CRD summary

The findings of the review indicated that effective delivery of multi-component programmes in drinking environments may reduce alcohol-related harm and related costs; these findings were limited by the methodological shortcomings of the included studies. The authors' cautious conclusions reflect the evidence presented, but the reliability of their conclusions is unclear given questions about the review methods.

Authors' objectives

To examine the effects of interventions implemented in drinking environments to reduce alcohol use and associated harms.

Searching

MEDLINE, PsycINFO, ETOH, Web of Science, ASSIA, ERIC, Project Cork, The Cochrane Library and Alcohol Studies databases were searched for studies published from 1990 to July 2008. Search terms were reported. Alcohol research-related websites were searched. Reference lists of relevant articles, reviews and book chapters scanned for additional material. Conference abstracts were excluded.

Study selection

Studies that evaluated interventions delivered in drinking environments and aimed to reduce the harm associated with alcohol consumption were eligible for inclusion. Outcomes of interest were violence, injuries, assaults, aggression, anti-social behaviour, crime, road traffic crashes and pedestrian injuries, health service utilisation, and excessive alcohol consumption. To be included, interventions needed to targeted individuals in drinking environments including patrons, workers, owners and managers, as well as licensed alcohol service premises or areas of multiple licensed alcohol service outlets. Studies were excluded if they evaluated interventions targeting the sale and supply of alcohol to underage drinkers via the "off trade" only, or that regulated the physical availability of alcohol.

The included studies evaluated server and patron interventions, policing and enforcement programmes, and multi-component programmes. Outcomes included change in violence or injuries, drink driving outcomes, changes in alcohol consumption, responsible service practices, and sales to underage or intoxicated customers. Most studies were conducted in the USA or Australia; the rest were conducted in Sweden, the UK and Canada.

The authors did not state how many reviewers selected studies for inclusion.

Assessment of study quality

Quality was assessed using the Effective Public Health Practice Project (EPHPP) tool for most study designs. For studies with an interrupted-time-series design, criteria defined by the Cochrane Effective Practice and Organisation of Care group were used including: intervention implemented at clearly defined point in time; more than three data points; protection against secular trends and detection bias; completeness of data; and reliability of primary outcome measure. Studies were scored as strong, moderate or weak.

The authors did not state how many reviewers conducted the quality assessment.

Data extraction

Data were extracted on the change in relevant outcomes.

Methods of synthesis

Data were grouped by intervention type and study quality, and combined in a narrative summary. Additional information was provided in tables.

Results of the review

Twenty-eight studies in 39 articles were included in the review. Seven studies were randomised controlled trials (RCTs), seven studies were non-randomised controlled trials, five were interrupted-time-series studies, three were cohort analytic studies and six were non-controlled before-and-after studies. Seven studies had a global quality rating of moderate; 16 studies were rated as weak. Of the interrupted-time-series studies, three were rated as strong and two rated as moderate.

Server and patron interventions: Mixed evidence was reported from this group of studies. Seven studies evaluated server training interventions. Two studies reported some improvement after training for responsive service practices; one study found no impact. Two studies reported a reduction in the percentage of patrons with high blood alcohol levels compared with control groups; one study reported no significant differences between groups. One study found no significant reductions in underage sales or sales to pseudo-intoxicated patrons. One study requiring alcohol servers to be trained found a statistically significant effect on single-vehicle night-time traffic accidents (23% at end of third year). One study of an intervention designed to reduce aggression in bars reported a modest impact on moderate and severe aggression. Five studies targeting patrons were of weak quality; three found limited or no impacts, and one study had a negative impact.

Policing and enforcement programmes: Three studies evaluated policing interventions. Evidence of the effectiveness of police interventions or increased enforcement were inconclusive. Two studies reported short-term effects on sales to underage and intoxicated patrons. One study reported a significant reduction in alcohol-related crashes in 16 to 20 year olds, but not 21 to 25 years olds. Two studies reported an increase in the number of assaults recorded as a result of the interventions; one study reported a decrease. All three studies found some positive effect on some outcomes as a result of the intervention.

Multi-component programmes: Three well-designed studies found evidence that multi-component programmes combining community mobilisation, responsible beverage service training, house policies and stricter enforcement of licensing laws had some effect in reducing assaults, traffic crashes and under-age sales. Four low-quality studies that focused on community mobilisation, awareness, responsible beverage service training and law enforcement for under-age access to alcohol and intoxicated patrons also found some evidence of effectiveness.

Authors' conclusions

The findings indicated that effective delivery of multi-component programmes in drinking environments may reduce alcohol-related harm and consequently costs to health services, criminal justice agencies and a range of other public services. However, the findings were limited by the methodological shortcomings of the included studies.

CRD commentary

The review question and inclusion criteria were broadly defined. Several relevant sources were searched for published articles, but it was unclear whether any language restrictions were applied. Review methods were not reported, so it was unclear whether appropriate methods were used to reduce reviewer error and bias in the review process.

The methodological quality of the included studies was assessed using appropriate criteria. The results for individual studies were reported. A narrative summary was appropriate given the differences between studies for study design, interventions and outcomes. The authors appropriately acknowledged limitations of the review including the variable methodological quality of the included studies.

The authors' cautious conclusions reflect the evidence presented, but the reliability of the conclusions is unclear given the lack of reporting of review methods and uncertainty regarding language restrictions

Implications of the review for practice and research

Practice: The authors stated that, although the clearest indication of effectiveness came from multi-component programmes, these would require adaptation before implementation into other settings because of differences in cultural behaviour and environment. Support was also required to enable national and local agencies to develop, evaluate and implement effective interventions in drinking environments.

Research: The authors stated that further robust research was required which should report detailed descriptions of the intervention including its completeness and transferability. Additional research was needed to assess the transferability of evidence from multi-component programmes in drinking environments to other settings (cultural factors and environment). There was also a need to develop further knowledge and understanding of alcohol behaviours and alcohol-related harms to enable the creation of safe drinking environments and to effectively target and adapt interventions.

Funding

Part funded by the European Commission.

Bibliographic details

Jones L, Hughes K, Atkinson AM, Bellis MA. Reducing harm in drinking environments: a systematic review of effective approaches. Health and Place 2011; 17(2): 508-518. [PubMed: 21257334]

Original Paper URL

http://www.sciencedirect.com/science/article/pii/S135382921000184X

Indexing Status

Subject indexing assigned by NLM

MeSH

Alcohol Drinking /adverse effects /prevention & control; Harm Reduction; Humans; Law Enforcement; Licensure /legislation & jurisprudence; Residence Characteristics; Social Behavior; Social Environment; Social Values; Wounds and Injuries /prevention & control

AccessionNumber

12011004767

Database entry date

21/06/2012

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.