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Alcohol Abuse Prev Strategies ALCOHOL ABUS(= PREVENTION STRATEGIES A Profile of One City - San Francisco United States Conference of Mayors 1620 Eye Street, Northwest Washington, D,C, 20006 ---~-----'--------,--,--_._,-- "-".-"- -------- ---~--- United States Conference of Mayors Helen G, Boosalis, President Mayor of Lincoln, Nebraska John J, Gunther Executive Director Acknowledgement This publication was written by Elizabeth Campbell, Staff Associate, in consultation with Carol Moody Becker, Staff Director for the Alcohol Abuse Prevention Project. Pat Troll- inger, Office Associate, assisted in the preparation, The alcohol abuse prevention strategies of the Conference fall under the Office of Employment, Education and Human Resources, which is directed by James L, Parsons, The U,S, Conference of Mayors prepared this publica- tion under contract number ADM 281-80-0017 from the National Institute on Alcohol i6,buse and Alcoholism (N IAAA) The findings and conclusions do not neces- sarily reflect the policies of NIAAA -------- --- -- ------- -- ----------------------- Contents Preface, , I. Overview, II. Alcohol Abuse in San Francisco Costs to the Criminal Justice and Health Systems, " Community Substance Abuse Services"", '" Community Involverlent '" " Coordinated Approach to Alcohol Abuse Prevention, Role of the Mayor III. San Francisco's Alcohol Abuse Prevention Strategies The Mayor's Blue Ribbon Committee, Bartender Training Sobriety Hotels, , Media Campaign, " Healthy Youth Project, , , Employee Assistance Program IV. Resources Use of Student Volunteers, Special Liquor Tax, " ' Organizations and f\gencies, Footnotes, Page v , 1 ,3 3 3 4 ,4 4 ,5 5 6 ,6 7 8 ,9 11 , 11 , 11 , 11 , 13 ììi Special Acknowledgement The Conference of Mayors would like to express its appreciation to Mayor Feinstein and to the San Francisco city officials who offered both information and valuable insights on the alcohol abuse prevention program in their city, Special thanks is given to Larry Meredith, Ph,O" Program Chief, Community Substance Abuse Services, City and County of San Francisco, for his time and the assistance he has provided to the Conference of Mayors' Alcohol Abuse Prevention Program, ------ IV The U ,S, Conference of Mayors, in coop- eration with the National Institute on Alcohol Abuse and Alcoholism (N lAM), has explored over the past eighteen months innovative city approaches in alcohol abuse treatment and prevention, Special attention has been focused on prevention efforts involving city policy in areas such as criminal justice, civil service, and health, Through the publication of the issue paper Alcohol Abuse Prevention Strategies in Cities and presentations at three Mayors Lead- ership Institutes the Conference has brought ex- emplary city approaches to the attention of the Mayors, Preface After reviewing various city alcohol abuse prevention strategies in the kst issue paper, the Conference felt that it would be useful to concentrate on one city's approach, Through such a focus, other cities could analyze the various components necessary to develop, organize, and implement prevention strategies, as well as learn effective ways to involve the community and the private sector, Conse- quently, this report provides an in-depth presen- tation of the comprehensive alcohol abuse prevention program in San Francisco, San Francisco is one of the cities which has done extensive work in the alcohol abuse field and has always had a focus on prevention, The city's prevention effort addresses alcohol abuse through model programs anc policy ap- proaches, It is hoped that this description of one city's experience in prevention will provide guidance to Mayors and oHler local officials in impacting upon alcohol abuse and alcoholism in their cities, v Alcohol abuse and alcoholism cost the na- tion billions of dollars annually and much of the financial burden is borne by local governments, Cities are faced with the costs and conse- quences of: public inebriates and their impact on the health and criminal justice systems and on downtown revitalization: drunken drivers who cause half of all traffic fatalities;; and alcohol abusing and alcoholic employees, 25 percent of whose salary is lost due to absenteeism, ineffi- ciency, and other factors,2 Increasingly, Mayors are looking to alcohol abuse prevention pro- grams to address these costs, San Francisco's coordinated approach to alcohol abuse prevention can provide a model for other cities wishing to impact on their alcohol problems, With the strong support of Mayor Dianne Feinstein, the city has developed a multifaceted approach to the prevention issue, This approach-involving the criminal justice system, the schools, and the civil service system-includes an ambitious public informa- tion/media campaign and an innovative seven year plan for housing public