was developed, including vid- eotaped scenes of bartenders turning intoxicated patrons away gently and other simulations of actual situations. By the time the first pilot was launched, both the tavern owners and the Division of Alcoholism were enthusiastic about it. The strategy was finding a common interest between the restaurant owners and the Division of Alcoholism. The common goal is based on the economic liability to which the restaurant owners were subject, not due to a change in social values, but to smart lawyers who were suing them and to what they were consequently paying for insurance coverage. The strategy is to do something positive, rather than wait to repair damage after the fact. I do not think it is a matter of people being less tolerant of drunkenness, but one of economic interest. ROBERT Ross, State of New York The Division of Alcoholism is now planning 15 local training sessions, reaching approximately 1,000 people, for which the restaurant owners will pay while our division provides the expertise and staffing. We will train the employees, not just the owners, who work in member restau- rants of the state association; it is not costing the state anything extra. The restaurant people, who come voluntarily, see the training as a big plus because they would otherwise have to purchase it at much greater cost. From our point of view the training is a big plus because it establishes a working relationship with an industry surrounded by a lot of friction due to regulations, increased taxes, drunk-driving law changes, etc. This is an isolated instance of cooperation in the midst of a battle between the industry and the state government.
74 PREVENTION OF ALCOHOL PROBLEMS HENRY KING, United States Brewers Association Mothers Against Drunk Drivers, in cooperation with the Tavern and Restaurant Owners in Sacramento, has an ongoing educational pro- gram, as does the University of Massachusetts. Morris Chafetz at the Health Education Foundation is developing a program. The Presidential Commission on Drunk Driving is making very strong recommendations that the industry conduct educational programs for owners and employ- ees; that report will be a stimulus for the industry and other groups. We are just at the threshold. New York was one of the first. I think that in two to three years this will be a national program with some continuity to it. GEORGE HACKER, Center for Science in the Public Interest What is the relative amount of drinking that occurs at home or in private settings versus the amount that occurs at public gatherings like sports events or in public taverns and restaurants, where professional servers control the situation? To the extent that we develop policies aimed at limiting excessive drinking in public settings, do we run the risk of ignoring the broader prevention policies that will affect people who drink in their own homes and other private settings? HENRY KING, United States Brewers Association Less than 40 percent of beer is consumed in taverns and restaurants. There is someâwe do not know how muchâillegal consumption of beer by those under legal age. It would be safe to say that probably 65 percent of the beer is consumed either in the home or in a place other than a tavern. LARRY STEWART, Caucus of Producers, Writers, and Directors If we could find data showing that too many alcohol-related accidents happened to people leaving stadiums, arenas, etc., then it would be a problem for the private sector, the various leagues, to solve, perhaps by exerting efforts to "cool it," to curtail consumption in fourth quar- ters, ninth innings, etc. HENRY KING, United States Brewers Association The brewing industry supports such an effort. We have had terribly unruly situations, for example, with 10-cent-beer nights at baseball
ENGAGING THE BUSINESS SECTOR 75 games. It does not enhance the image of the brewing industry to have people brawling and throwing things at ballplayers. It certainly does not make for moderation and intelligent use. There should be some controls. In some cities and some areas that have controls, they do not have those kinds of violent actions. The brewers have made overtures to these athletic groups. If other constituent groups would join in and raise the roof, we could get more attention. JAMES F. MOSHER, Medical Research Institute of San Francisco Even though most of the beerâin fact most of the alcohol in all formsâis consumed beyond the purview of professional servers, a program or policy to change servers' behavior is an important general preventive measure for two reasons: the proportion of drinking over- seen, while not the majority in terms of volume, is quite substantial; and serving practices in private settings will inevitably be affected both by the public example of concern set by new professional practices and by the diffusion of experience gained by employees, trainers, and researchers into the common body of knowledge and custom. JEFFREY E. HARRIS, Massachusetts Institute of Technology General interest in life-style change and disease prevention has been growing in the population and the modern American corporation. There seems to be an enormous demand for life-style-related programs, such as fitness and exercise programs, which have the additional advantage of being tax-exempt fringe benefits. The prevention of alcohol abuse is an area in which modern corporations must become increasingly inter- ested. According to the federal Rehabilitation Act, a company cannot simply fire someone who comes in drunk; it has to take remedial action. This is a particular gap that needs to be filled. LARRY STEWART, Caucus of Producers, Writers, and Directors In the television and motion picture industries, eight major studios have opened facilities on their lots for Alcoholics Anonymous (AA) meetings, collateral Al-Anon meetings, and the like. The same studios are now financing a halfway house for motion picture and television employees, be they carpenters or executives. That new thrust has occurred over the last few years. AA involvement has become a bulletin board item in those studios; every employee who checks out by the clock or checks job-related situations on bulletin boards is aware that those facilities are open and help is available within the studio system.
