Alcohol

Brief Introduction

Alcohol continues to be the most widely used substance by both adults and youth in the United States. In fact, 2015 statistics from the National Survey on Drug Use and Health (NSDUH) report that 86% of adults have drank alcohol in their lifetime. When asked about the past year, that number drops to 70%, but is still the majority of adults. Just over half of adults say they drank in the last month. Most of these adult drinkers however, drink modest amounts and experience little to no health impacts for their drinking. A smaller percentage, approximately 27% of adults are binge drinkers and it is this behavior that is driving around three-quarters of the total costs related to alcohol misuse in this country which in 2010 amounted to a stark $249 billion. Some of these binge drinkers become heavy drinkers or meet the criteria for an Alcohol Use Disorder (AUD). In fact, it is estimated that 15 million adults had AUD in 2015. Alcohol misuse is related to unintentional injury and death; it is the third leading preventable cause of death in this country, and many are losing their lives to the consequences of alcohol- impaired driving (represents 31% of all driving fatalities). In addition, heavy alcohol use places a significant burden on our healthcare system. Almost half of all liver disease and cirrhosis deaths are attributable to excessive and continued use of alcohol andalcohol increases one’s risk of certain types of cancer (e.g. pharynx, breast, mouth,esophagus). Unborn children are impacted by alcohol misuse at a growing rate sincethe late 1990’s which can be seen in the prevalence of Fetal Alcohol Syndrome (NIAAA, 2018)

In addition, alcohol is typically the first substance that young people try in their teenage years. These same 2015 NSDUH statistics found that around 20% of youth between the ages of 12 and 20 years-old drank alcohol in the past month and approximately 13% engaged in binge drinking. Youth alcohol use is particularly concerning given what we now know about the human brain, which is not fully developed until the mid-twenties. Research suggests that the earlier a person begins using alcohol, the more likely they are to develop alcohol problems later in life. In addition, young people put themselves at risk for a variety of negative consequences associated with drinking such as drinking and driving, accidents, and they are more likely to be the victim of a physical or sexual assault (or engage in one as the perpetrator).

A wealth of research on the prevention of alcohol has been conducted over the pastcouple of decades and while prevention science has advanced in many ways, “what works” hasn’t changed significantly over the years. Many successful strategies havefocused on limiting the amount of alcohol available in the environment, enforcing existing laws against sales to minors, increasing the consequences associated with excessive alcohol use, and increasing the price of alcohol. The research is clear that reduced access to alcohol for both adults and youth results in less drinking and alcohol related problems. Also, people tend to be price-sensitive (as the price of alcohol goes up, excessive drinking tends to go down). Some strategies have aimed to change the community norms associated with excessive alcohol use and underage drinking. A significant focus has been placed on minimizing risk factors and increasing protective factors as they relate to youth. Regardless of the strategies a community decides to implement, communities must consider their unique qualities and ensure that they are carrying out data-driven plans that address a variety of factors simultaneously (Harding, et al., 2016).

Methods

Data Sources and Searches

We followed a predefined protocol to identify and select peer-reviewed manuscripts to include in this literature review. We began our search by identifying resources for systematic reviews on this topic. Given that there are several existing systematic reviews on the topic, we used them as a starting point from which to build our search efforts. We selected the following two sources for this purpose: (1) The Guide to Community Preventive Services (The Community Guide), and (2), the County Health Roadmaps. This particular topic area is titled “Excessive Alcohol Consumption” in The Community Guide, which includes underage drinking, and “Alcohol and Drug Use” in theCounty Health Roadmaps. The following is a brief description of each of these resources.

The Guide to Community Preventive Services (The Community Guide) Established in 1996 by the U.S Department of Health and Human Services (HHS), The Guide to Community Preventive Services is a collection of systematic reviews and recommendations on evidence-based interventions to improve public health. This work, which is ever-expanding (a topic prioritization process is conducted every five years), is overseen by The Community Preventive Services Task Force (CPSTF), a group of 15 nonfederal experts in public health and prevention research, practice and policy, appointed by the Director of the Centers for Disease Control and Prevention (CDC). A group of staff members based at the CDC provide the scientific, technical and administrative support needed to carry out this work to include coordinating systematic review teams, maintaining adherence to the approved review methods, writing and publishing findings, and disseminating the recommendations to audiences who can use them to improve public health policy and practice. High quality systematic reviews like the ones conducted by the CPSTF provide a reliable source of evidence to guide program, practice and policy. The reason is that they are guided by a specific protocol for finding relevant research articles, determining whether or not to include them in the analysis of findings, and eliminating reviewer bias by involving a minimum of two people in the systematic review process. Systematic review findings can be extremely valuable for informing practice because they do not focus on the components, settings, target audiences and outcomes of one single study. Instead, they take the body of research on a particular program or intervention and determine whether or not it is likely to produce a benefit even if it is executed in slightly different ways in a community.

The Community Guide findings are reported in the following three categories: (1) Recommended: Strong or sufficient evidence that the intervention is effective. (2) Recommended Against: Strong or sufficient evidence that the intervention is harmful or not effective. (3) Insufficient Evidence: The available studies do not provide sufficient evidence to determine if the intervention is, or is not, effective. More research is necessary before a recommendation can be made.

