Bolier L., Voorham L., Monshouwer K. et al.
Substance Use & Misuse: 2011, 46(13), p. 1569–1591.
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In pubs and clubs, especially for young patrons, out-of-control intoxication is sometimes the aim rather than an undesirable outcome to be prevented. How in these circumstances to reduce use and harm has been investigated in the 17 studies analysed in this review.
Summary Alcohol and drug use is considerably more common than average among people who frequently patronise night-time entertainment venues, and can cause serious problems such as life-threatening alcohol intoxication, overheating and dehydration after ecstasy use, and long-term risks such as addiction, depression, and memory loss. Substance use can also lead to related problems such as traffic accidents, risky sex, sexual assault, and violence.
Offering promising opportunities for intervention, the nightlife environment and its stakeholders play a major role in the exacerbation or reduction of alcohol- and drug-related problems. They affect these problems by, for example, whether they sell drink to minors, serve intoxicated patrons, tolerate drug use, or even, as some door staff have done, supply drugs. Also the physical environment – such as ventilation, ease of access to free water, adequacy of emergency services and equipment, and bar design – greatly affects whether visitors are entering safe and healthy venues.
The featured review aimed to assess the impact of alcohol and drug interventions in licensed premises and nightlife environments, primarily in terms of substance use, but also substance-related problems. It was limited to studies in peer-reviewed journals which mounted and scientifically evaluated an intervention, but embraced research designs which fell short of the 'gold standard' randomised controlled trial, such as those which relied on before and after measures.
In all 17 studies were found reported in 21 papers. All but two concerned alcohol use. Three studies were conducted in Europe, 11 in North America, and three in Australia. The review categorised the interventions as:
• community interventions, all of which involved the wider community through for example media campaigns and advocacy for policy changes, plus training staff in venues and improving law enforcement;
• alcohol server interventions, limited to training venue staff and managers in their legal and other responsibilities for their patrons and giving them the information and skills to fulfil these responsibilities;
• educational interventions, seeking to inform patrons about the general risks of substance use related to leisure-time venues, or the particular risks they faced as individuals; and
• policy interventions, involving heightened and more highly publicised enforcement of relevant laws and regulations and the establishing and implementation of related policies by venue managements.
Four studies sought variously to mobilise communities to prevent drug use in nightlife settings, stop underage or drunk patrons being served alcohol, and to reduce alcohol related injuries and traffic crashes.
In one study featuring staff training, enforcement and media advocacy, the proportion of doorstaff who denied access to patrons pretending to be 'high' on drugs increased from 7.5% to 27%. The interventions targeting drinking variously reduced high-risk drinking, alcohol-related injury from traffic accidents and assault, violent crimes, and supply to underage or intoxicated patrons. An analysis of Swedish studies found the interventions cost-effective in reducing violent crime and improving/saving lives. However, these positive findings were not universal.
In summary, it seems that community interventions can reduce substance-related harm and that this potential remains apparent in the higher quality studies.
Six studies investigated alcohol server training interventions in nightlife settings without attempting to bolster these through other components such as enforcement or community mobilisation. Aims are primarily to prevent serious intoxication and service to minors or to already intoxicated patrons. Over from three hours to a day, trainees were taught about the effects and risks of alcohol, relevant laws, and how to serve alcohol responsibly.
Results were mixed. Most studies reported significant effects on knowledge, some on the servers' own accounts of their behaviour, and others on more objective outcomes such as observed server behaviour and road accidents. However, probably due to poor support from management and poor implementation, one study found no positive effects on the blood alcohol levels of patrons, number of drink-driving offences, and whether pretend underage patrons were served. Likewise, in two other studies effects were small or lacking.
In summary, results are mixed and studies have mainly reported subjective outcomes. One study with the highest quality rating and which tested compulsory server training reported positive effects on an objective measure – road accidents.