inebriates, -----------,-------- I. OvelVi ew Following a description of the nature of the alcohol abuse problem in San Francisco, this report describes the operation of the city's Divi- sion of Alcohol Programs, A subsequent chapter provides detailed information on the various strategies, both traditional and in- novative, which San Francisco has employed to impact on alcohol abuse, It is recognized that cities are not identical and that programs and approaches are adapted to differing urban needs, Therefore, this profile of San Francisco is presented to stimulate thought and discussion and to offer a new framework for planning alcohol abuse prevention strategies, ------ -------- ---- San Francisco often has been character- ized as a "hard drinking town," For many years the city has led the nation in the incidence of alcohol related problems among its citizens, with the highest per capita level of alcohol con- sumption and alcohol cirrhosis in the United States,3 However, since 1970, with the im- plementation of an effective service delivery system for alcohol abuse and alcoholism, the cirrhotic death rate has declined 47 percent. Costs to the Criminal Justice and Health Systems As in cities across the country, alcohol abuse has a major impact on San Francisco's criminal justice and health systems, Alcohol related arrestees crowd the jails and overload the court system, Most of the arrests are for public drunkeness-16, 167 arrests in 1979,4 Studies show that housing the public inebriate in jail is a costly and ineffective way of dealing with the problem, Compared with a cost of $90 for processing and jailing; the cost for housing the public inebriate in a city funded detoxifica- tion facility averages $33-one third the cost." II. Alcohol Abiuse In San Francisco It is more difficult to measure the impact of alcohol abuse on San Fra lcisco's health facilities, However, it is well known that chronic inebriates repeatedly utilize hospital emergency rooms, San Francisco General Hospital serves a large number of public inebriates, "Normally between 35 percent and 45 percent of emergency room patients seen by the Medical Staff Worker are diagnosed as alcoholics or problem drinkers," 6 Community Substance j~buse Services To respond to the wide range of alcohol related problems in the community, San Fran- cisco's Division of Alcohol Programs, Commun- ity Substance Abuse Services (CSAS), maintains a comprehensive service system, Currently, CSAS funds 25 different treatment and referral agencies which provide a variety of alcohol related services, The fiscal year 1981 budget to support these programs totalled $4 million with the largest percentage from state general funds-$2,6 million, Federal formula grants comprised $651,000 of the total. 3 Community Involvement The community is an active participant in the planning of the city's alcohol programs through the Citywide Alcoholism Advisory Board (CMB), This 15-member board, established in 1971, provides the Division of Alcohol Programs with community input regarding programs, policies, and priorities, The CMB reviews the program budget and the community's alcoholism prevention, treatment, and rehabilita- tion needs, In addition, the CMB promotes public understanding of the problems of alcoholism and encourages public support for the development and implementation of effec- tive alcoholism programs, A prevention task force of the CMS has been active in pursuing means through which the community can be more effective in ad- dressing problems created by drunk drivers. Representatives of the Police Department, the judicial system, the American Automobile Association, and concerned citizens are par- ticipating in this forum, Coordinated Approach to Alcohol Abuse Prevention One of the keys to the comprehensive alcohol abuse prevention program in San Fran- cisco is a coordinated approach, Community Substance Abuse Services (CSAS) emphasizes the importance of good working relationships with other health and human service agencies in the city, The Director of CSAS promotes this community coordination of alcohol related serv- ices by his involvement in a range of health and human service organizations. The Division of Alcohol Programs has established linkages with the criminal justice, welfare, mental health, and public health systems, enabling them to stretch their resources, These relationships help to bridge gaps in care and have provided productive cross referral opportunities, In addition, the Director of CSAS feels that because of this in- 4 teragency involvement and communication, the services of law enforcement, public and mental health, and employers are more sensitive to the needs of those with alcohol problems, Since the major share of the city's alcohol abuse services are provided under contract ar- rangements, the Division of Alcohol Programs also requires that providers develop effective working relationships with the