76 PREVENTION OF ALCOHOL PROBLEMS KEITH SCHUCHARD, Parental Resource Institute for Drug Education The Georgia Power Company is educating every member of the company, from janitors to the chairman of the board, on the health consequences of alcohol and drug abuse. The company is trying to help everyone understand the content of advertising and to appeal to them as intelligent citizensâas parents, young people, friends, etc.âto make use of the employee counseling resources. This program is not focusing just on illness or on Georgia Power's concern about safety in its nuclear power plants; the company is calling on its employees to be part of the solution, and the effort has drawn a tremendously positive response. Around the state of Georgia 14,000 employees have become a new resource for speakers at the PTA, the Rotary Club, and the Elks. They are a resource in every community to help raise money for prevention and other programs. The employees, including young people, appreci- ate receiving straight health information for their own good, the good of their company, and the safety of their colleagues. But they also appreciate the appeal not to let drug and alcohol problems happen to those around themâan appeal to decency. Many young workers par- ticularly have said that no one ever asked them to help before; it was assumed that they were the problem. Many companies that are mounting drug education programs for cost efficiency are keeping interesting figures on what is happening to absen- teeism, utilization of health services, job and product safety, and lia- bility charges for people who fall off the dam when they are stoned. This effort is imaginative, with new companies getting involved, and there will be much to learn from it. ALFRED MCALISTER, University of Texas Health Sciences Center Historically in the field of public health, huge political battles were fought before sanitary reform was accomplished. It was finally achieved when large industrialists realized that in order to concentrate a produc- tive labor force in a city, people had to be provided with clean water. When industrialists saw that their profits would be maximized by a large-scale public health measure, they took action. There has been a revolutionary change in recent years as employers have taken respon- sibility not only for job-related diseases, a trend that has a long history, but for their workers' non-job-related diseases, seeing the relationship not only to productivity but also to their share of health care costs. Large corporations will have enormous power in health planning in the future.
ENGAGING THE BUSINESS SECTOR 77 MARILYN GOLDWATER, Maryland House of Delegates Another group that needs to be a part of this picture is the insurance industry. Their reimbursement policies dictate what kinds of programs and services are available. Although they call it health insurance, the companies tend rather to provide illness insurance. I think that we need to explore with them the benefits to society and to the industry itself of changing their reimbursement policies somewhat to become education- oriented, not just treatment- or illness-oriented. BEN MASON, Adolph Coors Company Many of the beverage manufacturers have established wellness clin- ics for their employees, are very aggressively pursuing the participation of employees in educational and training sessions, and are working to develop cost-effectiveness data. These positive contributions to health promotion are an important commitment on the part of these firms, and I think that it is good to take note of it. We would be pleased to share what we are learning with the research and public health communities. PATRICIA SCHNEIDER, Wine Institute Wine Instituteâwhose president, John DeLuca, I representâhas great access to and communication with its members. We can talk to our members about advertising practices, moderation, and safe drinking concepts in a way that those outside do not and perhaps cannot. The education process ought to include the active participation of all seg- ments of the alcohol beverage industry. LAWRENCE WALLACK, University of California, Berkeley What should be the relationship between the government role and the other roles we have talked about? I think that what matters is that a relationship exists. One of the ways the panel's report is different from past efforts is that it no longer sees alcohol-related problems as primarily individual problems, but starts to see them as systems prob- lems. When we talk about systems problems, we identify things that exist on many different levelsâindividuals, schools, families, com- munities, social institutions. We cannot work on all of these levels all the time, but we can have as a goal the development of actions and
78 PREVENTION OF ALCOHOL PROBLEMS purposes that are consistent across these levels. Too much comes out in the form, "It is this or that" and not enough in the form, "It is all of these things, and each has to be developed and constructed in relation to the development and construction of the others." A single program in and of itself may not make a detectable difference, but in relation to other strategies, both individual and aggregate, every individual effort may in fact serve a very important function.