The County Health Roadmaps

A collaboration between the Robert Wood Johnson foundation and the University of Wisconsin’s Population Health Institute, the County Health Roadmaps serve as a guidefor groups working to improve community health to prioritize efforts. Programs and policies are given a rating based on the amount and type of evidence on the topic, and the quality of that evidence. Systematic reviews such as those published by the Community Preventive Services Taskforce (CPST) and high quality peer-reviewed studies with designs that demonstrate causality as it pertains to specified outcomes andare given the most “weight” in this process. In addition, grey literature (not formally orcommercially published) is incorporated into the search, selection, and assessment process. There are six rating categories designated by two analysts’ assessments ofeach strategy. Community members are encouraged to prioritize strategies with the strongest evidence of effectiveness before selecting those with insufficient or mixed evidence, and to avoid those with evidence of ineffectiveness. Guidance is also provided on how to consider innovation and community context when implementingstrategies, and various “tools for action” are made available to help communitiessucceed with their work.

The rating categories are as follows:

(1) Scientifically Supported: Strategies with this rating are most likely to make a difference. These strategies have been tested in multiple robust studies with consistently favorable results.

(2)  Some Evidence: Strategies with this rating are likely to work, but further research is needed to confirm effects. These strategies have been tested more than once and results trend favorable overall.

(3)  Expert Opinion: Strategies with this rating are recommended by credible, impartial experts but have limited research documenting effects; further research, often with stronger designs, is needed to confirm effects.

(4)  Insufficient Evidence: Strategies with this rating have limited research documenting effects.  These strategies need further research, often with stronger designs, to confirm effects.

(5)  Mixed Evidence: Strategies with this rating have been tested more than once and results are inconsistent; further research is needed to confirm effects.

(6)  Evidence of Ineffectiveness: Strategies with this rating are not good investments. These strategies have been tested in multiple studies with consistently unfavorable or harmful results.

Rather than attempt to recreate these efforts, our review committee integrated them into our process. First, we reviewed The Community Guide and determined that anyenvironmental strategy identified as “recommended” in The Community Guide wasdesignated as “evidence-based” in our review, unless new literature was identified that provided evidence against the strategy. Next, we reviewed the County Health Roadmaps, which included updated reviews on all of the interventions reported in theThe Community Guide. For example, the evidence cited for Responsible Beverage Server Training in the County Health Roadmaps included the findings from The Community Guide in addition to various studies published through August 2015 (The Community Guide review of this intervention ended in October 2010). Because their review methodology was quite similar to ours, we determined that any environmentalstrategy identified as “scientifically supported” in the County Health Roadmaps wasdesignated as “evidence-based” in our review, unless new literature was identified that provided evidence against the strategy.

We searched the peer-reviewed literature on the topic since The Community Guide or the County Health Roadmaps completed their systematic review to identify any new research. The results of this search method are reflected in Table A1 below. Although there are a small number of articles reported in the review, this only reflects the articles in the protracted time period. Please keep in mind that there are multiple studies within the systematic reviews reported in both The Community Guide and County Health Roadmaps. Thus, this review is an update to these two systematic reviews.

After reviewing all The Community Guide and the County Health Roadmaps, we conducted a broad literature search to identify any additional strategies to reduce alcohol use and underage drinking that were not included in either The Community Guide and the County Health Roadmaps. For that search, we searched for articles that were published over the last 10 years (August 1, 2008 through August 31, 2018).

Table A1 presents the search periods corresponding to each intervention included inThe Community Guide and the County Health Roadmaps:

Table A1. Search Dates for Interventions Listed in The Community Guide and/orCounty Health Roadmaps

Dates	Intervention
August 1, 2008 - August 31, 2018	Social Host Laws Mass Media Campaigns Against Underage & Binge Drinking
January 1, 2014 – August 31, 2018	Responsible Beverage Service Training Social Norms Media Campaigns Restrictions on Drink Promotions Publicized Sobriety Checkpoint Programs Alcohol Outlet Density Restrictions
August 1, 2014 – August 31, 2018	Dram Shop Liability Laws Retailer Compliance Checks Advertising and Marketing Restrictions
August 1, 2015 – August 31, 2018	Keg Registration Laws
March 1, 2017 – August 31, 2018	Privatization of Off-Premises Retail Alcohol Sales
May 1, 2017 – August 31, 2018	Restrictions on Hours and Days of Sale Campus Alcohol Bans

All searches were conducted electronically using PubMed. Searches were limited to peer-reviewed, scholarly articles and we did not include research studies conducted in settings outside of the United States. In addition, all searches included the following string: ("alcohol consumption" OR "drinking" OR "alcohol abuse" OR “alcohol use” OR"drinking alcoholic beverages" OR "binge drinking"). All searches incorporated the following filters in PubMed: clinical study, journal article, meta-analysis, observational study, Randomized Controlled Trial, Review, Systematic Reviews; Species Humans; title/abstract (search fields). Table A2 provides the number of relevant manuscripts found for each search by intervention type. The number of articles selected for review is also provided. Please note that if an existing systematic review was used in the assessment, it is listed along with the number of articles included in the respective review.