entire alcohol service delivery system, In addition, the Division holds a monthly providers meeting so that all the units providing services can share informa- tion and troubleshoot problems, This service delivery system, with its network of interdepen- dent linkages, permits the city to more effec- tively serve the community. Role of the Mayor Mayor Dianne Feinstein, a strong advocate of the city's alcohol abuse prevention activities, has provided leadership and ~lelped to raise community awareness of alcohol problems in San Francisco. With the Mayor's support, and in some cases active participation, the city: ap- pointed a committee to study the public in- ebriate problem, conducted a training session for bartenders, began planning for low cost housing for public inebriates, developed a public information campaign on 'alcohol abuse, instituted an alcohol risk reduction program in the schools, and has plans to broaden its alcohol assistance program for municipal employees, These approaches are described in the following section, By employing a comprehensive broad- based approach to the alcohol abuse issue, the Mayor has been able to minimize the costs to the city of San Francisco which result from alcohol abuse. - ------------- - -- -- -- -- n_-- -- - -- - The Mayor's Blue Ribbon Committee As in cities across the country, San Fran- cisco was faced with mounting concerns over the impact of public inebriates on businesses and neighborhoods, In addition, the processing of public inebriates in the criminal justice system was costly, largely ineffective, and a misdirected approach for dealing with the prob- lem, In response to these problems and to a study analyzing the impact of alcohol abuse on the criminal justice system, Mayor Dianne Feinstein appointed a 25 member "Blue Ribbon Committee on Public Inebriates," Recognizing the need for broad based support in the resolution of the problem, the Mayor appointed representatives from all sec- tors of the community including: alcohol treat- ment service organizations, the criminal justice and health systems, the corporate sector, and neighborhood organizations, Professional sup- port was provided by the Mayor's office, as well as the Division of Alcohol Programs of Com- munity Substance Abuse Services, - --- - -- -- - - - - -- - -- - --- ------ - - --- ---- ---- ------- -- ----------- III. San Francisco's Alcohol Abuse Prevention Strategies The committee's function was to explore the public inebriate problem and to suggest solutions addressing criminal justice, health, and residential issues, Testimony was received from a wide range of sources-including the Department of Public Health, the Police Depart- ment, the Salvation Army, the business sector, concerned citizens, and public inebriates-in an effort to determine the size and nature of the problem, current local responses, and what should be done, In order to receive community input and recommendations, two well attended public hearings were held, The committee's final recommendations were then submitted to the Mayor, Findings and Recommendations The findings and recommendations of the Blue Ribbon Committee deal with the alcohol abuse problems in San Frarcisco, However, as many cities face these same problems, the committee's recommendations (some of which have already been implemented) may have a broad applicability, Among the findings and recommendations were the following: 7 --- -- -- ,---- --- --- --------- - -------- 5 . Sober Residences: San Francisco's alcohol recovery system should be expanded to meet the need for sober residences, Due to lack of these facilities many persons become re- involved in the criminal justice system because they have no place to go upon com- pletion of the detoxification program, (For fur- ther information on sober residences see the description of sobriety hotels in this report on page 6,) . Reception Centers: Public inebriates should be diverted from the criminal justice system which is a costly and inappropriate response to the problem, The committee recommends that the police transport public inebriates to reception centers rather than to jail and that there be increased communication and coor- dination between the police and reception centers, . Public Awareness: A media campaign should be developed to promote public awareness of the size and cost of the public inebriate problem and the resources necessary to place those who need help into the alcohol recovery system, (The city media campaign will begin in mid-March, See the description of this effort on page 7,) . Alcohol Tax: The Mayor should support passage of state legislation increasing the alcohol excise tax, The additional funds would be earmarked for increased alcoholism serv- ices, For further information on the Mayor's Blue Ribbon Committee contact: Jim Buick Office of Criminal Justice City Hall San Francisco, California 94102 Bartender Training A