Implementing and Sustaining Effective Alcohol-Related Policies at the Local Level: Evidence, Challenges, and Next Steps

Implementing and Sustaining Effective Alcohol-Related

Policies at the Local Level: Evidence, Challenges, and

Next Steps

Norman Giesbrecht, Linda M. Bosma, Jennifer Juras, and Maria Quadri

Alcohol-related problems are experienced most directly at the local level. There have been significant

strides in evaluating locally based alcohol policies and prevention strategies. This article draws from

this existing body of research to answer three questions: What is known about effective local

interventions and policies? What are the main challenges facing local action on alcohol and how can

those challenges be addressed? How can local action on alcohol be sustained? This article reviews

evaluated local alcohol interventions and policies, focusing on several countries where these

initiatives have been evaluated: for example, Australia, Canada, Finland, New Zealand, Norway,

Sweden, and the United States. The positive outcomes associated with community-based initiatives

are summarized and features of successful local action are identified. Although current research

finds a number of positive outcomes of local alcohol interventions and policies, a number of

challenges of this work remain; these challenges include providing adequate training, resources, and

tools for local action; building local resource streams and coalitions to sustain expertise; sustaining

long-term commitment to monitor and evaluate the effects of policies; and addressing the vested

interests of community stakeholders in alcohol policy efforts. Lessons learned and recommendations

for future community-based alcohol prevention initiatives are drawn from the findings and

challenges of current work.

KEY WORDS: community-based, alcohol policy, evidence-based

Introduction

Alcohol-related problems are a major burden to many societies. These

problems are experienced most directly at the local level. While there is

international guidance for addressing alcohol-related problems (World Health

Organization [WHO], 2010), the local community is often faced with a range of

harm from alcohol that is related to easy access to alcohol, extensive marketing,

ineffective regulation, inadequate enforcement, or the absence of an organized

response (e.g., Anderson, Chisholm, & Fuhr, 2009; Casswell & Maxwell, 2005). To

learn how communities may effectively address local alcohol problems, this

article draws from existing research to address three questions: What is known

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about effective local interventions and policies? What are the main challenges

facing local action on alcohol, and how can they be addressed? What does

available research tell us about sustainable and efficient local interventions?

Globally, the World Health Organization (WHO) has recently estimated that

alcohol is the fifth leading contributor to disease and disability (WHO, 2013). In

some medium-income countries in Latin America or in Eastern Europe it is

higher. Over 200 diseases or conditions have been linked to alcohol, including

numerous chronic diseases, many types of trauma, some infectious diseases, and

a wide range of social problems (Rehm et al., 2009). The harm to people other

than the drinker has been a central theme in efforts to curtail drinking and

driving, alcohol-related violence, fetal alcohol spectrum disorders (FASD), and

other alcohol-related harm (Giesbrecht, Cukier, & Steeves, 2010; Laslett

et al., 2010).

Local communities have sought to respond to alcohol issues for centuries,

but the growing interest in evaluated community-based action on alcohol is a

relatively recent development. The large scale heart-health projects in Europe

and the United States that focused on smoking reduction, exercise, and diet

provided a central stimulus and model for community-based projects focusing

on alcohol (Holder & Howard, 1992). In 1994, Edwards et al. briefly reported

on several “community organization” projects with an evaluation component

(Casswell & Gilmore, 1989; Giesbrecht, Pranovi, & Wood, 1990; Hingson et al.,

1993; Wallack & Barrows, 1983), and concluded: “The evaluation of community

organization approaches is a relatively new but growing field of alcohol

research endeavor. As yet, evidence for an impact on alcohol-related problems

is limited, but this is a strategy worthy of further research” (Edwards

et al., 1994, p. 176).

During the 1980s and 1990s, a number of alcohol-specific projects emerged

that stimulated initiatives that continue to this day (e.g., Casswell, Ransom, &

Gilmore, 1990; Duailibi et al., 2007; Hingson et al., 1996; Holder et al., 1997;

Holmila, 1997; Wagenaar et al., 1999; Wallin, Gripenberg, & Andreasson, 2005).

The goals intervention foci, and main impacts of six projects (Andreasson,

Lindweld, & Rehnmen, 2000; Casswell & Gilmore, 1989; Hingson et al., 1996;

Holder et al., 2000; Holmila, 1997, 1999; Wagenaar, Murray, & Toomey, 2000)

were summarized by Giesbrecht and Haydon (2006, Table 3). They note that these

projects point to the importance of documenting process and outcome impacts

using a combination of quantitative and qualitative tools. The challenges related

to project implementation are described and include community involvement and

engagement; using a sound and evidence-based conceptual model; and lack of

support for reducing access to alcohol due to the vested interests of retailers,

producers, and governments.

In the WHO-affiliated reports by international research teams (Babor

et al., 2003, 2010, pp. 129, 149, 168, 253, 254) several projects were highlighted.

These include the Rhode Island project (Stout et al., 1993; Putnam, Rockett, &

Campbell, 1993), the Saving Lives project (Hingson et al., 1996), the Communities

Mobilizing for Change on Alcohol project (CMCA) (Wagenaar et al., 2000), the

204 World Medical & Health Policy, 6:3

COMPARI project (Midford & Boots, 1999), and the Community Trials Project

(Holder et al., 1997). In the 2010 revised edition (Babor et al., 2010, pp. 155–58)

these projects were noted and attention was also drawn to projects by Wallin,

Lindewald, and Andreasson (2004); Homel, Hauritz, Wortley, Mellwain, and

Carvolth (1997); Hauritz, Homel, McIlwain, Burrows, and Townsley (1998); Treno,

Gruenewald, Lee, and Remer (2007), and Wiggers et al. (2004).

These earlier reports summarized what is known about effective community-

based projects in several countries, and we build and expand on this work

below, providing highlights from over 20 evaluated projects. While there has

been substantial alcohol policy work on college campuses (Saltz, 2010; Saltz,

Paschall, McGaffigan, & Nygaard, 2010, 2014), we chose not to include them in

the focus of this article due to the unique dynamics of college settings and space

constraints.

Scope and Methods

We focus primarily on publications from 1990 onwards because most

community-focused efforts have taken place in the past 25 years. Searches were

undertaken using key words that included local alcohol policy, alcohol policy,

and environmental alcohol policy, and the search engines included Google

Scholar, PubMed, and Psyinfo. Each author focused on a different global region

in conducting the search. Our focus was on publications with a clear community-

based focus, locally oriented alcohol policy or prevention strategy, and with an

evaluation component. The article does not document every publication located

that met the criteria, but rather highlights studies conducted in the United States

and several other global jurisdictions that showed a positive impact that could be

linked to the intervention. We provide examples from Australia, Canada, Finland,

New Zealand, Norway, Sweden, and the United States. The findings of these

studies are expected to provide guidance to aid planning future initiatives with

sufficient potency and focus to achieve desired goals, and also provide lessons

learned to overcome the challenges of addressing alcohol-related problems at the

local level.