Table A2. Search Results

Intervention	Search Strategy	Articles Identified (#)	Articles Selected (#)
Responsible Beverage Service Training	("alcohol consumption" OR "drinking" OR "alcoholabuse" OR “alcohol use” OR "drinking alcoholic beverages" OR "binge drinking" OR “underage drinking”) AND (“alcohol server” OR “responsiblebeverage service” OR "RBS" OR "server- intervention" OR "retailer")	17	4 + County Health Roadmaps (7)
Social Norms  Media Campaigns	("alcohol consumption" OR "drinking" OR "alcohol abuse" OR “alcohol use” OR "drinking alcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("media campaign" OR "information campaign" OR "social norms" OR"norming" OR “social marketing”) AND("prevention" OR "intervention" OR "community- based" OR "educational")	74	1 + County Health Roadmaps (2)
Restrictions on Drink Promotions	("alcohol consumption" OR "drinking" OR"alcohol abuse" OR “alcohol use” OR "drinkingalcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("happy hour" OR“price” OR “promotion” OR “marketing” OR “purchase” OR “two-for-one” OR “free drinks” or “drink specials” OR “price reduction” or “unlimited beverages”) AND ("prevention" OR "intervention"OR "strategy" OR "implementation" OR“community-based”)	262	1 + County Health Roadmaps (15)
Publicized Sobriety Checkpoint Programs	("alcohol consumption" OR "drinking" OR"alcohol abuse" OR “alcohol use” OR "drinkingalcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("sobriety checkpoint" OR "sobriety checkpoints" OR "DUI checkpoints")	14	1 + The Community Guide (6) + County Health Roadmaps (5)
Restrictions on Hours and Days of Sale	("alcohol consumption" OR "drinking" OR"alcohol abuse" OR “alcohol use” OR "drinking alcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("days of sale" OR"hours of sale")	17	0 + The Community Guide (3) + County Health Roadmaps (4)
Social Host Laws	("alcohol consumption" OR "drinking" OR"alcohol abuse" OR “alcohol use” OR "drinkingalcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("social host" or “socialhost liability” or “social host ordinance”)	13	2+ County Health Roadmaps (2)
Dram Shop Liability Laws	("alcohol consumption" OR "drinking" OR "alcohol abuse" OR “alcohol use” OR "drinkingalcoholic beverages" OR "binge drinking") AND("dram shop liability” OR “criminal liability” OR “civil liability” OR “dram shop laws” OR “liability” OR “commercial host”) AND ("prevention" OR"intervention" OR "strategy" OR "implementation"OR “policy”)	8	0+ The Community Guide (11) + County Health Roadmaps (2)
Retailer Compliance Checks	("alcohol consumption" OR "drinking" OR"alcohol abuse" OR “alcohol use” OR "drinking alcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("retailer compliance"OR "purchase survey" OR "compliance check")	1	1 + The Community Guide (1)
Retailer Mystery Shop Programs	("alcohol consumption" OR "drinking" OR "alcohol abuse" OR “alcohol use” OR "drinkingalcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("servers and clerks"OR "alcohol outlets" OR "retail mystery shop")	99	1
Use of ID Scanners for Retailers	("alcohol consumption" OR "drinking" OR"alcohol abuse" OR “alcohol use” OR "drinkingalcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("fake ID" OR "falseID" OR "scanner")	40	1
Alcohol Outlet Density Restrictions	("alcohol consumption" OR "drinking" OR "alcohol abuse" OR “alcohol use” OR "drinking alcoholic beverages" OR "binge drinking") AND ("alcohol outlet” OR “density” OR “liquor stores” OR “outlets”) AND ("prevention" OR"intervention" OR "strategy" OR "implementation"OR “community-level)	148	2 + The Community Guide (19) + County Health Roadmaps (5)
Privatization of Off-Premises Retail Alcohol Sales	("alcohol consumption" OR "drinking" OR"alcohol abuse" OR “alcohol use” OR "drinkingalcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("alcohol retailprivatization" OR "retail alcohol sales" OR "private alcohol sales")	8	0+ The Community Guide (14) + County Health Roadmaps (4)
Advertising and Marketing Restrictions	("alcohol consumption" OR "drinking" OR"alcohol abuse" OR “alcohol use” OR "drinking alcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("alcohol advertising"OR "alcohol marketing" OR "media exposure" OR "advertising ban" OR "advertising restriction")	84	0+ County Health Roadmaps (5)
Mass Media Campaigns Against Underage & Binge Drinking	("alcohol consumption" OR "drinking" OR"alcohol abuse" OR “alcohol use” OR "drinking alcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("communication campaign" OR "information campaign" OR "media campaign" OR "youth drinking prevention campaign" OR "underage drinking prevention campaign" OR "parents who host" OR "talk they hear you" OR "social media campaign")	32	3 + County Health Roadmaps (1)
Keg Registration Laws	("alcohol consumption" OR "drinking" OR"alcohol abuse" OR “alcohol use” OR "drinking alcoholic beverages" OR "binge drinking" OR “underage drinking”) AND ("keg registration” OR “identification tags” OR “beer kegs”)	0	0+ County Health Roadmaps (7)
Campus Alcohol Bans	("alcohol consumption" OR "drinking" OR"alcohol abuse" OR “alcohol use” OR "drinkingalcoholic beverages" OR "binge drinking" OR“underage drinking”) AND ("campus alcoholbans" OR "alcohol policies" OR "university alcohol policy" OR "alcohol ban" OR "dry campus")	15	0+County Health Roadmaps (3)

Study Selection

All titles and abstracts were independently screened by 1 of 2 investigators (AD or WG). Articles that were considered relevant advanced to full-text review. In order to be eligible, an intervention must have been implemented in the United States. Commentary and policy statements were not included. Table A2, above, includes the number of relevant manuscripts for each intervention. We focused on environmental-level as opposed to individual-level strategies with meaningful outcomes related to drinking behavior, associated risk factors, and related consequences for both adults and youth. We focused on strategies that coalitions in North Carolina can successfully impact at the local-level. Given this, we decided not to include blood alcohol concentration (BAC) laws, alcohol taxes or minimum legal drinking age (MLDA) laws in this review.

Data Extraction and Quality Assessment

One of 2 researchers (AD or WG) independently read selected articles. Using the standardized article assessment form, the following data was captured: study design (including type of study, whether or not the study was a replication study, use of reliable and valid instruments, and measurement of intervention dose), standardization of the intervention, population studied, setting, and sample size. A brief description and overview of findings were documented. Additionally, the investigators coded the type of intervention (e.g., alcohol outlet density restrictions, responsible beverage service training, etc.) and environmental strategy (e.g., availability/access, price, promotion, etc.).