special seminar on alcohol abuse was given to San Francisco bartenders, restaurant and bar owners, and waiters and waitresses in December, The seminar was sponsored by the city's Community Substance Abuse Services as one of a number of positive steps toward preventing problems, particularly during the holi- day season (with its usual increase in alcohol related fatalities and accidents), Techniques for cutting off bar service to intoxicated patrons, how to recognize when a person is becoming intoxicated, myths about alcohol, and drinking capacity of people by weight were among the topics discussed, The training was deviseel by the State of California's Department of Alcoholic Beverage Control-the state regulatory agency that licenses all sales of alcohol. F'reviously training was given to all restaurant ard bar owners at each establishment and was considered to be very effective, However, this practice was discontinued due to lack of funds, The training seminar emphasizes the responsibility of the servers toward intoxicated and near intoxicated persons, and manage- ment's responsibility for supporting a server's decision to refuse further service to a patron, The seminar is an excellent example of how government and industry can work together to solve common problems, The participation of bartenders in this training program can help to prevent injuries and save lives, as well as reduce one of the major headaches associated with running a bar or restaurant. For further information on bartender train- ing contact: Mara Mugford State of California Department of Alcoholic Beverage Control 1215 0 Street Sacramento, California 95,314 Sobriety Hotels The Mayor's Blue Ribbon Committee, as previously described, identified the need for sober environments for those public inebriates who wish to maintain sobriety, Recovery from alcohol abuse is significantly improved when a person can live in a controlled, alcohol free en- 6 vironment. Sober residences minimize the "revolving door" syndrome in treatment set- tings and the criminal justice system, Currently, the demand for residential services in San Fran- cisco is high due to, among other factors, the housing shortage which leaves few low cost housing alternatives, Bridgeway Project The Bridgeway Project, a sober hotel which has been in existence for eight years, of- fers the chronic alcoholic an alcohol free living environment. This successful program provides referral links to health and other services available in the community, as well as providing round-the-clock counseling, Of the 100 beds in the hotel, 40 are for long term alcoholics who are sober, The goal is for the problem drinker to "graduate" and remain in the hotel. Island of Sobriety Project Using the Bridgeway Project as a pro- totype, the Division of Alcohol Programs "Island of Sobriety Project" has as its seven year goal the establishment of ten sober hotels in San Francisco, To respond to the need for addi- tional sober environments, these hotels will pro- vide long term residence to chronic alcoholics, In addition to reducing the costs to the public, the project will enhance the personal and social conditions of these individuals, The first phase of the project calls for a funding strategy to raise the money necessary to set up and begin operation of ten 1 OO-bed hotels, This money will come from a mix of private investment, public monies, and capital fund raising, After identifying potential investors and arranging real estate and banking transac- tions, the Division of Alcohol Programs will oversee the purchase and renovation of the facility and then select and administer the facili- ty management team, In addition to providing stable, low cost housing, the hotels will include job training and rehabilitation services so that individuals can become productive citizens, Cost savings are foreseen in the criminal justice and health systems, For further information on the Island of Sobriety Project contact: Wayne Clark, Ph,D, Division of Alcohol Programs Community Substance Abuse Services 170 Fell Street San Francisco, California 94102 Media Campaign The San Francisco Department of Public Health, Division of Alcohol Programs, has developed a media-based alcoholism informa- tion and prevention program, Under a contract with Cole Communications (a private advertising firm), the campaign will increase community awareness about the nature and effects of "atypical" alcohol use and the resources available to assist the alcohol abuser, The cam- paign strategy is based on the premise that alcohol abuse affects not only the problem drinker, but all members of the community, Therefore, alcohol abuse will be presented as a community problem requirinç a community response, The information dissemination campaign will be targeted to reach specific population groups including Blacks, youth, women, men, and the elderly, Recognized and respected com- munity