Effective Interventions and Policies at the Local Level

There have been a number of syntheses and compilations on this topic. The

scope, foci, and outcomes of a number of these projects have been highlighted in

reports of symposia on this topic (e.g., Allamani et al., 2000; Casswell et al., 1999;

Greenfield & Zimmerman, 1993; Larrsson & Hanson, 1999; World Health

Organization, 1998) in overview papers (e.g. Casswell, 2000; Giesbrecht, 2003;

Giesbrecht & Ferris, 1993; Giesbrecht & Haydon, 2006; Giesbrecht & Rankin, 2000;

Graham & Chandler-Coutts, 2000; Hydman et al., 1992; Room, 1990; Treno &

Lee, 2002) and international reports of alcohol consumption, harm, and policy

interventions (Babor et al., 2003, 2010). The text below adds to this knowledge

and highlights challenges and sustainability issues.

Giesbrecht et al.: Sustaining Local Alcohol Policies 205

United States

Over the past 40 years there have been extensive local efforts to reduce

alcohol-related problems and alcohol-related harm at the local level in communi-

ties in the United States (U.S.). Many have focused on youth (see Giesbrecht &

Bosma, 2011) or drinking and driving (Fell & Voas, 2006; Hingson et al., 1996). A

range of research designs is involved, including randomized assignment of small

communities to either intervention or comparison module (Wagenaar et al., 2000),

three matched pairs of intervention and comparison communities (Holder

et al., 2000), to comparison of focus community experiences with the rest of the

state (Hingson et al., 1996). After pre- and post-intervention information had been

collected and centralized funding ran out, typically state or federal, the project

did not continue. Nevertheless, there are ongoing initiatives to sustain the lessons

from these projects through funding of local initiatives that are modeled after

them. Examples of these local initiatives are described below.

The California Prevention Demonstration Program (Wallack & Barrows, 1981)

involved a three-community design: in one site community action and media

were used, in a second media only was used, and the third served as the control

(Room, 1990). The effects of the interventions were modest—while respondents

could recognize commercials about the benefits of not drinking too much, there

was no evidence that the intervention changed attitudes or behavior concerning

drinking (Room, 1990).

The Rhode Island Community Alcohol Abuse/Injury Prevention Project (Buka &

Birdwhistle, 1999; Putnam et al., 1993; Stout et al., 1993) involved one intervention

and two “control” communities. The focus was on reducing alcohol-related

injuries. Several strategies were used: a Responsible Beverage Service training

program, policy development for on- and off-premise sales, enhanced enforce-

ment of liquor and driving while intoxicated laws, police training, and mass-

media campaigns. The main impacts seen in the intervention communities were a

significant improvement in knowledge and self-reported serving behavior, a

27 percent increase in alcohol-related assault arrests that was related to enhanced

enforcement, and declines in emergency room visits: 9 percent for injuries,

21 percent for assaults, and 10 percent for motor vehicles crashes (Stout et al.).

Babor et al. (2003, p. 149) note: “Although the project showed immediate success,

follow-up data indicated that the increased enforcement by the project was not

maintained after the project ended” (Stout et al.).

Project Northland Minnesota and Chicago (Komro, Maldonado-Molina, &

Tobler, 2007; Perry et al., 1993, 1996) involved multi-component interventions

focusing on students in grade 6 and higher. These involved: parental skills

training, home team approach and homework assignments, peer-led school

curricula and programs, and community-wide policy changes: merchant educa-

tion, enforcement of laws, ordinance development, and implementation of new

school policies. Surveys given to students at the end of the study sought to assess

self-reported behavior involving alcohol use. In the Chicago context, the inter-

vention was not effective in reducing alcohol use, drug use, or any other type of

206 World Medical & Health Policy, 6:3

hypothesized outcome. There were reductions in access to alcohol at commercial

outlets, including a 64 percent reduction in sales in areas where a merchant

pledge strategy was employed, although this finding was not statistically

significant when compared to the control communities. In contrast, the students

in the Minnesota Project Northland benefited from the intervention, reporting:

reduction in alcohol use, tendency to use alcohol, and combined cigarette and

alcohol use; reduction in peer norms and influence on use; introduction of skills

to resist peer influences; and increased parent–child communication about

consequences of drinking. Project Northland Chicago (PNC) demonstrates the

challenge of replicating a program that is successful in one location in an area

with different conditions and demographics: the Minnesota communities were

almost entirely self-contained, small rural towns with largely Caucasian popula-

tions, whereas the Chicago project was implemented in diverse urban neighbor-

hoods in a context with more complex social and economic challenges. While

some adaptations were made for the more diverse, urban environment, PNC was

unable to implement local ordinances at the neighborhood level, so it was

necessary to focus the intervention on changing institutional practices.

The Saving Lives Program, conducted from 1989 to 1993 (Hingson et al., 1996),

sought to implement a comprehensive strategy to reduce alcohol-impaired

driving and related problems such as speeding, other moving violations, and

failure to wear safety belts. The program relied extensively on mass media and

increased surveillance by law enforcement. It involved six program communities

and five unfunded communities—those selected varied in population size and

geographic location within the state. Also, in each community there was a full-

time coordinator from the local government who organized a task force

representing various city departments. It was found that compared to the rest of

the state, the program communities experienced a 25 percent reduction in fatal

crashes, a 47 percent reduction in the number of fatally injured drivers who were

positive for alcohol, a 5 percent decline in visible crash injuries, and an 8 percent

decline in crash injuries affecting 16- to 25-year olds. The study also reported a

decline in self-reported driving after drinking by teenagers (Babor et al., 2003,

p. 168).

The Communities Mobilizing for Change on Alcohol (CMCA) (Wagenaar

et al., 1999, 2000) project featured locally organized approaches to reduce

underage drinking. CMCA was a randomized control trial implemented in 15

communities in Minnesota and Wisconsin. It involved hiring a part-time

organizer in each community and employing grass roots community organizing

in order to implement interventions designed to reduce youth access to alcohol.

The interventions included: citizen monitoring, changes in hours of alcohol sales,

responsible beverage service training, and education. Evaluation conducted over

two and a half years pointed to several positive outcomes: alcohol merchants

increased age identification checks and reduced their propensity to sell alcohol to

minors; 18–20-year-olds were less likely to consume alcohol themselves and less

likely to provide it to other underage persons (Wagenaar et al., 2000); and there

was a statistically significant decline in drinking and driving arrests among 18- to

Giesbrecht et al.: Sustaining Local Alcohol Policies 207

20-year-olds and disorderly conduct violations among 15- to 17-year-olds (Babor

et al., 2003, p. 129; Wagenaar et al., 2000).