Four investigators (AD, BG, MW, and KW) reviewed and discussed all the articles that underwent full-text review and data extraction in order to assess the evidence for each intervention using the operational definitions and Matrix of Level of Effectiveness,described in this report’s Introduction. The interventions were identified as: evidence- based, promising, or insufficient evidence / not evidence-based.

Results

Responsible Beverage Service Training (RBST)

Evidence Level	Evidence-based Rationale: RBST is most effective if part of a broader strategy for reducing alcohol use. There is minimal information on the reduction of underage drinking, but the data indicates a positive impact on youth drinking behavior. In addition, RBST improves risk factors associated with underage drinking such as retail availability and decreases alcohol related consequences such as impaired driving.
Transparency	4 peer-reviewed articles + County Health Roadmaps
Research	4 experimental + 1 systematic review
Standardization	2 standardized; 2 unknown
Replication	Unknown
Fidelity Scale	Unknown
Meaningful Outcomes	There are multiple outcomes reported including ID checks, serving intoxicated patrons, intra-store communication about best practices, changes in store signage and changes in store policies.

References

1. Danaher, B.G, Dresser, J., Shaw, T., Severson, H.H., Tyler, M.S., Maxwell, E.D. & Christiansen, S.M. (2012). Development and process evaluation of a web-based responsible beverage service training program. Substance Abuse Treatment, Prevention and Policy, 7(41). https://doi.org/10.1186/1747-597X-7- 41.

2. Fell, J.C., Fisher, D.A., Yao, J. & McKnight, A.S. (2017). Evaluation of a responsible beverage service and enforcement program: Effects on bar patron intoxication and potential impaired driving by young adults. Traffic Injury Prevention, 18(6), 557-565. https://doi.org/10.1080/15389588.2017.1285401

3. Lenk,K.M.,Erickson,D.J.,Nelson,T.F,Horvath,K.J,Nederhoff,D.M,Hunt, S.L, Ecklund, A.M & Toomey, T.L. (2018). Changes in alcohol policies and practices in bars and restaurants after completion of manager-focused responsible service training. Drug and Alcohol Review, 37(3), 356-364. https://doi.org/10.1111/dar.12629

4. Wolff, L.S., El Ayadi, A.M, Lyons, J.N., Herr-Zaya, K., Noll, D., Perfas, F, & Rots, G. (2010). Improving the alcohol retail environment to reduce youth access: A randomized community trial of best practices toolkit intervention.Journal of Community Health, 36(3), 357-366. https://doi.org/10.1007/s10900- 010-9316-8

Reviews

5. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Responsible Beverage Server Training. (2015). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works- for-health/policies/responsible-beverage-server-training-rbsrbst

Social Norms Media Campaigns

Evidence Level	Promising Rationale: The research is mixed. Some data indicates positive impacts while other do not. In addition, most of this research applies to college students who are underage as opposed to younger (15-18 year old’s). The evidence isstronger on student perceptions than actual use, but with the right conditions it appears this can be effective for youth drinking.
Transparency	1 peer reviewed article + County Health Roadmaps
Research	1 quasi-experimental + 1 systematic review
Standardization	Unknown
Replication	Unknown
Fidelity Scale	Unknown
Meaningful Outcomes	In general, the types of campaigns can be effective. However, it is important to select the right campaign (both in terms of content and delivery methodology) for the right audience. Abstinence based messaging, in general, showed the greatest impact on attitudes and behavior.

References

1. Glassman, T.J., Sloan Kruger, J., Deakins, B.A., Paprzycki, P., Blavos, A.A., Hutzelman, E.N. & Diehr, A. (2016). Abstinence, social norms, and drink responsibly messages: A comparison study. Journal of Alcohol and Drug Education, 60(2), 72-90.

Reviews

2. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). School-based social norming: Alcohol Consumption. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve- health/what-works-for-health/policies/school-based-social-norming-alcohol- consumption

Restrictions on Drink Promotions

Evidence Level	Evidence-Based Rationale: Studies have found associations between discounted alcohol prices (e.g. two-for-one specials, happy hours, free or unlimited drinks) and increased excessive alcohol consumption. However, underage drinking outcomes tend to focus on the college student population (i.e. 18-20 years-old). With that said, coalitions serving communities with college campuses may benefit from assessing and limiting drink promotions. Additional research is needed to determine if there are any effects for high school-aged youth.
Transparency	1 peer reviewed + County Health Roadmaps
Research	1 quasi-experimental + 1 systematic review
Standardization	No
Replication	No
Fidelity Scale	Unknown
Meaningful Outcomes	Outcomes are focused on impacts among the older underage drinker population and individuals at or above the Minimum Legal Drinking Age (MLDA). In addition, to findings related to reduced alcohol consumption, there is some evidence indicating that lower prices increased the amount of drinking a person plans to do. There is also an association between increased alcohol prices and decreased alcohol-related motor vehicle accidents, traffic offenses and other negative health effects.

