The Role of Breathalyzer Test for Understanding Drinkers’ Patterns and Behaviors: a Study Conducted in Porto Party Settings

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The Role of Breathalyzer Test for Understanding Drinkers’ Patterns and Behaviors: A Study Conducted in Porto Party Settings

Helena M. Carvalho, Cristiana Vale Pires, Jose López-Guerrero & Marta Pinto Agência Piaget para o Desenvolvimento (APDES)

ABSTRACT This study explores the relevance of the breathalyzer test as a harm reduction tool in outreach interventions implemented in nightlife environments. Specifically, it analyzes (i) gender and age differences on Blood Alcohol Concentration (BAC); (ii) the association between BAC levels and expected effects and (iii) the relationship between BAC levels and intentional behavior in a driving and non-driving sample. It was conducted for a two-month period during an outreach intervention implemented in one of the most important Portuguese nightlife districts - Movida at Porto. Real time data concerning sociodemographic dimensions and BAC were collected. Gender differences were found both on subjective and objective measures of alcohol ingestion. Participants with BAC levels below 0.5 g/l tend to overestimate their expected BAC levels, while those with BAC levels over 0.8g/l seem to underestimate them. Partygoers that did not intend to drive had higher alcoholic rates, compared to the ones that intended to continue to drink throughout the night. Breathalyzer tests can be performed to improve knowledge regarding the phenomenon of alcohol use; namely, drinking patterns in nightlife environments, gender-related differences, alcohol estimation bias and collective consciousness on alcohol-related harms. Implications of the study will be discussed considering harm-reduction interventions on nightlife environments. Keywords: alcohol, harm reduction, pleasure, party settings, breathalyzer, blood alcohol concentration (BAC)

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INTRODUCTION: ightlife environments (bars, disco clubs, party districts, Nfestivals) are privileged leisure space-times highly valued by youth and young adults (e.g., Hollands, 1995; Valente, Pires, & Carvalho, 2018). The mainstreaming of nocturnal leisure has numerous benefits and, growingly, an important cultural and economic dimension in post-modern cities (Eldridge & Nofre, 2018). However, important risks, as well as urban and social costs, also relate to these night-time economies, namely through infrastruc- tures, crowding, pollution, violence and crime, acute alcohol intoxication and traffic accidents (Eldridge & Nofre, 2018; van Liempt & Aalst, 2012; Wikham, 2012). Important health and social risks, such as acute alcohol intoxication, traffic accidents and interpersonal violence, are strongly correlated with the normalization of heavy episodic drinking or binge drinking in nightlife environments (Berridge, Thom, & Herring, 2007). The prevalence of alcohol and drug use among people who go out frequently is, on average, considerably higher than in the general population (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA, 2006). Moreover, excessive drinking is common in European nightlife weekend recreational settings (Calafat et al., 2013; EMCDDA, 2012; Hughes et al., 2011) as well as in the US (Grant, et al., 2017). Considering this, nightlife environments are key contexts to implement interventions aiming at the promotion of safer environments and safer drinking patterns (Valente et al., 2018). Worldwide, several organizations are planning and imple- menting intervention responses to prevent or reduce alcohol and drug use related risks. The variety and diversity of interventions developed with the aim of limiting problems associated to alcohol consumption in the nightlife settings is vast, and some of them are well established and evaluated (Bolier, Boorham, Monshouwer, Hasselt, & Bellis, 2011; Jones, Hughes, Atkinson, & Bellis, 2011; Sanem et al., 2015). Among them, harm- reduction responses demonstrated at least the same effectiveness as abstinence-ori- ented approaches (Marlatt & Witkiewitz, 2002). The need for applying the harm-reduction paradigm to address alcohol use among young people (Peele, 2006) has been remarkable, specifically, in what concerns drug impaired driving (Watson & Mann, 2017). However, impact evaluation of policy and practice pres- 28 THE ROLE OF BREATHALYZER TEST ently used in this domain is lacking, including the analysis of the factors which contribute to effectiveness and which do not (Akbar et al., 2011). The use of breathalyzers as a harm reduction tool to inform partygoers about their alcohol-drinking patterns is widely used by several outreach projects in nightlife environments (Hughes, Furness, Jones, & Bellis, 2010). However, more research is needed to evaluate their relevance as an efficient preventive/edu- cative/harm-reduction resource (Calafat et al., 2013; Glindemann, Geller, Clarke, Chevaillier, & Pettinger, 1998; Kerber & Schlenker, 2006). Despite being a well-accepted intervention among partygoers (Glindemann et al., 1998), Calafat and colleagues (2013) argue that, in some cases, knowing the objective alcohol rate could motivate people to continue ingesting alcohol. Although, in western countries, binge drinking is a relatively common behavior among youth and young adults, research on the real extent of alcohol consumption in nightlife environments is still scarce, namely in what concerns: variations between countries and between rural and urban settings; age and gender differences; planned behavior prior to drinking onset; or the intentions to drive after drinking (Fernando, Buckland, & Melwani, 2018; Labhart, Anderson, & Kuntsche, 2017). Additionally, the majority of studies regarding alcohol use in nightlife environments is solely based in self-reporting or is anchored in specific subpopulations such as college students (Calafat et al., 2013; Kaestle, Droste, Peacock, Bruno, & Miller, 2017), which generates reliability and validity problems. Studies involving objective measures of BAC in natural environments and the analysis of the contrast between those and self-reporting are still lacking. For instance, an important line of research has been focused on the impact of acute alcohol effects on self-reports and on alcohol-use disorders, problems and dispositions (Kuitunen-Paul et al., 2018). An underestimation effect that can result from the inaccuracy of self-report estimation of alcohol consumption has been documented also in general population surveys (Livingston & Callinan, 2015). Therefore, it is critical to gain knowledge about drinking patterns in natural nightlife environments using objective measures in order to inform decision-making processes. This study is relevant also because it provides data on two under-researched topics previously identified: characteristics of THE ROLE OF BREATHALYZER TEST 29 alcohol use in nightlife environments and the use of a breathalyzer as a harm-reduction tool. Therefore, this paper aims to analyze both the need and the relevance of the use of breathalyzers as a harm-reduction tool in nightlife environments, namely to contribute for increasing knowledge on: (i) gender and age differences on objective and subjective measures of alcoholic rates; (ii) the association between expected BAC and BAC levels and (iii) the effect of alcoholic test results in the reported behaviors of driving and non-driving participants.