leaders, role models jar each specific audience, will appear in ads declaring themselves as "typical" drinkers but not pro- blem drinkers, They then will outline the symp- toms of problem drinking and state the help available, The focus will be en all citizens as "significant influences" on al1 alcohol abuser and stress that they are in a position to in- tervene on behalf of the problem drinker, Media use will include television, radio, newspapers and magazines, special community events, posters, and yellow pages advertising, ------- ------ ___n---- 7 -~~---- -----~-, ---- Funding Strategy The campaign has looked to all segments of the community to share in sponsorship, Foundations have been approached and cor- porate sponsors are being sought. As a means of securing private sector support, a Sponsor Participation Book has been sent to businesses in San Francisco, A company can choose to sponsor one particular item in a certain media, such as a radio ad or a poster, donating the amount listed as the production cost of that item only, The advertisement would then depict the firm as the corporate sponsor, The campaign has received positive responses from the media in San Francisco, One station has already donated the production of a videotape session on alcohol problem prevention with a group of local notables-a contribution valued at $35,000, This will be a central component in the overall media-based prevention effort. Citizen Participation Prior to the development of the advertising strategy, a community survey regarding at- titudes on alcohol was conducted, The survey measured the public's level of awareness in order to gear the campaign to community needs, , A public meeting was held for community !nout on campaign goals as well as the major Issues and needs to be addressed, In addition the city's health service providers were inter- ' viewed to ascertain their needs in a community outreach campaign, Goals The primary goal of the public information campaign is prevention-a reduction in the in- cidence of alcohol related problems, The city is also seeking to achieve an increased communi- ty awareness that: . the misuse of alcohol is a serious problem for everyone, not just the abuser: - - -------- ----- 8 ------- - ------------ ---- -- ----- -- ---.. --- . an extensive network of services exists to help the problem drinker: and . all citizens are significant influences on the alcohol abuser and can help to relieve this problem, For further information on the media cam- paign contact: Art Cole Cole Communications 1700 Union Street San Francisco, California 94123 The Healthy Youth ProjE~ct The Healthy Youth Project is a risk reduc- tion program established threugh a joint effort of the San Francisco Department of Public Health and the San Francisco Unified School District. The aim of this peer teaching, parent, and teacher health promotion program is to deter the onset of smoking and alcohol abuse among youth. The abuse of alcohol and tobacco can lead to illness, disability, and (jeath, However prevention programs can help to minimize' these risk factors, Since it is during adolescence that experimentation with alcohol and tobacco usually begins, it is an optimal time to educate youngsters in the responsible use of these products, As in other San Francisco prevention ef- forts, community involvement is an integral component of the program, The community and parents are involved in all phases of planning and Implementation, The project has a com- munity advisory group with representatives from the public and private sectors, This group assists in mobilizing the suppert of concerned citizens, transmitting information to the com- munity, and advising on policy matters, The project addresses the use of alcohol and tobacco on three levels: parental influence on children's smoking and drinking behavior, -- - --- ----- ----- ----- ---~ _._----------~ ---- ------- - --------- ,-------- teachers and other school staff influence on this behaviorl and peer pressure to smoke and drink, The curriculum focuses on learning social skills such as building a positive self image and includes facts and dispels myths about smoking and drinking, By January, 1983, the project hopes to have delivered risk reduction programs at three schools, providing students with the necessary life skills training to resist social pressures to smoke and drink, For further information on the Healthy Youth Project contact: Larry Meredith, Ph.D, Comllunity Substance Abuse Services 170 Fell Street San Francisco, California 94102 Employee Assistance Program The National Council on Alcoholism estimates that up to ten percent of the nation's workforce are problem drinkers, and that as much as 25 percent of a problem drinker's salary is lost due to absenteeism, excessive sick leave, and low productivity, Mayors are particularly concerned with this problem as fiscal constraints lead to a shrinking