References

1. Baldwin, J.M., Stogner, J.M. & Miller, B.L. (2014). It's five o'clock somewhere: An examination of the association between happy hour drinking and negative consequences. Substance Abuse Treatment, Prevention, and Policy. 597(x), 9- 17. https://doi.org/10.1186/1747-597X-9-17

Reviews

2. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Drink Special Restrictions. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works- for-health/policies/drink-special-restrictions

Publicized Sobriety Checkpoint Programs

Evidence Level	Evidence-Based Rationale: While the research is unable to link sobriety checkpoints with underage drinking, well-publicized programs can increase the perception or risk associated with alcohol- impaired driving. They are recommended as part of a comprehensive strategy. They appear to be more effective when they are conducted on a regular basis (at least monthly) and include mass media campaigns to promote awareness. High media coverage with lower frequency checkpoints is more effective than checkpoints on their own.
Transparency	1 peer-reviewed study + 1 peer-reviewed systematic review (The Community Guide) + County Health Roadmaps
Research	1 quasi-experimental study + 2 systematic reviews
Standardization	Unknown
Replication	Unknown
Fidelity Scale	Unknown
Meaningful Outcomes	Outcomes focused on decreasing drinking, decreasing impaired driving, and decreasing traffic injuries.

References

1. Browning, S., & Thompson, K. (2016). Specific deterrence and the infrequent use of sobriety checkpoints. Security Journal, 29, 340-351. https://doi.org/10.1057/sj.2013.31

Reviews

2. Bergen,G.,Pitan,A.,Qu,S.,Shults,R.A.,Chattopadhyay,S.K.,Elder, R.W., Sleet, D.A., Coleman, H.L., Compton, R.P., Nichols, J.L., Clymer, J.M., & Calvert, W.B. (2014). Publicized sobriety checkpoint programs: a community guide systematic review. American Journal of Preventive Medicine, 46(5), 529-539. https://doi.org/10.1016/j.amepre.2014.01.018

3. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Breath Testing Checkpoints. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what- works-for-health/policies/breath-testing-checkpoints

Restrictions on Hours and Days of Sale

Evidence Level	Promising Rationale: While these studies focus primarily on adult use the resulting decreasing in adult drinking and drinking consequences are directly related to retail availability which is a key risk factor for youth.
Transparency	2 peer-reviewed systematic reviews (The Community Guide) + County Health Roadmaps
Research	3 systematic reviews
Standardization	Unknown
Replication	Unknown
Fidelity Scale	Unknown
Meaningful Outcomes	Most significant outcomes relate to decreased drinking and behaviors associated with drinking including and assaults, impaired driving. While there were no youth outcomes measured, the decreasing of retail availability (described elsewhere) is an important strategy for reducing underage drinking.

Reviews

1. Hahn, R. A., Kuzara, J. ., Elder, R., Brewer, R., Chattopadhyay, S., Fielding, J., Naimi, T.S., Toomey, T., Middleton, J.C., Lawrence, B., & the Task Force on Community Preventive Services. (2010). Effectiveness of policies restricting harms. American Journal of Preventive Medicine, 39(6), 590–604. https://doi.org/10.1016/j.amepre.2010.09.016

2. Middleton, J.C., Hahn, R.A., Kuzara, J.L, Elder, R., Brewer, R., Chattopadhyay, S., Fielding, J., Naimi, T.S., Toomey, T., Laurence B. & the Task Force on Community Preventive Services. (2010). Effectiveness of policies maintaining or restricting days of alcohol sales on excessive consumption and related harms. American Journal of Preventive Medicine, 39(6):575–589. https://10.1016/j.amepre.2010.09.015

3. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Alcohol days of sale restrictions. (2017). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works- for-health/policies/alcohol-days-of-sale-restriction

 

Dram Shop Liability Laws

Evidence Level	Evidence-Based Rationale: There are two systematic reviews described here. While there are some associations for adult binge drinking behaviors, this is limited by mixed findings on some risk factors. There is no discussion on the impact of youth initiation, or drinking behavior and very little on youth risk factors.
Transparency	1 peer-reviewed systematic review (The Community Guide) + County Health Roadmaps
Research	2 systematic reviews
Standardization	Unknown
Replication	Unknown
Fidelity Scale	Unknown
Meaningful Outcomes	These laws have the most significant impact on those who binge drink in retail establishments. While these may be an important part of a comprehensive community strategy, there is little known about the anticipated impact on youth drinking behavior.

Reviews

1. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Dram Shop Liability Laws. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works- for-health/policies/dram-shop-liability-laws

2. Rammohan, V., Hahn, R.A., Elder, R., Brewer, R., Fielding, J, Naimi, T.S., Toomey, T.L., Chattopadhyay, S.K., Zometa, C. & Task Force on Community Preventive Services. (2011). Effects of dram shop lability and enhanced overservice law enforcement initiatives on excessive alcohol consumption and related harms. American Journal of Preventive Medicine, 41(3), 334-343. https://doi.org/10.1016/j.amepre.2011.06.027

Retailer Compliance Checks

Evidence Level	Evidence-Based Rationale: While there is limited research linking retailer compliance checks with youth drinking behaviors, this intervention is strongly associated with a decrease in alcoholsales to both “decoys” (individuals judged to appear underthe age of 21) and actual underage purchasers. Therefore, this intervention is likely to benefit communities that identify retail purchases at off-premises establishments as significant access points for youth. It is important to note that effective compliance check programs are conducted on a regular schedule due to the effects decaying over time, and include publicity efforts.
Transparency	1 peer-reviewed + The Community Guide
Research	1 quasi-experimental study +1 systematic review
Standardization	Unknown
Replication	Yes
Fidelity Scale	Unknown
Meaningful Outcomes	Outcomes were focused on how many agencies that conduct compliance checks use optimal methods-including checking all establishments in the jurisdiction, conducting checks at least 3 to 4 times per year, conducting follow-up checks within 3 months, and penalizing the licensee (not only the server/clerk) for failing a compliance check, and (iii) characteristics of the agencies that conduct compliance checks.