The Community Trials Intervention (Holder et al., 1997, 2000; Voas, Holder, &

Gruenewald, 1997) was conducted in three experimental communities with three

matching communities, over 5 years, with the pairs selected for geographical and

cultural diversity. The goal was to reduce alcohol-related harm and risk through

local interventions. Community coalitions supported preventative interventions

which consisted of five components: mobilizing the community and targeting

community knowledge and values, responsible beverage service, reduction of

underage drinking, enforcement of drinking and driving, and using zoning to

reduce access to alcohol. The interventions were considered to contribute to a

decrease in average quantity of alcohol consumed, reduction of heavy drinking

levels, reduced self-reported frequency of driving when over legal limit, a

reduction in the rates of nighttime motor vehicle crashes by 10 percent each

month, and a 6 percent monthly decrease in DUI crashes (Holder et al., 1997,

2000; Voas et al., 1997). The program evaluation pointed to several statistically

significant results: increased coverage of alcohol issues in local media, reduction

in alcohol sales to minors, increased adoption of policies restricting alcohol

sales to minors, and a reduction in alcohol-involved traffic crashes over the initial

28-month intervention period. These effects were considered to be largely due to

the introduction of highly visible drinking-driving enforcement initiatives that

were supported by increased media coverage (Babor et al., 2003, p. 254). Overall

the intervention communities experienced lower self-reporting rates of alcohol

consumption and observed rates of harm, showing that this type of study can

benefit the entire community being studied.

A community-based project involved 20 cities in four geographic areas in

the U.S. Midwest (Wagenaar, Toomey, & Erickson, 2005). The goal was to test the

effectiveness of the intervention “Complying with the Minimum Drinking Age

Project” (CMDA) on training for management retail alcohol establishments, and

of enforcement checks of alcohol. A multi-community time series quasi-experi-

mental trial with a nested cohort design was used in this 4-year project. Research

staff attempted to purchase alcohol without showing age identification after the

alcohol outlets in the community were given interventions such as the program

ARM Express, education, and enforcement checks. There was a 17 percent

decrease in alcohol outlets’ likelihood to sell to underage youth immediately

following an enforcement check, this number was modified to 11 percent 2 weeks

after the enforcement check and to 3 percent 2 months after the enforcement

check. Underage youth benefit directly from these enforcement checks because

they restrict them from becoming involved in dangerous alcohol behavior. The

results point to importance of interventions being continuously implemented and

updated; just implementing a strategy one time is not considered to have long-

lasting effects. This is borne out by results from a randomized trial of 231 on-sale

alcohol outlets conducted by Toomey and colleagues (2008), which initially

reduced sales to pseudo-intoxicated buyers by 23 percent but then saw a return

to baseline levels at three months. Toomey et al. (2008) caution that reliance on

208 World Medical & Health Policy, 6:3

management training programs alone is not sufficient to reduce sales or related

problems.

It should be noted that preemption in some states prohibits local governments

from enacting stricter laws at the local level (Gorovitz, Mosher, & Pertschuk,

1998). While centralized controls may preempt local initiatives in some settings,

local efforts have proved effective in numerous settings where they have been

continuously administered. Results show that post-intervention rates of alcohol-

related problems tend to go back to pre-intervention rates without sustained

implementation and enforcement.

Replication and Dissemination of U.S. Studies

While there is a rich U.S.–based history of evaluated community-based

alcohol policy projects (e.g., Hingson et al., 1996; Holder et al., 1997; Stout

et al., 1993; Wagenaar et al., 1999) only a handful have been replicated. Several

examples are provided in the following paragraphs.

Alcohol retailer strategies based on the Community Trials model successfully

reduced sales to youthful appearing decoys from 33 percent at baseline (n¼ 13

outlets) to 0 percent in nine tribal settings in California (Moore et al., 2012).

Similarly, a study in 36 communities in Oregon involved a mix of law

enforcement and other community-based activities such as RYAA (Reducing

Youth Access to Alcohol) program. Intervention also included community

mobilization, “Reward and Reminder,” and media advocacy of the four

interventions; RYAA was found to be the most significant in having an effect on

reducing the likelihood that retail clerks would sell alcohol to underage persons,

but did not show a corresponding reduction in youth drinking rates. However,

post hoc analysis showed statistically significant reductions in past 30-day use and

binge drinking related to law enforcement efforts targeted at underage drinking

(Flewelling et al., 2013).

In the Sacramento Neighborhood Alcohol Prevention Project (SNAPP),

Treno and colleagues (2007) replicated community mobilization and merchant

strategies from the Community Trials study in two diverse, economically

challenged neighborhoods in Sacramento; this 5-year project involved five project

interventions which were implemented in both North and South Sacramento and

included (1) community mobilization effort, (2) community awareness, (3) respon-

sible beverage service, (4) under-age access law enforcement, and (5) intoxicated

patron law enforcement. There were significant reductions in sales to minors,

car crashes, and assaults. Both North and South Sacramento communities

benefited from the SNAPP program interventions, regardless of ethnicity or

income.

Currently, Komro and colleagues (2014) are undertaking a Community Based

Participatory Research (CBPR) study which includes direct action community

organizing components based on CMCA with Screening, Brief Interventions, and

Referral to Treatment (SBIRT) in the Cherokee Nation that will address alcohol

use and related problems in an American Indian setting.

Giesbrecht et al.: Sustaining Local Alcohol Policies 209

As the body of research has increased, local community groups have

undertaken implementation of several of the projects described above. While

alcohol policy initiatives are currently evident in many U.S. communities, they

are typically not coupled with design and rigorous evaluation that will allow for

drawing substantial conclusions about their impact. Less peer reviewed docu-

mentation of these efforts exists, but several projects have national or local level

evaluation efforts taking place, showing promise for implementing these efforts at

the local level.

Two of these United States-based efforts, Communities Mobilizing for Change

on Alcohol and the Community Trials Project, have been rigorously evaluated

and placed on the U.S. government’s Substance Abuse and Mental Health

Services Administration’s National Registry of Evidence-based Programs and

Practices (2014). This allows local groups that are required to implement

evidence-based programming with their funding to implement these two

programs. CMCA has a national training program administered by the Youth

Leadership Institute to support and train groups implementing CMCA (Youth

Leadership Institute, 2014). A few examples of these local initiatives are

summarized in the following paragraphs.

Many local jurisdictions have increased efforts to reduce underage alcohol

sales through greater enforcement, training servers and sellers of alcohol, and

enacting more restrictive local ordinances and regulations. To reduce problems

around establishments, local level nuisance and neighborhood livability laws,

such as in Puerto Rico, are contributing to reductions in alcohol-related crime.

Alcohol restrictions in public places, such as parks or beaches, reduce

opportunities for youth to engage in public drinking and parties. Social host

laws, which hold adult homeowners accountable for underage drinking

parties on their property, are being passed in many cities and counties in the

United States, although rigorous study of such laws is still needed (Stewart

et al., 2009).