METHOD: Procedure This study was part of a broader harm-reduction intervention called SafeIn1 Porto promoted by Agência Piaget para o Desenvolvimento - APDES2 and funded by Porto Municipality. This project targeted party goers in Movida, an important nightlife district in the city, and was implemented with the general aim of reducing the risks related to alcohol and drug use in nightlife environments. A total of 20 outreach interventions were conducted in a 2-month period (between 22 of July and 23 of September 2017) between 11:00 p.m. and 4:30 a.m. The intervention was implemented by a team of two outreach workers experienced in conducting harm-reduction interventions in nightlife environments. The project beneficiaries were con- tacted through outreach approaches like an info stand offering pragmatic, non-invasive and non-moralist information and services. Available services included harm-reduction counselling (free and confidential), support in crisis situations, referral to health community services and harm-reduction materials, such as informational leaflets, masculine and feminine condoms and 1 Safe!n Porto was a integrative project that was developed in order to improve health and security conditions in nightlife settings in Movida area in Porto. This project included an 8-month intervention that comprehended bars and discos staff training on recreational health and security, bars and discos certification and harm reduction intervention in Movida setting. 2 APDES is a non-profit NGDO (Non-governmental Development Organization) that aims to promote the integrated development of vulnerable communities and people, in order to improve their access to healthcare services, employment and education. Additional information can be found in http://www.apdes.pt/en/apdes/about-us.html 30 THE ROLE OF BREATHALYZER TEST breathalyzers. As to what concerns the data collection, the inclu- sion criteria was the interest of the beneficiaries in knowing their BAC and reported use of, at least, one alcoholic beverage that night. After being informed of the main aim of the study and of the protection and of confidentiality procedures, those who gave their consent filled the questionnaire. However, more than informing the beneficiaries about their BAC, the team provided personal- ized, brief harm-reduction advice regarding alcohol, drugs or any other nightlife-associated risks. Additionally, all questionnaires included a question regarding data processing authorization. From a total of 4000 partygoers reached by the intervention, 836 (20,6%) agreed to participate in this study. Instrument Data were collected using a self-administered questionnaire developed specifically for the project. The instrument included 3 sections with a total of 14 questions regarding drinking patterns, sociodemographic information and expected BAC levels. After responding to information regarding the intention to drive that night, the type and amount of alcohol consumed and the expected BAC levels, participants were invited to do a breathalyzer test and objective BAC levels were accessed. The breathalyzer model used was Alcoteste 3000, equipped with an electrochemical sen- sor capable of determining the alcohol level even in the presence of cigarette smoke and even when the alcohol concentration is low. The breathalyzer test was conducted with respondents who reported ingesting the last drink, at least 15 minutes before, in order to guarantee realistic BAC results. After the result, remain- ing data regarding intention to drive, alcohol associated problems, relevance of the intervention and sociodemographic information were collected. The decision of dividing the data collection in two different moments was intentional in order to compare the expec- tations of the beneficiaries and also the reported impact of the breathalyzer test in their alcohol-related behaviors. Considering the touristification of Movida Nightlife district, and in order to include non-Portuguese partygoers, the team had available Portuguese and English versions of the questionnaire. Data were analyzed using IBM-SPSS 24. THE ROLE OF BREATHALYZER TEST 31