References

1. Erickson, D. J., Smolenski, D. J., Toomey, T. L., Carlin, B. P.,
& Wagenaar, A. C. (2013). Do alcohol compliance checks decrease underage sales at neighboring establishments? Journal of Studies on Alcohol and Drugs, 74, 852–858.https://doi.org/10.15288/jsad.2013.74.852

Reviews

2. Elder RW, Lawrence BA, Janes G, Brewer RD, Toomey TL, Hingson RW, Naimi TS, Wing S, Fielding J. Enhanced enforcement of laws prohibiting sale of alcohol to minors: Systematic review of effectiveness for reducing sales and underage drinking. Transportation Research Circular. 2007;2007 (E-C123):181–188. http://www.preussergroup.com/trbanb50/ec123.pdf#page=187%20.

Retailer Mystery Shop Programs

Evidence Level	Promising Rationale: This research describes an approach that parallels compliance checks except for the involvement of law enforcement and ensuring that all decoys are actually legal purchasers. Only one study could be found and it has positive results.
Transparency	1 peer reviewed
Research	1 experimental
Standardization	Yes
Replication	No
Fidelity Scale	Unknown
Meaningful Outcomes	Outcomes are focused on decreases of alcohol-related driving fatalities, alcohol consumption, alcohol-related violence, and alcohol-related diseases. Decreased ratio of drinking to nondrinking drivers under age 21 involved in fatal crashes.

1. References
2. Grube, JW, DeJong, W, DeJong, M, Lipperman‐Kreda, S, Krevor & Brad S. (2018). Effects of a responsible retailing mystery shop intervention on age verification by servers and clerks in alcohol outlets: A cluster randomised cross-over trial. Drug and Alcohol Review, 37,774-781. https://doi.org/10.1111/dar.12839

Use of ID Scanners

Evidence Level	Promising Rationale: Although there is only one study that considers this approach, the desing was rigorous and considered meaningful outcomes. More research is needed on this topic to move it to an evidence-based practice.
Transparency	1 peer reviewed article
Research	1 experimental
Standardization	Unknown
Replication	No
Fidelity Scale	Unknown
Meaningful Outcomes	Found that the false ID laws with scanner provision significantly reduce underage drinking, including up to a 0.22 drink decrease in the average number of drinks consumed by underage youth per day. This effect is observed particularly in the short-run and more pronounced for non-college students and those who are relatively younger.

References

1. Baris, Y.K. (2014). Can technology help to reduce underage drinking? Evidence from the false ID laws with scanner provision. Journal of Health Economics, 36, 33-46. https://doi.org/10.1016/j.jhealeco.2014.03.004

Alcohol Outlet Density

Evidence Level	Evidence-Based Rationale: There is strong evidence that this approach is important for reducing underage drinking by decreasing retail access for adults and youth.
Transparency	2 peer-reviewed + 1 peer-reviewed systematic review (The Community Guide) + County Health Roadmaps
Research	2 systematic reviews + 1 experimental + 1 quasi- experimental
Standardization	Unknown
Replication	Unknown
Fidelity Scale	Unknown
Meaningful Outcomes	Research clearly describes that outlet density is associated with high levels of drinking and binge drinking for adults, college underage drinking, and younger drinking. The general research findings is that reducing alcohol outlet density will decrease underage drinking.

References

1. Scribner, R., Mason, K., Theall, K., Simonsen, N., Schneider, S. K., Towvim, L. G., & DeJong, W. (2008). The contextual role of alcohol outlet density in college drinking. Journal of Studies on Alcohol and Drugs, 69(1), 112-120.

2. Tanumihardjo, J., Shoff, SM.S., Koenings, M., Zhang, Z. & Lai, H.J. (2015). Association between alcohol use among college students and alcohol outlet proximity and densities. Wisconsin Medical Journal, 114(4), 143-147.

Reviews

3. Campbell CA, Hahn RA, Elder R, et al. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms. American Journal of Preventive Medicine. 2009;37(6):556–69.

4. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Alcohol Outlet Density Restrictions. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what- works-for-health/policies/alcohol-outlet-density-restrictions

Privatization of Off-Premises Retail Alcohol Sales

Evidence Level	Evidence-Based Rationale: While local communities can rarely impact this area the research presented here is clear that privatization significantly increases all types of drinking and negative consequences associated with drinking.
Transparency	1 peer-reviewed systematic review (The Community Guide) + County Health Rankings
Research	2 systematic reviews
Standardization	Unknown
Replication	Unknown
Fidelity Scale	Unknown
Meaningful Outcomes	Privatization requires strong counter-measures and can significantly impact both adult and youth drinking behavior. Privatization is associated with increased outlet density and increased retail outlets, both of which increase negative drinking behaviors. It may be important for coalitions in privatized states to understand how privatization leads to increased drinking so they can plan counter strategies appropriately.

Reviews

1. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Retail Alcohol Sale Privatization. (2017). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works- for-health/policies/retail-alcohol-sale-privatization

2. Hahn, R.A, Middleton, J.C, Elder, R., Brewer, R et al. (2012). Effects of alcohol retail privatization on excessive alcohol consumption and related harms: A community guide systematic review. American Journal of Preventive Medicine, 42(4), 418-427.

Advertising and Marketing Restrictions

Evidence Level	Insufficient Evidence Rationale: There is some evidence that exposure to alcohol advertising and marketing through various communications mediums has an impact on youth alcohol related beliefs (of varying types). Numerous studies look at the kinds of marketing and advertising messages aimed at youth and how they may differ by geographical area. Very little research provides a link between advertising and drinking behavior and numerous studies were published internationally and not part of our review. We saw no studies looking at the effects of an intervention aimed at restricting advertising and marketing as a single strategy.
Transparency	County Health Roadmaps
Research	1 systematic review
Standardization	Unknown
Replication	Unknown
Fidelity Scale	Unknown
Meaningful Outcomes	Outcomes focused on changes in alcohol-related beliefs among youth and adults, impacts on alcohol brand preferences, and the kinds of messaging alcohol companies are directing toward youth.