Furthermore, local initiatives in California employ the planning and zoning

and general business licensing authority to build a local alcohol control

system and thus evade the limits of the centralized alcohol control laws or

regulations that are less restrictive (Room, April 28, 2010, personal communica-

tion; Wittman, 2007). Another United States-based example comes from the

Minnesota Join Together Coalition to Reduce Underage Drinking (MJT), funded

by the Robert Wood Johnson Foundation (Bosma & Nachbar, 2002). This

statewide policy coalition distributed 82 mini-grants over five years to local

groups including law enforcement and advocacy, youth, and public health

groups to encourage policy efforts at the local level; this also helped build

support for MJT’s state policy efforts, including passage of a state-wide social

host law.

Alameda County Alcohol Fee Ordinance. More evidence that local alcohol policies

may reduce crime related to alcohol outlets comes from Alameda County,

California, which enacted an Alcohol Fee Ordinance requiring all alcohol

210 World Medical & Health Policy, 6:3

licensees to pay an annual fee to cover the cost of annual compliance checks,

health inspections, and Responsible Beverage Server (RBS) training. Preliminary

evidence from analysis of crime data from 2008 to 2010 suggests the ordinance

may be contributing to a reduction in crime (Bosma & Parker, 2011). Results on

past 30 day drinking are mixed, but the first five years of evaluation indicate

reductions in perception of access to alcohol from both commercial and social

sources and increased compliance with minimum age of sale laws (Bosma, 2013,

2014).

Drug-Free Communities. In the United States, local policy work has continued;

unfortunately there is still only limited public information on these projects.

Two federal programs in the United States that can implement local policy

approaches are the SPF SIG (Strategic Prevention Framework State Incentive

Grant) administered by the United States Substance Abuse and Mental

Health Services Administration (SAMHSA) and the Drug Free Communities

(DFC) project administered by the Office of National Drug Control Policy

(ONDCP). SPF SIG is primarily a state-level funding initiative, although

states often fund local efforts. Of those local efforts, 44 percent have been

categorized as environmental strategies, some of which have included RBS

training (9 percent) and compliance checks (8 percent). Outcome results

are not yet available, and since RBS and compliance checks are a small

part of a larger initiative, it will be difficult to determine if these strategies

have contributed to reduced alcohol use or problems (Buchanan et al.,

2010).

The Drug Free Communities (DFC) program has shown reductions in alcohol

use by middle and high school students, and may provide better insight into

how local policy work promoted through community trials is being implemented

in real world settings. Awarded at the local level, the DFC requires strong

community coalitions to work on reducing use of at least two of the following

substances: alcohol, tobacco, marijuana, or prescription drugs. In 2012, 693 local

coalitions were funded. Coalitions are now required to implement environmental

strategies. Again, there is a difficulty in assessing how much local policy work

can be tied to specific outcomes, since coalitions can work on any of four

substances. Each coalition develops evaluation plans and methods to collect the

core data required of all DFC grantees—so quality of administration of student

surveys may vary greatly (Office of National Drug Control Policy, 2013).

Information is limited by the wide variety of interventions local coalitions can

implement, although many coalitions used common strategies: 79 percent of

coalitions promoted law or policy changes to decrease substance use and

associated negative behaviors and 75 percent engaged in activities to change

physical environments to decrease opportunities for and encouragement of

substance use (Office of National Drug Control Policy, 2013). Despite these

limits, there is some cause for optimism that local policy work is taking place

and contributing to reductions in alcohol use among young people in many U.S.

communities.

Giesbrecht et al.: Sustaining Local Alcohol Policies 211

Canada

The Municipal Alcohol Policy (MAP) Initiative was started in 1980 in Ontario,

and between 1980 and 1996 there were 177 Ontario communities that formally

adopted a MAP and an additional 71 were in development (Douglas, 1990;

Gliksman, Douglas, & Rylett, 1999; Gliksman, Douglas, Rylett, & Narbonne-

Fortin, 1995). Evaluation included three types of communities with a matched

control community for each. MAP had five components: formation of a policy

committee, development of terms of reference and a review of the situation,

feedback to the community, policy adoption by the municipality, and social

marketing to inform the community and users of facilities owned or managed by

the municipality where alcohol was made available. In one survey of 107

communities that had adopted formal policies, 44 percent reported a reduction in

problems while 7 percent found no reduction. Once policies were in place for

more than six months, more communities saw a reduction in problems.

A multi-site study was undertaken involving three southern Ontario commu-

nities with populations ranging from 8,000 to 12,000 (Giesbrecht et al., 1990). In

the intervention community the activities included media advertisements,

newspaper stories, mail-outs, presentations and workshops, meetings with health

and social service committees and local professionals, and an Alcohol Education

and Counseling Program (AECP) for heavy drinkers. The latter component

indicated a dramatic decline in self-reported consumption—measured using

weekly drinking diaries—with the percent consuming 14 or more standard drinks

decreasing from 55 percent to 21 percent. However, the before and after surveys

of a random sample of the local populations in all communities did not

demonstrate a substantial change in the distribution of consumption over time.

A large-scale study by Graham and colleagues (2004) was designed to

evaluate the effectiveness of the “Safer Bars” intervention to reduce aggression in

bars. It was conducted between 2000 and 2002 in Toronto: 18 high-capacity bars

and clubs were assigned to receive the intervention and 12 were control bars.

Owners and managers of bars and nightclubs completed a risk assessment

workbook to identify ways of identifying and reducing risk, and 373 staff and

owners also attended a 3-hour training session which focused on preventing

escalation of aggression and working as a team to resolve problem situations

safely. Comparing pre–post aggression for the intervention versus control bars,

the project team found a significant effect of the intervention in reducing severe

and moderate aggression in bars.

Australia and New Zealand

In New Zealand and Australia, liberal central government alcohol policies

have led to increased alcohol availability and promotion since the 1990s, and

communities are increasingly relying upon local policies and community action

to address alcohol-related problems (e.g., Casswell & Maxwell, 2005; Maclennan,

Kypri, Langley, & Room, 2012; Duigan & Casswell, 1992; Maclennan, Kypri,

212 World Medical & Health Policy, 6:3

Room, & Langley, 2013; Stewart, 1997). Recent research has found strong public

support among New Zealanders for local governments to restrict the hours of

operation of on-licensed premises, to use liquor bans to control drinking in public

places, and for local governments and police to be stricter in their enforcement of

drinking laws (Maclennan et al., 2012) and researchers are beginning to examine

barriers to adopting local alcohol policies, such as legislative boundaries set by

central government and special-interest groups becoming involved in local policy

agendas (Maclennan et al., 2013). The influence of special-interest groups is also

seen in community action initiatives to address local alcohol problems, as funding

this work has become focused on projects targeting high risk groups and contexts

such as indigenous drinkers, young people, and drink-driving as opposed to

general population approaches (Conway & Casswell, 2003).

New Zealand. The Community Action Project involved four treatment and two

comparison communities (Casswell & Gilmore, 1989; Casswell et al., 1999; Stewart

& Casswell, 1993). The goal was to build support for key public policies, which

included restrictions on alcohol availability and alcohol advertising, and a pricing

policy. The community action involved media advocacy, public events, a mass

media campaign, and building intersectoral alliances to provide a public health

perspective in local alcohol policy development. The project had an impact on

support for policies and on the way alcohol issues were conceived by opinion

leaders. The support for control policies held steady in the treatment communi-

ties, indicating a positive outcome (Edwards et al., 1994, p. 175; Giesbrecht &

Haydon, 2006).