Participants The final sample included 830 questionnaires (3 were elimi- nated for being outliers and 3 were not analyzed for being underage participants3). Most of the respondents were male (71.3%), followed by female (28.6%), one being a respondent transgender. Participants’ age ranged between 18 and 67 years old (M = 30.6; SD = 9.2). Participants’ level of education most represented in the sample was graduation/master (63.7%), 12º level (28.7%) and PhD (1.7%). Twenty-six nationalities participated in the study, the majority of respondents were from Portugal (85.3%), followed by Spain (6.6%) and Brazil (1.8%). Considering driving, 88.7% of the respondents reported having a driving license. Driving expe- rience ranged from 1 month to 49 years (M = 11.64 years, SD = 8.68 years). For concerns related to alcohol-related problems, 3.9% reported accidents as drivers, 1.8% accidents as passengers, 4.4% conflicts, 1.7% received medical care and 10.8% have had penalties. Information regarding the exact hour of the intervention was also collected. Participants were asked to report at what time they started to drink that night. Since the intervention period ranged from 11:00 p.m. to 4:30 a.m., in order to calculate what time participants spent drinking, variable assessing differences were computed between the moment they started to drink and the moment the intervention was calculated (MID_TIME). The intervention reached people who started to drink immediately before the intervention and then in 13 hours, being the mean at 4 hours and 35 minutes (SD = 2:37). Regarding previous interventions, 34.1% of the sample had never done prior breathalyzer tests and the great majority of the respondents (98.8%) considered the availability of breathalyzer tests pertinent when getting out.

RESULTS Before conducting the analysis, the Kolmogorov-Smirnov test was used to assess normality. Since normality assumption was

3 Although legal inhibition to drink has been set since 2015 in 18 years old, considering the harm reduction framework intervention wasn’t denied to underage individuals. Nevertheless, we decided not to include these individuals since legal framework imposes additional challenges on data collection analysis. 32 THE ROLE OF BREATHALYZER TEST not achieved for the continuous variables under study, nonpara- metric statistics were conducted (Mann-Whitney and Spearman correlation tests). Qui square for categorical variables was also calculated. Participants’ alcohol information was evaluated through subjective and objective measures. Subjective data were estimated by inquiring participants about their expected BAC levels. This value was based on the individual evaluation of their physical and mental state. Objective data was measured using a breathalyzer device. Participants expected BAC levels ranged from 0 to 5g/l (M = 0.40, SD = 0.38) and BAC levels ranged from 0 to 2.24g/l (M = 0.24, SD = 0.22). Considering that expected BAC levels per se is not informative on participants’ ability to make accurate estimations, a computed variable labelled discrepancy in BAC (DISC_BAC) was calculated. This variable results from the difference between subjective and objective states. Men and woman seem to differ significantly in both BAC expected levels (U = 50551.5, Z = -5.32, p < 0.001, r = -.19) and on BAC levels (U = 57626.5, Z = -3.99, p<0.001, r = .12). In both cases, men had higher values (BAC expected Mdn_men = 435.49; Mdn_women = 362.15; BAC Mdn_men = 435.49, Mdn_women = 362.15). Men (Mdn = 433.29) seem also to report higher values than women (Mdn = 336.22) of discrepancy between the BAC expected levels and BAC (U= 56384, Z = -3.33, p<0.001, r = 0.12). Younger participants also seem to have higher BAC (rho = -0.073, p<0.05) but no significant association was found between BAC expected levels (rho = -0.029 p=.41) and age. Concerning the discrepancy in BAC, there were no significative differences concerning participants’ age (rho =0.15, p>0.05). For the variable time spent drinking (MID_TIME) men Mdn = 300.08) seem to spend more time drinking than women (Mdn = 250.77) (U= 27509 Z = -3.23, p>0.001, r = -0.14). Age differences were not found (rho = 0.069, p<0.05). Test value was positively associated with the time people spend drinking (rho = 0.144, p>0.001). A positive association was found between DISC_BAC and BAC expected levels (rho= .716, p<0.001). On the contrary, a more moderate and negative association was found between DISC_BAC and BAC (rho= -0.139, p<0.001). This last effect size indicates that although DISC_BAC was computed from test value data, these variables didn’t overlap and measure different