Reviews

County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Alcohol Advertising Restrictions. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/alcohol-advertising-restrictions

Keg Registration Laws

Evidence Level	Insufficient Evidence Rationale: The County Health Rankings Roadmap classifieskeg registration laws as “insufficient evidence”. Studies donot indicate that keg registration laws have no direct relationship to underage drinking. In addition, many of the studies measure the outcome of underage drinking (as opposed to drinking).
Transparency	County Health Roadmaps
Research	1 systematic review
Standardization	Unknown
Replication	Unknown
Fidelity Scale	Unknown
Meaningful Outcomes	Keg registration has been recognized as potentially beneficial in part of a multi-component approach to reduce impaired driving. However, there is also evidence demonstrating that keg registration alone is not related to beer consumption, binge drinking, or impaired driving. In fact, some research indicates a negative impact resulting in increases in impaired driving and binge drinking.

Reviews

County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Keg registration laws. (2015). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/keg-registration-laws

Campus Alcohol Bans

Evidence Level	Insufficient Evidence Rationale: According to the County Health Rankings Roadmap there is very little evidence to support the relationship between campus alcohol bans and decreased use of alcohol. In fact, the research indicates no significant relationship between underage drinking and campus alcohol bans.
Transparency	County Health Roadmaps
Research	1 systematic review
Standardization	Unknown
Replication	Unknown
Fidelity Scale	Unknown
Meaningful Outcomes	It is estimated that about 34% of four year colleges and universities have some sort of campus alcohol ban. Research demonstrates small decreases in frequency of alcohol use, but no impact on binge drinking.

Reviews

County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Campus alcohol bans. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/campus-alcohol-bans

Social Host Laws

Evidence Level	Promising Rationale: The research here shows some impact on group drinking behavior and group binge drinking with less impact on overall drinking for youth. It also appears that different kinds of social host laws have differing impacts on youth drinking behavior. The research cited here focuses on laws that deter underage drinking parties which hold the individuals who control the property accountable for underage drinking that occurs on the premises, irrespective of who provided it.
Transparency	2 peer-reviewed + County Health Roadmaps
Research	2 experimental + 1 systematic review
Standardization	Unknown
Replication	Unknown
Fidelity Scale	Unknown
Meaningful Outcomes	Social host laws appear to be most effective for creating extra barriers for youth drinking by decreasing the amount of youth drinking in large groups in private homes. It is unclear how this impacts overall drinking and initiation, but some evidence suggests it can reduce drinking for those who have already started drinking. Local social host policies that include strict liability and civil penalties that are imposed administratively may be associated with less frequent underage drinking in private settings

References

Wagoner, K.G., Sparks, M., Francisco, V.T., Wyrick, D., Nichols, T. & Wolfson, M. (2013). Social host policies and underage drinking parties. Substance Use and Misuse, 48(1-2), 41-53. https://doi.org/10.3109/10826084.2012.722158

Paschall, M.J., Lipperman-Kreda, S., Grube, J.W. & Thomas, S. (2014). Relationships between social host laws and underage drinking: findings from a study of 50 California cities. Journal of Studies on Alcohol and Drugs, 75(6), 901- 907.https://doi.org/10.15288/jsad.2014.75.901

Reviews

County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Social Host Liability. (2015).

References

1. Baldwin, J.M., Stogner, J.M. & Miller, B.L. (2014). It's five o'clock somewhere: An examination of the association between happy hour drinking and negative consequences. Substance Abuse Treatment, Prevention, and Policy. 597(x), 9-17.

2. Barıs,Y.K.(2014).Cantechnologyhelptoreduceunderagedrinking?Evidence from the false ID laws with scanner provision. Journal of Health Economics, 36, 33- 46.

3. Bergen, G., Pitan, A., Qu, S., Shults, R.A., Chattopadhyay, S.K., Elder, R.W., Sleet, D.A., Coleman, H.L., Compton, R.P., Nichols, J.L., Clymer, J.M., & Calvert, W.B. (2014). Publicized sobriety checkpoint programs: a community guide systematic review. American Journal of Preventive Medicine, 46(5), 529-539.

4. Browning, S., & Thompson, K. (2016). Specific deterrence and the infrequent use of sobriety checkpoints. Security Journal, 29, 340-351.

5. Campbell CA, Hahn RA, Elder R, et al. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms. American Journal of Preventive Medicine. 2009;37(6):556–69.

6. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Responsible Beverage Server Training. (2015). Retrieved from:http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/responsible-beverage-server-training-rbsrbst

7. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Alcohol Advertising Restrictions. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/alcohol-advertising-restrictions

8. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). School-based social norming: Alcohol Consumption. (2014). Retrieved from:http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/school-based-social-norming-alcohol-consumption

9. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Drink Special Restrictions. (2014). Retrieved from:http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/drink-special-restrictions

10. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Breath Testing Checkpoints. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/breath-testing-checkpoints

11. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Campus alcohol bans. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/campus-alcohol-bans

12. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Alcohol days of sale restrictions. (2017). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/alcohol-days-of-sale-restrictions

13. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Dram Shop Liability Laws. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/dram-shop-liability-laws

14. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Alcohol Outlet Density Restrictions. (2014). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/alcohol-outlet-density-restrictions

15. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Retail Alcohol Sale Privatization. (2017). Retrieved from:http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/retail-alcohol-sale-privatization

16. County Health Rankings & Roadmaps. What works for health (Alcohol and Drug Use). Keg registration laws. (2015). Retrieved from: http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for- health/policies/keg-registration-laws

17. Danaher, B.G, Dresser, J., Shaw, T., Severson, H.H., Tyler, M.S., Maxwell, E.D. & Christiansen, S.M. (2012). Development and process evaluation of a web-based responsible beverage service training program. Substance Abuse Treatment, Prevention and Policy, 7(41).

