Addictive Behaviors 39 (2014) 1050–1051

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Addictive Behaviors

Commentary

“Obvious intoxication” isn't so obvious Adam E. Barry a,⁎, Robert M. Weiler a, Maurice Dennis b a b

Department of Health Education & Behavior, University of Florida, FLG-16, Gainesville, FL 32611, United States Center for Transportation Safety Texas A&M Transportation Institute College Station, TX 77843, United States

H I G H L I G H T S

• We question the utility of visually determining intoxication. • Outward manifestations of intoxication may not be observable at legal per se levels. • There is little evidence to support that persons can accurately and consistently judge intoxication visually.

a r t i c l e

i n f o

Available online 3 March 2014 Keywords: Overservice Intoxication Obvious intoxication Alcohol enforcement Impaired driving

1. Introduction

1.1. Is it obvious when someone is intoxicated?

Selling alcoholic beverages to obviously intoxicated patrons at both on-premise (e.g., bars, restaurants) and off-premise (e.g., liquor stores) establishments is illegal in the U.S. (Mosher et al., 2009). Recent investigations have posited that enforcement strategies to prevent sale of alcoholic beverages to obviously intoxicated patrons (i.e., overservice) are an underutilized method of reducing alcohol-related problems such as impaired driving (Lenk, Toomey, Nelson, Jones-Webb, & Erickson, 2013). Although systematic reviews of current strategies have reported that there is limited evidence that premise-level interventions will reduce patron intoxication (Brennan, Moore, Byrne, & Murphy, 2011), reducing the intoxication levels of bar patrons and the associated alcohol-related consequences that accompany intoxication does represent a significant public health problem which requires novel approaches. That said, at this time we question whether using visual observation techniques in on-premise settings to determine the intoxication levels of patrons is an effective strategy to reduce the public health problems resulting from overservice, such as impaired driving.

Previous examinations of overservice have primarily employed pseudo-intoxicated actors to portray drunk bar patrons (Andreasson, Lindewald, & Rehnman, 2000; Toomey, Erickson, Lenk, & Kilian, 2008; Toomey, Erickson, Patrek, Fletcher, & Wagenaar, 2005; Toomey et al., 2004; Toomey et al., 1999). These actors portrayed intoxicated characteristics such as slurred speech, as well as loss of motor control (e.g., staggered gait, fumbling with money, stumbling into objects) and cognitive functions (e.g., repeating questions, appearing forgetful). It is important to note that among average drinkers such outward manifestations (or “signs of visible intoxication”) are not visibly present at the legal per se limit of intoxication (80 mg/dl or 0.08%) in the United States (Brick & Erickson, 2009, p1498). Moreover, the majority of chronic drinkers may not appear visibly intoxicated at blood alcohol concentrations (BACs) of less than 150 mg/dl (i.e., Brick & Erickson, 2009). Those tolerant to alcohol may even be able to mask signs of visual intoxication at BACs that could be potentially incapacitating or lethal to other, less experienced, drinkers (Roberts & Dollard, 2010). Consequently, reliance on two of the more common enforcement strategies employed by enforcement agencies, agency walk throughs and visible observations for overservice at alcohol establishments (see Lenk et al., 2013), will

⁎ Corresponding author. Tel.: +1 352 294 1809 (Office); fax: +1 352 392 1909. E-mail address: aebarry@ufl.edu (A.E. Barry).

http://dx.doi.org/10.1016/j.addbeh.2014.02.017 0306-4603/© 2014 Elsevier Ltd. All rights reserved.

A.E. Barry et al. / Addictive Behaviors 39 (2014) 1050–1051

undoubtedly fail to capture intoxicated persons who may pose a public health risk to themselves and others. 1.2. Is it obvious when someone is too intoxicated to drive? While impairment of driving-related skills begins with any departure from 0.0 mg/dl (0.00%), most persons demonstrate impairment on at least one measure of driving ability (e.g., divided attention) beginning around 20 mg/dl (0.02%) BAC (Moskowitz, Burns, Fiorentino, Smiley, & Zador, 2000; Moskowitz & Fiorentino, 2000; Moskowitz & Robinson, 1988; Ogden & Moskowitz, 2004). The majority of the current scientific literature reports that 50 mg/dl (0.05%) BAC is the point at which driver performance measures (e.g., reaction time, tracking, psychomotor performance) are significantly impacted (Moskowitz & Robinson, 1988; Moskowitz et al., 2000). Even trained professionals such as police officers, however, have been unable to accurately and consistently identify legally intoxicated persons or those too intoxicated to operate a motor vehicle at BACs less than 150 mg/dl (0.15%) (Brick & Carpenter, 2001; McGuire, 1986). Other investigations have also documented physicians demonstrating poor accuracy at identifying acute intoxication (Gentilello et al., 1999). Thus, regardless of profession or training there currently exists little evidence that police officers, bartenders, servers, or even health professionals can accurately assess the intoxication of strangers through informal observations (Rubenzer, 2011). Ability to accurately assess the intoxication of individuals is further decreased in large group settings, such as public restaurant and bar establishments (McKnight, Langston, Marques, & Tippetts, 1997). As Brick and Erickson (2009) assert, without the use of specialized testing, such as a hand-held portable alcohol breath testers or standardized field sobriety tests, “the identification of alcohol intoxication at BACs producing impaired driving is not a simple matter to determine” (p1491). 2. Conclusion Overall, there is a litany of methodological and practical limitations associated with using visual cues to determine intoxication (see Barry & Dennis, 2013; Brick & Erickson, 2009). Therefore, reliance on visually determining whether a patron is “obviously intoxicated” will likely result in significantly impaired drivers going undetected. It should be noted that “obvious” is not completely synonymous with “visible”. Since obvious is defined as apparent to the eye or mind, a person who has consumed enough alcohol to reach an illegal BAC (N .08%) would legally be considered obviously intoxicated regardless of their outward appearance. Consequently, enforcement strategies seeking to prevent overservice would be more objective if the “number of drinks consumed” was used as the measure to determine when a patron should no longer be sold alcoholic beverages, instead of the subjective visual assessment. Even that approach, however, is not without its own limitations. For instance, currently used binge drinking guidelines (5 + drinks) predict relatively low (i.e., legal) BACs (Lange & Voas, 2001) and fail to capture whether a drinker reached intoxication (Perkins, Linkenbach, & DeJong, 2001). Thus, even when a considerable amount of alcohol is consumed it is possible that a patron has not reached legal per se limits of intoxication. Law enforcement and public health officials must consider the constellation of factors outlined herein and design and use enforcement strategies which are sensitive enough to assess intoxication levels that may not be visually obvious.

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Role of funding sources No funding was used to support this research and/or the preparation of the manuscript. Contributors Barry conceptualized the manuscript and prepared its first draft. Weiler and Dennis consulted on the conceptual development of the manuscript and its subsequent refinement. Barry takes responsibility for the paper as a whole. Conflict of interest The authors have no conflicts of interest to report.

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