The Auckland Regional Community Action Project (ARCAP) was an evaluated

regional community action project to reduce underage social and off-license

access to alcohol, address drinking and intoxication in public places, and

challenge social norms about alcohol use among young people (Greenaway,

Conway, Casswell, Huckle, & Sweetsur, 2005). Intervention components included

monitoring alcohol sales made without age identification, media advocacy, and

enforcement. Evaluation of ARCAP demonstrated promising results. A pre–post

intervention purchase survey indicated that the proportion of sales made without

age identification decreased from 60 percent to 46 percent and age identification

signage increased from 53 percent to 64 percent. Results from the purchase

surveys also highlighted the importance of the roles of police and licensing staff

in monitoring and enforcement (Huckle, Conway, Casswell, & Pledger, 2005). A

media advocacy campaign to increase awareness of age verification practices was

found to have sustained momentum both nationally and locally and placed the

issue of easy access to alcohol by minors on political and community-level

agendas (Huckle et al., 2005).

The Community Action on Youth and Drugs Project (CAYAD) was another

community action project involving community members taking local action to

address alcohol and drugs. CAYAD is funded by the Ministry of Health and

based on a model developed and evaluated by Massey University’s SHORE/

Whariki research teams (Litmus, 2006). A 2004–2006 evaluation (Centre for Social

Giesbrecht et al.: Sustaining Local Alcohol Policies 213

and Health Outcomes Research and Evaluation & Te Ropu Whariki, 2006) found

that networking and collaborative work contributed to a high level of alcohol and

drug awareness among community and local service providers and information

sharing with agencies and community people was a key part of this increased

awareness. There were changes in school policies based on CAYAD input, and

there were significant decreases in drug-related suspensions in two sites.

Youth leadership development was a focus of capacity building, and the

evaluation showed a significant increase in young people reporting that their

parents expected to know where they were going in the daytime, and measures

of community perception and social cohesion also showed positive changes.

However, the evaluation also found a lack of strategy development to reduce the

supply of alcohol and drugs to young people, and there was a perceived drop in

police enforcement against the supply of alcohol to young people in one site

(Centre for Social and Health Outcomes Research and Evaluation & Te Ropu

Whariki, 2006).

Youth Access to Alcohol (YATA) was a community action project that began in

2002 and was implemented by the Alcohol Advisory Council of New Zealand

(ALAC) in 30 rural and urban communities. The overall goal of the project was to

support community action to reduce the supply of alcohol by adults to young

people. The project uses a community action approach to set up collaborative

partnerships of key agencies, deliver key strategies, and implement multimedia

awareness-raising campaigns. Communities identify unique issues regarding

alcohol abuse and young people and develop action plans incorporating a range

of strategies that include community mobilization, local and social media

information campaigns, and alcohol-free youth events (Clark, 2007).

Evaluation methods included pre–post intervention data for liquor infringe-

ment notices, Controlled Purchase Operations (CPOs), alcohol related anti-social

behavior and drink driving data; environmental scan; panel surveys; and media

monitoring. The evaluation found a decrease in sales from CPOs from approxi-

mately half of all visits resulting in a sale to less than 26 percent, and a small but

significant decrease in numbers of young people being supplied alcohol for

unsupervised drinking (Clark, 2007).

The “Should You Supply?”?“Think before you buy under-18s drink” campaign was

a component of YATA. It was designed to increase adults’ knowledge of the risks

of supplying alcohol to teens, encourage norms change so that only a minor’s

parent is considered appropriate to supply alcohol, and reduce the percentage of

adults who supply alcohol to minors for unsupervised consumption. It included

community consultation on design and implementation, local newspaper and

radio advertisements concerning the dangers of supplying alcohol to teenagers,

local radio and print media interviews with community workers, media events,

billboard advertisements, distribution of printed material, and presentation of

campaign information at point of sale (Kypri & Dean, 2002; Kypri, Dean, Kirby,

Harris, & Kake, 2005). The main indicators of the campaign’s effectiveness were

changes in the levels at which parents supplied their teenagers with alcohol for

unsupervised drinking and levels of binge drinking among teenagers.

214 World Medical & Health Policy, 6:3

The evaluation found that parental supply of alcohol for unsupervised

drinking decreased in the two intervention districts (from 36 percent to 30

percent) when compared with the comparison district but the difference was not

significant. Levels of binge drinking decreased but the differences were also not

statistically significant (Kypri & Dean, 2002; Kypri et al., 2005).

The Piha Booze and Beach Ban was a community-driven action to address

safety and well-being following an escalation in alcohol related incidents in the

New Zealand beach community of Piha. A community coalition was developed

and action strategies including a beach alcohol ban, radio and print media

campaigns, and increased enforcement consisting of beach patrols and breath

testing were implemented. Evaluation data included key informant interviews, a

survey, police data, and participant observation. Both the frequency and severity

of incidents of alcohol-related problems significantly decreased while the alcohol

ban was in place and evidence was not found that the problems were displaced

to other nearby beaches. The success of the initiative was attributed to strong

community ownership, strong intersectoral partnerships, and a common vision

(Conway, 2002).

Australia. The Surfers Paradise project (Hauritz et al., 1998; Homel et al., 1997)

focused on reducing violence and disorder associated with the high concentration

of licensed establishments in the resort town of Surfers Paradise in Queensland.

The project involved three main strategies: creation of a Community Forum,

including the development of task groups and a safety audit; implementation of

risk assessment, Model House Policies, and a Code of Practice; and regulation of

licensed premises and liquor licensing inspectors. These strategies were consid-

ered to contribute to significant improvements in alcohol policy enforcement in

the bar environment, in bar staff practices, and in the frequency of violence. The

project was replicated in three North Queensland cities, where positive impact

was also noted. The number of incidents dropped from 9.8 per 100 hours of

observation during pre-intervention to 4.7 in Surfers Paradise; however two years

following the intervention it had gone up to 8.3 per 100 hours of observation

(Babor et al., 2003, p. 149).

In the 1990s, community groups in a number of regional towns and

settlements in northern Australia implemented initiatives to restrict alcohol

availability. D’Abbs and Togni (2000) reviewed community action initiatives in

Tennant Creek, Curtin Springs, and Elliott in the Northern Territory and in Halls

Creek and Derby in Western Australia. Three communities (Elliott, Tennant

Creek, and Curtin Springs) implemented restrictions for both on-premise (ranging

from banning admission of children to bars to restricting days and time of sales

to halting sales to Aboriginal people residing in or traveling to Ngaanyatijarra

Pitjantjajara Yankunytjatjara lands) and take-away sales (including maximum

purchase limits, ceasing or limiting sales on some days or during certain hours,

limiting size of take-away containers, etc.) while two communities (Halls Creek

and Derby) implemented take-away restrictions only. In all cases, restrictions

were found to have a modest impact on alcohol consumption and a significant

Giesbrecht et al.: Sustaining Local Alcohol Policies 215

impact on alcohol-related harm. Communities that had full support of the

restrictions benefited the most. Community mobilization was a major component

of each initiative, and in each case widespread community support was found for

the restrictions.