18. Elder RW, Lawrence BA, Janes G, Brewer RD, Toomey TL, Hingson RW, Naimi TS, Wing S, Fielding J. Enhanced enforcement of laws prohibiting sale of alcohol to minors: Systematic review of effectiveness for reducing sales and underage drinking. Transportation Research Circular. 2007;2007(E-C123):181–188.

19. Erickson, D. J., Smolenski, D. J., Toomey, T. L., Carlin, B. P., & Wagenaar, A. C. (2013). Do alcohol compliance checks decrease underage sales at neighboring establishments? Journal of Studies on Alcohol and Drugs, 74, 852–858.

20. Fell, J.C., Fisher, D.A., Yao, J. & McKnight, A.S. (2017). Evaluation of a responsible beverage service and enforcement program: Effects on bar patron intoxication and potential impaired driving by young adults. Traffic Injury Prevention, 18(6), 557-565.

21. Glassman, T.J., Sloan Kruger, J., Deakins, B.A., Paprzycki, P., Blavos, A.A., Hutzelman, E.N. & Diehr, A. (2016). Abstinence, social norms, and drink responsibly messages: A comparison study. Journal of Alcohol and Drug Education, 60(2), 72-90.

22. Grube, JW, DeJong, W, DeJong, M, Lipperman‐Kreda, S, Krevor & Brad S. (2018). Effects of a responsible retailing mystery shop intervention on age verification by servers and clerks in alcohol outlets: A cluster randomised cross-over trial. Drug and Alcohol Review, 37,774-781.

23. Hahn, R. A., Kuzara, J. L., Elder, R., Brewer, R., Chattopadhyay, S., Fielding, J., Naimi, T.S., Toomey, T., Middleton, J.C., Lawrence, B., & the Task Force on Community Preventive Services. (2010). Effectiveness of policies restricting hours of alcohol sales in preventing excessive alcohol consumption and related harms. American Journal of Preventive Medicine, 39(6), 590–604.

24. Hahn, R.A, Middleton, J.C, Elder, R., Brewer, R et al. (2012). Effects of alcohol retail privatization on excessive alcohol consumption and related harms: A community guide systematic review. American Journal of Preventive Medicine, 42(4), 418-427.

25. Harding, F.M., Hingson, R.W., Klitzner, M., Mosher, J.F., Brown, J., Vincent, R.M., Dahl, E. & Cannon, C.L. (2016). Underage drinking: A review of trends and prevention strategies. American Journal of Preventive Medicine, 51(4)(S2), S148- S157.

26. Lenk, K.M., Erickson, D.J., Nelson, T.F, Horvath, K.J, Nederhoff, D.M, Hunt, S.L, Ecklund, A.M & Toomey, T.L. (2018). Changes in alcohol policies and practices in bars and restaurants after completion of manager-focused responsible service training. Drug and Alcohol Review, 37(3), 356-364.

27. Middleton, J.C., Hahn, R.A., Kuzara, J.L, Elder, R., Brewer, R., Chattopadhyay, S., Fielding, J., Naimi, T.S., Toomey, T., Laurence B. & the Task Force on Community Preventive Services. (2010). Effectiveness of policies maintaining or restricting days of alcohol sales on excessive consumption and related harms. American Journal of Preventive Medicine, 39(6):575–589.
28. National Institute on Alcohol Abuse and Alcoholism. (2018). Alcohol facts and statistics. Retrieved from Title. Retrieved from https://pubs.niaaa.nih.gov/publications/AlcoholFacts&Stats/AlcoholFacts&Stats.htm
29. Paschall, M.J., Lipperman-Kreda, S., Grube, J.W. & Thomas, S. (2014). Relationships between social host laws and underage drinking: findings from a study of 50 California cities. Journal of Studies on Alcohol and Drugs, 75(6), 901-907.
30. Rammohan, V., Hahn, R.A., Elder, R., Brewer, R., Fielding, J, Naimi, T.S., Toomey, T.L., Chattopadhyay, S.K., Zometa, C. & Task Force on Community Preventive Services. (2011). Effects of dram shop lability and enhanced overservice law enforcement initiatives on excessive alcohol consumption and related harms.American Journal of Preventive Medicine, 41(3), 334-343.
31. Scribner, R., Mason, K., Theall, K., Simonsen, N., Schneider, S. K., Towvim, L. G., & DeJong, W. (2008). The contextual role of alcohol outlet density in college drinking. Journal of Studies on Alcohol and Drugs, 69(1), 112-120.
32. Tanumihardjo, J., Shoff, SM.S., Koenings, M., Zhang, Z. & Lai, H.J. (2015). Association between alcohol use among college students and alcohol outlet proximity and densities. Wisconsin Medical Journal, 114(4), 143-147.
33. Wagoner, K.G., Sparks, M., Francisco, V.T., Wyrick, D., Nichols, T. & Wolfson, M. (2013). Social host policies and underage drinking parties. Substance Use and Misuse, 48(1-2), 41-53.
34. Wolff, L.S., El Ayadi, A.M, Lyons, J.N., Herr-Zaya, K., Noll, D., Perfas, F, & Rots, G. (2010). Improving the alcohol retail environment to reduce youth access: A randomized community trial of best practices toolkit intervention. Journal of Community Health, 36(3), 357-366.