municipal workforce, In order to address this problem and in- crease the effectiveness of the city's workforce, San Francisco's Division of Alcohol Programs instituted an Employee Assistance Prog ram (EAP), The program provides information and referral services to employees who are ex- . periencing job performance problems due to alcohol abuse and other personal problems, which can cause stress and lead to substance abuse, The EAP is designed to help in the early identification of employees when their problems first impair job performance, There is ongoing training of supervisors to assist them in the early detection of possible troubled employees, The program aims to motivate the employee to ~--- ---- --- -- ----------, - receive the necessary treatment to resolve their problem, Treatment occurs outside the EAP after diagnosis, pre-treatment counseling, and referral have been made, Employees are assured that their job and future will not be jeopardized by utilizing this service. Many cities administer their employee assistance programs through the personnel department. However, San Francisco's ap- proach is for each department to design and budget for their own EAP, with the city's public health department providing technical assistance in establishing the program, In this way, the program can be structured to conform to the needs of individual departments and con- fidentiality is assured, As in their other successful alcohol abuse prevention programs, San Francisco stresses the importance of communication and coopera- tion in their EAP, Therefore, the city's effective Employee Assistance Program involves both management and unions from the planning stages, For further information en San Francisco's EAP contact: Larry Meredith, Ph.D, Community Substance Abuse Services 170 Fell Street San Francisco, California 94102 -----------, --- ,-~-_. 9 ---- -- --~--- Use of Student Volunteers San Francisco's Community Substance Abuse Services enlists the aid of graduate students in the Bay Area in their alcohol abuse prevention efforts, Across the country, colleges and universities, particularly those with graduate schools of medicine, public health, or social work, often have capable students who are anx- ious to find opportunities for field research, Graduate students can be especially helpful in gathering and analyzing data and writing case studies on alcohol abuse for a city's needs assessment Special Liquor Tax Mayor Feinstein's Blue Ribbon Committee on Public Inebriates recommended that in lieu of passage of state legislation to increase the alcohol excise tax, the Mayor should explore the feasibility of instituting a local alcohol tax, Several local governments have enacted designated liquor taxes,S and many other cities and states are considering taking similar action, The revenue generated by the tax would be .._-~- IV. Resources used specifically for alcohol prevention and treatment programs, Organizations and Agencies . The National Institute on Alcohol Abuse and Alcoholism, 5600 Fisher's Lane, Rockville, Maryland 20857, NIAM is an agency of the U ,S, Department of Health and Human Services. . The National Clearinghouse for Alcohol In. formation, P.O, Box 2345, Rockville, Maryland 20852, The Clearinghouse, part of N lAM, provides publications, literature searches, and other services regarding alcohol related subjects. Requests may be sub- mitted to the Clearinghouse by mail or by telephone, (301) 468-2600, . The State Alcoholism Authority in each state supports a range of alcohol services, in- cluding prevention programs, . The National Council on Alcoholism, 733 Third Avenue, New York, ~~Y 10017, NCA a private, nonprofit organization, has local af- filiates in many cities whicll can be of assistance in planning prevention efforts, 11 ------~ --------- - - __n -- -- - ------ Ernest p, Noble, ed" Third Special Report to the US, Congress on Alcohol and Health from the Secretary of Health, Education, and Welfare (Washington, D,c.: Government Printing Office, 1978), p, xi. 2 National Council on Alcoholism estimate, 3 Larry Meredith, Alcohol and Drug Services in San Francisco,' Current Status, Future Prospects (San Francisco: Community Substance Abuse Services, 1981), p, 1, ---- -- - --- - --- --- ---- --__n_- - ---- - -- __n- - _n ------ --- __n- -- Footnotes 4 Jenny White, Executive Summary-Alcohol Abuse and Alcohol-Related Problems in San Francisco,' A Needs Assessment for Alcoholism Treatment anÔ Prevention Serv- ices (San Francisco: Community Substance Abuse Services, 1980), p, 5, 5 Ibid" p, 6, 6 Ibid" p, 7, 7 The Blue Ribbon Committee on Public Inebriates, Report to the Mayor, October 22, 1981. pp, 8-14 8 John R, Deluca, ed" Fourth Special Report to the US, Congress on Alcohol and Health from the Secretary of Health and Human Services (Washington, D,C,: Government Printing Office, 1981), p,172, ------ _____n__~____--n__--_--- ------------------- 13