EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL MISUSE IN SCOTLAND: AN UPDATE TO THE LITERATURE REVIEW
SECTION FOUR: ENFORCEMENT
This section reviews the effectiveness and cost-effectiveness evidence relating to interventions to enforce legislation. The main findings of the previous review were:
there is limited evidence supporting community enforcement programmes for under-age drinking in the US;
random breath testing has been effective in enforcing drink drive legislation in the US and Australia, reducing fatalities, injuries and crashes;
a study modelling the costs and benefits of a sobriety checkpoint, using US data, showed benefits in excess of costs; and
a study of a server training programme in the US also found benefits in excess of costs.
The results of the present review:
confirm the effectiveness of both random breath testing and selective breath testing at sobriety checkpoints;
provide some support for server training but the effectiveness may depend on pre-existing levels of support for the objectives of the scheme;
confirm the cost-effectiveness of sobriety checkpoints
Results based on cost data from other countries may not directly translate into similar results in a UK setting. There is a lack of UK data relating to enforcement actions.
4.1 The previous section reviewed evidence relating to legislative interventions. The impact of legislation also depends on the action taken to enforce the measures and the visibility of the enforcement process. This section covers evidence relating to specific enforcement actions in the areas of:
legal drinking age;
drink driving; and
Only one new review of specific policies in this area was identified together with overviews of the evidence provided by Babor et al (2003) and Waller et al (2002).
LEGAL DRINKING AGE
Types of intervention
4.2 Enforcement of under-age sales laws frequently takes the form of 'decoy sales', in which under-age buyers attempt to purchase alcohol under observation of the enforcement agency. Enforcement campaigns may be accompanied by media publicity and training schemes aimed at sales outlets. No new reviews of this area were identified, although the importance of enforcement was identified in considering the effectiveness of minimum age legislation.
Types of intervention
4.3 No additional studies were identified relating to ignition interlock devices or 'administrative per se' licence suspension. The additional evidence relating to sobriety checkpoints is reviewed below.
4.4 A review by Elder et al (2002) confirms the effectiveness of both random breath testing (RBT) and selective breath testing (SBT) at sobriety checkpoints in reducing alcohol related crashes and consequential injuries and deaths. (SBT requires police to have a reason to suspect that the driver has been drinking; RBT does not). The studies reviewed suggest similar levels of effectiveness but there were no direct studies comparing the effectiveness of the two approaches. This review also demonstrated that sobriety checkpoints maintained their effectiveness over time. (These results are part of a wider review for the Task Force on Community Preventive Services and are also reported in Shults et al (2001). For the Task Force recommendations see Evans et al (2001)).
Table 4.1 Impact of sobriety checkpoints
Decrease in fatal crashes
Decrease in fatal and non fatal injury crashes
Decrease in property damage crashes
Median % (IQR)
Median % (IQR)
Median % (IQR)
22 (14 -35)
15 ; 26 *
20 ; 26*
20 (9 - 23)
24 (14 - 32)
*only two studies reported these results
Source: Elder et al (2002).
4.5 Babor et al (2003) also consider the limited evidence relating to designated driver programmes but any effect is modest. Ride services (free rides home for intoxicated persons who would otherwise drive) are popular but operate on too small a scale to have any impact at population levels.
Community sobriety checkpoint
4.6 In addition to the study reported in the previous review, Shults et al (2001) provide results from 3 non peer reviewed studies. All the studies report net benefits. The additional study of a SBT checkpoint gives a higher benefit to cost ratio $23:1 but has excluded part of the costs (publicity and education). Two studies of RBT checkpoints have been carried out in Australia and The Netherlands. The former reports very high net benefits based on an assumed 75% reduction in crashes. The latter study reports a more modest net benefit, and a benefit to cost ratio of $2:1, based on a 25% reduction in crashes. This is more consistent with the effectiveness literature.
4.7 The effect of server training will depend on other factors, such as the actual or perceived level of enforcement relating to underage drinking and serving intoxicated drinkers and the legal liability and penalties relating to owners and servers themselves. Studies of server training may evaluate outcomes in terms of server behaviour, drinking outcomes or further consequences in terms of accidents or other results of intoxication.
4.8 Shults et al (2001) report two studies showing improvements in appropriate server behaviour follow training; one based on observation and the other using researchers as customers. Three studies reporting BAC all showed reductions in the number of customers reaching specific levels (drink drive limits). One study showed a non-significant decrease in alcohol consumption although drinks per hour were reduced. Babor et al (2003) also review this area and indicate that voluntary agreements may be successful if supported by community pressure but there are no controlled evaluations.
QUALITY AND RELEVANCE OF EVIDENCE
4.9 The problems with drink driving studies were identified in the previous review (Ludbrook et al 2002 pp33-34). The reviews carried out for The Community Preventative Services Task Force take the quality of the studies into account and their recommendations indicate that the evidence is considered sufficiently robust.
4.10 The server training evaluations are fairly small-scale studies. Four out of 5 studies were based on volunteer programmes and one reports that most of the effect was due to one establishment with a particularly supportive manager. There is only short-term follow up and the results may not be generalisable.
4.11 The research requirements identified previously were:
UK evidence relating to enforcement actions, particularly with respect to under-age drinking;
the length of time for which the effects of enforcement actions are sustained; and
the level of enforcement that is optimal, in terms of costs and benefits.
The review by Elder et al (2002) indicates that the impact of sobriety checkpoints is maintained over time. The other research requirements remain to be met.