We undertook an overview over systematic reviews in order to give The Norwegian Health Directorate better documentation for interventions to counter overserving, serving underage people and alcohol-related harm/injuries linked to drinking venues. We included five systematic reviews of high to moderate methodological quality. The included reviews assessed the effect of different types of training for servers and owner/manager, enforcement of alcohol laws, heightened police supervisions and various community interventions. All interventions were compared to no interventions. Based on our results and our assessment of the quality of the documentation for effects of the preventive interventions in the five included systematic reviews, we draw the following conclusions:
- Server training interventions probably makes little or no difference to observed aggression exhibited by patrons, staff or self-reported server behaviour measured with behaviour index. The quality of the evidence has been assessed as moderate
- Training for severs and owner/manager may make little or no difference to observed server behaviour measured with pseudo-drunk actors
- Policy enforcement checks may make a little difference to observed server behaviour measured with alcohol sales to minor in the short term
- Heightened police supervision with regard to serving underage and intoxicated people may make little or no difference to violence
- Community interventions to counter overserving may slightly reduce police reported violence. These interventions may make little or no difference to underage purchase attempts, beer sales to underage and access to alcohol
The quality of the evidence has been assessed as low.
For most of the other identified comparisons, we have assessed the quality of the evidence as very low.
The Norwegian Directorate of Health (Department of Public Health) and the Police Directorate in collaboration with the municipality of Oslo and Oslo Police District have started the project SALUTT. The project is inspired by the STAD project (“Stockholm prevents alcohol and drug problems”), which aimed to develop methods to reduce serving intoxicated or underage clients and thereby to reduce alcohol related harm. The Norwegian Directorate of Health has commissioned a systematic review of effects of interventions to counter overserving, serving underage people, and alcohol-related harm linked to drinking venues. We have identified and present systematic reviews of effects of such interventions.
We aimed to summarise research on the effects of interventions to counter overserving, serving underage people, and alcohol-related harm linked to drinking venues.
We completed an overview of systematic reviews in accordance with the Handbook of the Norwegian Knowledge Centre for the Health Services. We searched for systematic reviews in 12 international databases and three internet sites. The search was completed in March 2013.
Two individuals independently screened all the titles and abstracts and proceeded to review in full text all potentially relevant reviews. All systematic reviews of high to moderate methodological quality that dealt with interventions to counter overserving, serving underage people, and alcohol related harm linked to drinking venues were included. From the included systematic reviews, we extracted all relevant results, summarized these in text and created tables when deemed appropriate. The quality of the documentation for our main outcome was assessed using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation).
The electronic search for literature resulted in total 2664 unique references. We read titles and summaries and excluded irrelevant publications. We read 25 potential relevant reviews in full text. 19 were excluded because they were not systematic reviews and one because of low methodological quality. We included five systematic reviews of high to moderate quality. These were published between 2008 and 2011. Three of the systematic reviews examined the effect of various preventive interventions on excessive alcohol consumption and alcohol related harm. Two systematic reviews dealt with the effect of enhanced enforcement of overservice laws.
Overserving, serving underage people and alcohol-related harm/injuries:
Three systematic reviews examined, respectively, the effects of interventions in the alcohol server setting for preventing injuries, the effects of alcohol interventions in nightlife settings and the effects of interventions implemented in drinking environments on a broad range of harms. They focused on different types of interventions: Server training, training for owner/manager, policy law enforcement, heightened police supervision and community interventions. The results varied:
- Effects of server training were measured by self-reported server behaviour, observed server behaviour, observed aggression and server knowledge, and the results varied across the studies. Mainly the results showed little or no differences between the interventions and the control groups. The quality of the evidence was either low or very low except for self-reported server behavior measured with behaviour index and observed aggression that we assessed to be of moderate quality
- For effects of training for owner/manager for observed server behavior there was no significant difference between the intervention and the control group. We assessed the evidence to be of low quality
- For effects of policy enforcement checks on propensity for alcohol sales to minor there was only reported lower percent of sales in the intervention group. The effect of control group was not reported. We assessed the evidence to be of low quality.
For observed server behaviour and injury/violence we are uncertain whether police enforcement checks improves the refusal of service to pseudo-patrons and serious assault rates obtained from police records as the quality of the evidence has been assessed as very low
- Heightened police supervision may make little or no difference to violence. We assessed the evidence to be of low quality
- For effects of community interventions such as for example the STAD-project (see page 28) there was a significant reduction in police reported violence. We assessed the evidence to be of low quality. For underage purchase attempts, the number of attempts were higher in the intervention group compared to the control group, for beer sales to underage there was no difference between the intervention and control group, and for access to alcohol the effect estimate was not reported. We assessed the evidence to be of low quality. For sales of alcohol to underage and pseudo intoxicated patrons the effect estimate was not reported and we assessed the evidence to be of very low quality
Overarching alcohol regulations
Two systematic reviews dealt with overarching alcohol regulation. One summarised the effects of dram shop liability and enhanced overservice law enforcement initiatives on excessive alcohol consumption and related harms. The second summarised the effects of policies restricting hours of alcohol sales in preventing excessive alcohol consumption and related harms. They focused on promoting responsible beverage service in on –premises retail alcohol outlets (e.g., bars and restaurants): dram shop liability and enhanced enforcement of overservice laws.
- For effects of overarching alcohol regulation we are uncertain whether limits of alcohol hours <2 hours improves purchase by minors and violent crimes and the quality of the evidence has been assessed as very low
The evidence base in this review of systematic reviews is comprehensive and the results vary in strength. Although the quality of the included systematic reviews was high to moderate, our quality of the documentation/studies varied in the reviews from very low to moderate quality. In most cases, the documentation was downgraded because the included studies were small, the results were inconsistent and the data was insufficient. There were also methodological study flaws.
In this overview of systematic reviews we found surveys that concluded with few positive effects of interventions to prevent intoxicated patrons, serving minors and alcohol-related violence in relation to licensed premises.
We could not use the included reviews as a whole, as several studies in the included reviews were not covered by our inclusion criteria. There is a need for more studies of high methodological quality studying the effect of interventions to prevent intoxicated patrons, serving minors and alcohol-related violence.