Alcohol related harm, particularly injuries and violence related to binge drinking, continues to enjoy a large amount of media interest. Such an ongoing concern cannot be considered misplaced; globally, alcohol related mortality and morbidity presents a significant public health problem. The World Health Organisation estimates that alcohol causes 1.8 million deaths worldwide (3.2% of total deaths), with unintentional injuries alone accounting for a third of these, and a loss of 58.3 million disability-adjusted life years (DALYs) (4% of total DALYs).¹ Alcohol related harm is a growing problem for both high and low income countries, and the need for effective interventions is ever more important.

To promote the uptake of effective interventions in the policy arena it is important that systematic reviews on the effectiveness of interventions are undertaken. The Cochrane Injuries Group (CIG) has recently published a review entitled “Interventions in the alcohol server setting for preventing injuries”.² The review was supported by the UK’s Alcohol Education Research Council and become the third completed CIG review to examine the effectiveness of interventions for preventing alcohol related injuries.^3,4

Alcohol related injuries are predominantly a problem posed by the substantial number of moderate drinkers who occasionally drink to intoxication, as opposed to alcohol dependent drinkers. Programmes aimed at facilitating sensible alcohol consumption to prevent drinkers from reaching intoxication, or those aimed at reducing the risk of injuries to those already intoxicated, are potential ways to reduce alcohol related harm. This recent CIG review examined the evidence for the effectiveness of such programmes when implemented in the alcohol server setting.

The reviewers searched for all randomised and non-randomised trials investigating the effectiveness of an intervention that was administered in the server setting (such as bars and restaurants) which attempted to modify the conditions under which alcohol was served and consumed, to facilitate sensible alcohol consumption and reduce the occurrence of alcohol related harm. The review’s main outcome of interest was the impact on the occurrence of any injury, but the impact on behaviour and knowledge was also recorded.

Twenty studies meeting the inclusion criteria were identified, six of which were randomised. The review included studies investigating a range of interventions including health promotion initiatives, a drink-driving service, environmental interventions, and a server policy intervention; however, the majority of the studies evaluated a server training intervention.

The reviewers concluded that there is no reliable evidence that interventions in the server setting are effective in preventing injury. However, there was a lack of studies measuring injury outcomes, and the reviewers found that the overall methodological quality of the trials was poor. The review found relatively low levels of intervention compliance, with an approximate 50% compliance rate achieved. In cases of low compliance, it is not certain that an observed non-significant effect is due to an ineffective intervention or to its incomplete implementation. In addition, if compliance is low in a trial situation it is likely to be even lower in practice.

The apparent compliance problem may have implications for the effectiveness of policies. One example of this may be the UK Government’s Alcohol Harm Reduction Strategy for England,⁵ which has a focus on voluntary agreements with the alcohol industry in preference to a mandated approach. The findings of this systematic review suggest that the UK Government should take a firmer stance with the alcohol industry in the adoption of harm prevention policy if any discernible effect is to be seen. There is, however, concern that lobbying by the alcohol industry has had an unduly strong influence on the development of public policy in this area.

While a lack of evidence of the effectiveness of interventions in the alcohol server setting should not necessarily prohibit their adoption, it is arguably preferable for policy makers to focus on interventions for which there is evidence of effectiveness (such as sobriety checkpoints and alcohol ignition interlocks) before investing in as yet unproven strategies. As is often the case, further research is required, but the methodology of programme evaluation needs to be improved, with consideration given to ways to maximise compliance.

It is undoubtedly a key priority for decision makers to identify and implement effective strategies to combat the increasing problem of alcohol related injury. It is important that adequately funded quality research is undertaken, that such research is reviewed by properly conducted systematic reviews, and that this research is widely available. The Cochrane Injuries Group would very much like to see more reviews of interventions aimed at preventing alcohol related injury published on The Cochrane Library, and are happy to hear from those interested in undertaking further reviews in this area.