Community Mobilisation for the Prevention of Alcohol Related Injury (COMPARI)

was an Australian community alcohol prevention program that was implemented

over a three year period in the West Australian regional city of Geraldton.

COMPARI consisted of 22 intervention components based on community

mobilization and development, networking and support, health education, health

marketing, policy institutionalization, and provision of alternative activities. The

evaluation found that individual intervention activities resulted in changes in

community knowledge and behavior (Midford & Boots, 1999) and a slight

reduction in per capita alcohol consumption in the project area compared to a

slight increase in the control area (Midford, Wayte, Catalano, Gupta, &

Chikritzhs, 2005).

Evaluations of the New Zealand and Australia initiatives highlight a number

of components that are attributed to their success in reducing youth access to

alcohol and reducing alcohol-related problems; these components include strong

community support and ownership, building local community capacity to drive

the work, intersectoral collaborations that include law enforcement, implementa-

tion of multiple strategies that fit with the local community, and strategies that

are based on local needs. Review of these studies also show that multiple data

sources, both qualitative and quantitative, that focus on both process and

outcome and are collected and examined over time are needed to understand the

impact of local alcohol initiatives.

Nordic Countries

As in other areas, Nordic countries have attempted to use policy approaches

to reduce alcohol consumption and related problems. Sweden and Finland

especially have implemented multi-component programs combining community

mobilization to create support for policy, efforts to reduce alcohol licensee sales to

underage and intoxicated patrons, increased enforcement at establishments that

serve and sell alcohol, and Responsible Beverage Server training. As Nordic

countries joined the European Union, they were challenged to adjust their

national alcohol laws to comply with the EU. This often resulted in greater

availability of alcohol through increased alcohol outlets, expanded hours and/or

days of operation, and reduced price through lower taxes. As national efforts

became more limited, Nordic nations have looked at local opportunities for

alcohol policy efforts.

Sweden. The STAD project (Stockholm Prevents Alcohol and Drug Problems) was

initiated in 1995 as a 10-year project with the aim to develop, apply, and evaluate

methods for prevention in the alcohol and drug field (STAD website). Strategies

included community mobilization, Responsible Beverage Server (RBS) training,

216 World Medical & Health Policy, 6:3

and enhanced enforcement efforts with licensees. Results included reducing

sales/service to over-intoxicated persons; as shown using male actors posing as

intoxicated persons and observers, the refusal rate increased from 5 percent in

1996 to 70 percent in 2001 in two parts of Stockholm (Andreasson, Gripenberg, &

Wallin, 2005). RBS and stricter enforcement efforts were also associated with

significantly decreasing violent crimes by 29 percent (Andreasson, Norstrom, &

Wallin, 2003). Follow-up research reanalyzing these results was somewhat lower

but strongly significant and uniform, reaffirming this finding (Norstrom &

Trolldal, 2013). A survey of 1,000 Stockholm County residents found strong

popular support for licensed premises to practice responsible beverage service

and for stricter enforcement of existing legislation by local authorities; whereas

strategies to reduce availability (e.g., increased alcohol price, reduced open hours)

were unpopular (Wallin et al., 2005).

Another study focused on over-drinking and violence related to student

parties at licensed establishments in Stockholm. It involved a multi-component

intervention focusing on April 1 to May 31 when most graduation parties take

place. There were three data points before and three after the intervention during

the 2005–2010 study period. It was considered successful at reducing violence as

measured by emergency room admissions among young people (Ramstedt,

Leifman, Sundin, & Norstrom, 2013).

Efforts to reduce youth access to alcohol in the form of medium-strength beer

in grocery shops were less conclusive: sales in both intervention and comparison

sites were reduced, but perceived availability by youth did not change.

Contamination between intervention and comparison sites may have occurred,

but of note is that there was little difference in outcomes between the intervention

of information and training compared to a policy of surveillance and sanctions in

the comparison areas, and information and training required fewer resources

(Rehnman, Larsson, & Andreasson, 2005).

Norway. In Norway, local efforts to address alcohol use and harms have been

conducted as part of Regionprosjektet which was centrally managed by the National

Health Directorate. In Regionprosjektet, local communities were encouraged to

apply for funding and allowed to choose from a menu of evidence-based programs

approved by the Directorate over a three-year period. When given the option of

choosing their own approaches, only one community selected a policy project,

implementing RBS training, and this effort showed no impact (Rossow &

Baklien, 2010). Other evaluations of RBS in Norway show it was not successful at

reducing underage or over-intoxicated sales; however, examination of implementa-

tion of RBS in these sites indicates that RBS implementation varied greatly among

sites and that not all content or elements were implemented consistently—described

by Rossow and colleagues as “RBS light” (Rossow, Storvoll, Baklien, & Pape, 2011).

Finland. The Lahti Project was carried out in a community of 100,000 inhabitants

during 1993–1994 and became a demonstration project for the WHO’s European

Office in 1993 (Holmila, 1997, 1999, 2000). The project included setting up

Giesbrecht et al.: Sustaining Local Alcohol Policies 217

educational events, an experimental study involving a brief intervention in

primary health care, a rich variety of activities among young people, and

counseling sessions for intimate others (Holmila, 2000). The prevention interven-

tions focused on alcohol-related public violence and promotion of responsible

service of alcohol. Both qualitative process evaluation and quantitative outcome

evaluation were undertaken (Holmila, 1997). While the heaviest drinking group

in Lahti reduced their drinking more than those in the comparison site, it was

noted that the overall level of alcohol use had not been reduced more than in the

comparison site. Nevertheless, respondents reported increased awareness of

alcohol as a serious problem and an increase in knowledge about some facts

about alcohol. It also created some new permanent methods for community-based

prevention activities (Holmila, 2000).

The PAKKA Project—Local Alcohol Project—was implemented in Finland

from 2004 to 2007. As with Regionprosjektet in Norway, PAKKA was adminis-

tered at the national level. The core components were community mobilization

and policy change, reducing social access to alcohol by youth, and reducing

commercial access through Responsible Beverage Server training and enforcement

of laws, media advocacy, alcohol-free events, and a drama-based parent educa-

tion program in the schools. Full-time staff at the local level worked with

community stakeholders, including alcohol licensing authorities and businesses

(Holmila & Warpenius, 2007). Results in one community indicate that PAKKA

was successful at reducing sales to intoxicated patrons. Refusal to serve in

licensed establishments increased from 23 percent to 42 percent in intervention

premises and actually decreased in the control areas from 36 percent to 27 percent

(Warpenius, Holmila, & Mustonene, 2010). Holmila and Warpenius (2012)

summarized the findings of the PAKKA Project. PAKKA saw improved compli-

ance with minimum age of sale laws; however, due to some contamination

effects, improvements occurred in both the comparison and control sites. Young

people also perceived it was more difficult to purchase alcohol after the

intervention than before and abstinence from alcohol among both boys and girls

increased. Public attitudes toward underage alcohol use became more restrictive

and social availability of alcohol also decreased. Service to intoxicated patrons

decreased (Holmila & Warpenius, 2012).