Just two studies trialled patron education interventions, one concerned with drugs, the other, alcohol. The drug-focused intervention distributed leaflets and info-cards to inform club visitors about the risks of ecstasy and GHB and to encourage them to use less or at least more safely. In comparison to a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group, before and after measures revealed neither health promotion effects nor any adverse effects among either users or non-users of 'club drugs'. After reading the leaflet or info-card, non-users became more negative about GHB, and after reading the info-card, less positive in their expectations about the consequences of using the drug. An important finding was that reading information intended for drug users did not have counterproductive effects on non-users.
Compared to before the intervention, 12 months later a brief intervention offered in bars and taverns and intended to reduce harmful alcohol use and binge drinking led to a significant decrease in drinking and related problems, including 'binge' drinking. The intervention involved assessing the severity of the drinker's alcohol problems using the brief AUDIT questionnaire and a blood alcohol test, the results of which were fed back to the drinker. Effects were possibly partly due to the intervention attracting people who were already considering cutting back on their drinking.
In summary, educational interventions produced small effects on negative attitudes and drinking, but studies were scarce and low quality.
Five studies reported the effects of alcohol policy interventions, the elements of which included risk assessment, training and consultation, enforcement checks, provision of tailored policy manuals and information, and promoting an alcohol prevention strategy at licensed premises via phone contacts, media, and publications. In two studies the intervention directly aimed to promote responsible service, especially in respect of minors and drunk patrons. Other interventions took a step back to develop and implement policies in the nightlife setting which promote responsible alcohol service, or to widely disseminate such a policy.
Such interventions proved effective across a number of outcomes. In one study, after regular enforcement visits bartenders were less likely to serve seemingly drunk patrons. In another, combined enforcement checks and management training restrained service to underage patrons. Policy interventions focused on implementation led to more alcohol policies being formulated and used by club owners after they underwent intensive training, and more licensed premises in a region adopting a responsible service policy. But some studies found that in the absence of enforcement checks, management training had no significant effects on sales to obviously intoxicated patrons. Furthermore, the effects of enforcement checks have been found to decay over time.
In summary, studies were of mixed quality and results, registering some positive effects in respect of responsible alcohol service, but no significant effects in the highest quality study.
In general this review of 17 studies of the prevention of harmful alcohol and/or drug use in nightlife settings found that interventions which include community mobilisation elements can have preventive effects on alcohol use, reducing high-risk consumption, related injuries and violent crimes, and reducing access to alcohol by minors and drunk customers. An enforcement element in policy-based interventions increases the chances of success. Alcohol server training too can foster responsible alcohol service, provided it is embedded in the community and, again, bolstered by regular enforcement visits. Little research has been conducted on educational interventions in nightlife settings, and, in contrast to alcohol, preventive drug interventions have rarely been formally evaluated.
Taking these results and the quality of the studies into account leads to the conclusion that server training and policy interventions have the potential to reduce alcohol-related problems in nightlife settings. Community interventions combining these elements seem particularly promising, and the chances of a positive outcome are improved by an enforcement element.
Implications for research are that cost-effectiveness and some widely used preventive interventions such as pill testing and education by experienced peers need further evaluation. Implications for practice are that a nightlife prevention programme has a greater chance of success when embedded in the community, and that enforcement of regulations should form a major part. As effects can decay, server training should be mandatory and both this and enforcement activities maintained. Educational elements have little impact, so should not be the sole element in a programme; crowded settings, noise, use of substances, and expectations of a good night out rather than a 'lecture', may act against them.
Young people often start their night out and their substance use at a friend's place before visiting a bar or club, and drinking beforehand is associated with higher alcohol consumption and a higher likelihood of incidents involving aggression. For these and other reasons, nightlife interventions are best seen as part of a wider drug and alcohol prevention strategy including schools and parents. Moreover, other substance-related issues such as violence and sexual health should also be part of a healthy nightlife strategy.
Beyond specific evidenced interventions, common sense factors contributing to a safe environment should be considered – factors such as the layout of the bar, ventilation, free water availability, and the style and sound level of the music.
The findings of this review should be interpreted in the light of the inclusion of several studies which did not feature a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group, leaving open the possibility that the results were due to something other than the intervention, such as the motivation of the people who chose to participate in the study. Few studies reflected the European context.
Last revised 10 June 2012
REVIEW 2003 Just say, 'No sir'