As with the North American, Australian, and New Zealand examples,

experience from the Nordic countries suggests that local level efforts that focus

on alcohol sales and service can be successful at reducing underage access and

service to over-intoxicated persons. There is some indication that such efforts can

also reduce violence and alcohol-related problems. The Nordic experiences also

show challenges with implementation and highlight the need for sufficient

staffing, capacity, and expertise.

Challenges

Despite three decades of research on local alcohol policy, school-based and

individual-focuses prevention programs are more readily available to local

218 World Medical & Health Policy, 6:3

practitioners seeking to address youth alcohol use. The U.S. National Registry

of Evidence Based and Promising Programs (NREPP) mainly lists individual

programs, with only the Wagenaar and Holder programs promoting policy.

Most of the studies of community-level efforts examined here are multi-

component studies, combining community organizing, policy implementation,

and enforcement efforts, as well as some that include media advocacy and

community awareness components. While promising, this research exposes

some challenges in how to effectively prevent alcohol-related problems at the

local level.

There is not a central systematic and updated resource of previous evidence-

based local projects so that new initiatives can efficiently benefit from previous

experiences. It is not evident that new initiatives provide adequate training,

resources, and tools for those undertaking local action on alcohol issues. There is

a gap in resources to foster sustainability, and funding typically lasts only a few

years. Projects need a stronger emphasis building local coalitions so that expertise

and commitment on local alcohol issues is sustained. The timeline of evaluation

and local resources and commitment are typically not sufficient to sustain projects

and to assess long-term impact to monitor/evaluate the effects of policies so that

there is knowledge on what will make a difference in the long term. The

following text elaborates on several of these.

While community mobilization is an important component of many studies,

only a handful provide detailed information on this process or describe what

constitutes a sufficient level of outreach and engagement to mobilize the

community. Several studies demonstrate that the community mobilization

component can require a substantial amount of staff effort and expertise.

Wagenaar and colleagues (1999) describe the implementation of the community

mobilization component of CMCA in some detail, demonstrating a significant

amount of community outreach through one-on-ones (n¼ 1,518 across seven

communities). Paid community organizers also recruited and maintained strategy

teams with 141 members. Bosma and colleagues provide perhaps the most

detailed description of the requirements of community organizing in the

Minnesota D.A.R.E. Plus Project (Bosma, Komro, Perry, Veblen-Mortenson, &

Farbakhsh, 2005), demonstrating the intensity of the community mobilization

process as well as the roles of volunteer community members (both youth and

adults in this case) recruited to action teams. Across eight sites over a 2-year

intervention period, adult action teams met 153 times and held 112 activities and

youth action teams met 420 times and held 721 activities. The study, which

addressed alcohol, tobacco, and marijuana, found significant decreases in alcohol

(as well as tobacco and drugs) access and use among boys, but no significant

differences for girls (Perry et al., 2003). Holder and colleagues used a slightly

different approach, and worked through existing coalitions rather than organizing

new entities, and introduced an alcohol policy agenda to an existing body already

working on community change (Holder, 2000a). It was also necessary to collect

data on the specific local problems related to alcohol outlet density and access

within each community so that strategies could be targeted appropriately and

Giesbrecht et al.: Sustaining Local Alcohol Policies 219

effectively, requiring local research capacity, followed by buy-in and support

from the local coalitions (Reynolds, Holder, & Gruenewald, 1997).

Firmer direction may be needed to encourage local groups to implement

policy efforts. Despite the evidence base, local groups may not elect to implement

policy options. When given the opportunity to implement evidence-based

programs in the Regionprosjektet in Norway, groups largely opted to continue

implementing the programs they were already administering, even though most

lacked an evidence base, and the National Directorate did not offer any policy

options among the menu of programs that local groups could select (Rossow

et al., 2011). Likewise, Bosma found resistance and skepticism among team

members required to implement science-based programming in a California

county (Bosma, 2012). The U.S. Drug Free Communities program appears to be

having success requiring local groups to implement environmental strategies.

While CMCA is being implemented in numerous sites, only limited evaluation or

research on implementation has occurred, leaving us with little knowledge of

how this research has translated to practice (Bosma, 2005a, 2005b, 2008).

Research designs may pose special problems for policy efforts. One challenge

is the role of the researcher, discussed by Holmila and Warpenius (2007) in

regard to the PAKKA project. In PAKKA, researchers helped identify the

initiatives and some have questioned if researchers can remain objective or if they

become too close to the efforts they are evaluating. When and what to measure

are also issues in community policy efforts—PAKKA found it useful to assess

intermediate outcomes related to specific policy initiatives (such as reduced sales

to underage or intoxicated persons as an intermediate measure assessing alcohol

availability, which is then believed to lead to reductions in consumption and

alcohol-related problems). Several projects identify the need or value of imple-

menting several efforts at once, which raises challenges for assigning causality.

Examining how projects are implemented may be essential to understanding if a

project’s lack of success is due to the intervention or to failure to sufficiently

implement the intervention. For example, the only policy strategy implemented

in the Norway study showed no impact, but researchers pointed out that only

education training (RBS) was conducted, without any enhanced enforcement or

community awareness, and this may explain the lack of impact (Rossow et al.,

2011).

Enacting policy at the local level is often constrained by higher-level policies

at the state/province, national, or international level. The European Union

presented a challenge for Nordic countries, as at least Sweden and Finland had

more restrictive national policies prior to integration into the EU. Joining the EU

required Nordic countries to adjust their national policies to align more closely

with EU standards. This has resulted in more alcohol outlets in Sweden, and has

lessened the ability to impose higher taxes in both Sweden and Finland

(Holder, 2000b). In the United States, a similar problem occurs in some states,

which pre-empt local governments from passing more stringent restrictions than

the state plateau. Likewise, Australia and New Zealand have experienced similar

challenges when central laws were relaxed. National policies in New Zealand and

220 World Medical & Health Policy, 6:3

Australia are highly influenced by the alcohol industry perspective and focus on

harm reduction strategies to reduce excessive and hazardous alcohol use in

specific settings and within at-risk groups, rather than the population-based

strategy that is used to reduce the prevalence of tobacco use in both countries

(e.g., Stewart, 1997).

Many local governments have been active in developing policies to address

their responsibilities under the Sale of Liquor Act (e.g., Casswell &

Maxwell, 2005). However, central government has not devolved power along

with responsibility to address alcohol problems (e.g., Casswell & Maxwell, 2005;

Maclennan et al., 2013). Central government sets legislative boundaries around

what local government can do to address alcohol-related harm; for example, in

some jurisdictions outlet density cannot be restricted under current legislation

and minimum prices cannot be set to offset price-based promotions in outlets in

high-density areas. In addition, special interest groups, including the alcohol

industry, have a strong impact on the adoption of local alcohol policies despite

the fact that most local government candidates run as independents rather than

as political party members. While there is substantial work to address community

alcohol-related problems through community action initiatives, shifts toward

liberalization of alcohol policy and accommodation of the liquor and hospitality

industries has resulted in funding for community action being primarily restricted

to projects targeting high-risk groups and contexts such as indigenous drinkers,

young people, and drink-driving (Conway & Casswell, 2003).

An ongoing challenge is that there have been few opportunities to systemati-

cally examine research findings in naturalistic settings. We know very little about

the results of strategies from CMCA, the Community Trials project, or other

programs when implemented by local practitioners without support and training

at the level of the initial research studies. In a number of cases the interventions

are relatively short term and intervention effects cease after the experimental time

period; rates of motor vehicle crashes, for example, start to rise again due to lack

of intervention in the community, which indicates that local interventions need to

be an ongoing effort.

Also, there is not sufficient attention in current projects to the dose-response

gradient. Future projects should be encouraged to provide estimates of factors

that are likely to be related to achieved outcomes, such as person-hours, monetary

costs, and level and type of training of staff and volunteers. For example, in

Project Northland Chicago, educating the youth at young ages did not change

their behaviors related to alcohol; in contrast Project Northland Minnesota was

more successful in impacting youth behavior, likely because of the ongoing

support from the community. An Ontario-based project had a short-term impact

on a small group of high-risk drinkers but no evidence of desired reduction in

consumption at the population level (Giesbrecht et al., 1990). It is feasible that the

goals were too ambitious, time frame too short, community organization

inadequate, and intervention too modest. There is little knowledge of what kinds

of adaptations are acceptable or what levels of fidelity are required to have an

impact. Further research is needed in this area.

Giesbrecht et al.: Sustaining Local Alcohol Policies 221

Stimulating Sustainable Effective and Efficient Local Interventions

Sustaining local efforts may be especially challenging when it comes to

alcohol policy (Holder & Moore, 2000). In light of the challenges involved in

undertaking policy initiatives, several elements appear to be essential to sustain-

ing local policy interventions.

Community Engagement. In general, local alcohol policy work is done

through coalitions or some type of community group or team, which, while

effective, requires ongoing buy-in and maintaining engagement among mem-

bers. Long-term community engagement necessitates continuing staffing by a

skilled project coordinator or community organizer to conduct outreach

and maintain relationships with community members and stakeholders, and

decision makers. Diverse, broad-based coalitions are necessary for maintaining

credibility of efforts and to recruit diffused support for efforts. The need for

community engagement to address local alcohol problems is seen across

countries. For example, New Zealand’s new guidelines for developing local

alcohol policies to address community alcohol problems in the Sale and

Supply of Alcohol Act (2012) have a strong emphasis on the input of local

communities (New Zealand Ministry of Justice, 2013) and recent research has

also found that adoption of local alcohol policies can be facilitated by

community mobilization efforts to create competition in local elections, make

alcohol an election issue, encourage well-known citizens sympathetic to

addressing alcohol issues to run for local government, and to encourage voting

(Maclennan et al., 2013).

Local Capacity. Local efforts require capacity in several areas. Understanding

the local political landscape is essential to know which bodies can impact efforts

and where power lies. Sufficient knowledge of how to collect data to learn where

local problems are is needed to justify new policies, garner support for efforts,

and monitor success. Understanding and knowledge of alcohol problems, harm,

and policy are essential to decision making about which local efforts to pursue to

impact a community’s specific problems. In addition, capacity building is often

necessary for coalitions to be able to authentically partner with and engage a

variety of stakeholder groups, including young people, in developing and

implementing local solutions.

Monitoring Implementation. Passing policies is only the beginning. Without

sufficient attention to implementation of the policy, many efforts will remain

ineffective and not produce the desired results. For example, in Alameda County,

California, the Alcohol Fee Ordinance was passed in 2006, and then modified in

2008 before full implementation could begin. A local committee of community

stakeholders, law enforcement, agency representatives, and their evaluator has

met regularly since passage to monitor implementation, identify challenges,

suggest improvements, and keep the County Board of Supervisors informed of

progress to ensure the ordinance is successfully implemented (Alameda County

Sheriff’s Office, 2010). Examples like this show the need for policy efforts to

continue well after initial passage of a new policy.

222 World Medical & Health Policy, 6:3

Sufficient Resources. Resources are difficult to obtain at the local level. The

Drug Free Communities program in the United States offers coalitions the

opportunity to apply for two five-year funding cycles (for a possible total of up to

10 years), but this duration is probably the exception, rather than the norm. Thus

it is important to identify additional sources of funding for local efforts.

Diversifying support so that local coalitions are not dependent on a single source

of resources is one solution; institutionalizing policy work in an ongoing

organization or body is another.

Conclusions and Limitations

A significant body of international research supports the pursuit of alcohol

policy at the local level to reduce consumption, underage use, and related

harms. Community-based initiatives have demonstrated a number of positive

outcomes, including, for example: increased support for restrictions on market-

ing and price controls, decreased alcohol sales to minors and reduced

consumption by youth, reduction in DUI arrests and fatal crashes, and declines

in violent crimes and assault injuries. Sustaining these efforts beyond an initial

study or grant period poses a challenge to ensuring the impact of such work is

sustained. Among the needed elements to ensure local policy efforts continue

to have an impact are community mobilization to support policy, developing

needed skills and expertise to maintain local capacity, ongoing engagement in

order to monitor implementation and ensure policies are enacted and carried

out, and sufficient resources at the local level.

However, this review shows that further research is needed to examine the

longevity of these effects. In particular, insufficient evidence is available on the

level of dosage required for successful outcomes, how to sustain policy efforts

over time, and how to develop systems that can maintain and sustain the

necessary capacity at the local level to undertake policy initiatives. While much

policy work is being undertaken at the local level, we do not know if this

development is because these efforts are more effective or out of necessity due to

cost or challenges of influencing policy at a regional or national level. Other

factors that remain largely unexamined are the differing contexts of local work

and whether lessons learned in one community setting are transferable to

another.

Norman Giesbrecht is a senior scientist emeritus, Centre for Addiction and

Mental Health, Toronto, and an Associate Professor, Dalla Lana School of Public

Health, University of Toronto.Linda Bosma is president of Bosma Consulting, LLC.Jennifer Juras is associate at the Sarah Samuels Center for Public Health Research

& Evaluation.Maria Quadri is a research volunteer at the Centre for Addiction and Mental

Health, Toronto, in the Social & Epidemiological Research Department.

Giesbrecht et al.: Sustaining Local Alcohol Policies 223

Notes

Conflicts of Interest: None declared.Corresponding author: Norman Giesbrecht [email protected].

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