34 THE ROLE OF BREATHALYZER TEST tion was done before conducting the breathalyzer test, so respondents didn’t know their BAC level. Participants who reported the intention to drive had significant lower BAC levels (U = 60669.5 p<0.001, r = -0.024) than the others. BAC expected levels were also lower in these individuals (U = 64648.5, p<0.001, r = -0.17). After receiving the breathalyzer test result, from the 350 respondents, 10,6% of this sub sample (37) reported changing their intention to drive that night. In order to understand more deeply the possible effect of the intervention, namely the influ- ence of breathalyzer tests on participants’ intentional behavior, additional inferential analysis was conducted. A significant difference in BAC levels was found between individuals who changed their initial intention to drive that night and the ones that didn’t (U = 3502.5 p<0.001, r = -0.20). Individuals that reported no intention to quit driving that night (Mdn = 230.21) had higher BAC levels, than the others (Mdn = 166.33). No gender (X2 (2, 350) = 0.361, p> 0.05) or age differences (U = 5333.00 p> 0.05) were found between individuals who intended to drive or quit driving that night after receiving the BAC results. In order to understand additional hypothetical effects of the intervention, we selected only the individuals that kept reporting that they would drive e.g. the individuals who reported not having changed their intention to drive after receiving the test results. From the initial pool of 350 individuals who showed intention to drive that night, 89.4% reported they kept that intention, but only 11 presented BAC levels that met the traffic offence criteria (equal or superior to .5g/l in Portugal). From this pool, 8 reported they would stop drinking. From the 480 individuals who did not intend to drive, a negative association was found between test value and intention to keep on drinking (U = 16140.0 p < 0.01, r = -0.16). Participants who reported they would continue to drink had higher BAC levels (Mdn = 248.7) than those who affirmed they would stop drinking (Mdn = 213.69). In this subsample, men seem to be significantly different than women in BAC levels (U = 19679.50 p< 0.001, r = -0.16), presenting higher values (Mdn_men = 255.2; Md_women = 206.7). No age differences were found (rho = -0.044, p>0.05). THE ROLE OF BREATHALYZER TEST 35

DISCUSSION A clearer picture of the varied uses of alcohol and cultures of drinking, including controlled intoxication among young people, would enhance public health understandings of alcohol consumption and its risks and pleasures (Keane, 2009, p.135). The purpose of this study was to contribute to a deeper understanding of the use of a breathalyzer as a harm-reduction tool able to prevent alcohol-related harms and to educate users for safer drinking patterns in nightlife environments. This study integrated a broader community-based intervention implemented with the aim of promoting safer drinking patterns in the Movida nightlife district, Porto. The previous analysis outlines three major results which address risk definition on alcohol use and are, for this reason, worthy of reflection. The first one is associated with gender differences considering subjective and objective measures of alcohol ingestion. In line with previous research (e.g., Schulte, Ramo, & Brown, 2009; Wicki, Kunsche, & Gmel, 2010), men seem to have higher BAC levels and report higher subjective measures of alcohol effects when compared with women. Recent research stressed the increasing number of women engaging in alcohol use in line with economic development (e.g., SICAD, 2017; Slade et al., 2016; WHO, 2014), being that gender differences are more discrete or absent in young adults (e.g., Shulte et al., 2009; Slade et al., 2016). However, gender differences in alcohol ingestion seem to be more complex than the amount of alcohol ingested or physiological sensitivity to ethanol. Broader social differences (Ahlström, Bloomfield, & Knibbe, 2001) have been found to play an important role in explaining qualitative differences regarding male and female drinking patterns. In a recent study conducted in 3 Southern European cities, one of which was Porto (Bologna and Tarragona), men seemed to report heavier drinking patterns, in terms of amounts of alcohol ingested, intensity, frequency of use and, consequently, in alcohol-related negative consequences than women in all categories except “harassment, abuse and sexual abuse” (Balasch, Faucha, Antelo, Pires, & Carvalho, in press). Women seem to adopt a more protective behavioral strategy when drinking in all the 3 categories under study Serious Harm Reduction Stop/Limiting Drinking and Manner of Drinking (Balasch et al., in press). This result, in line with previous ones that 36 THE ROLE OF BREATHALYZER TEST analyze sexual victimization among women in drinking environments (e.g., Kingree & Thompson, 2015; Pires, Pereira, Valente, & Carvalho, 2018; Sell, Turrisi, Scaglione, Cleveland, & Mallet, 2018), is relevant to inform gender-aware, harm-reduction and prevention interventions in these settings since it highlights the need to integrate individual and environmental strategies. A second relevant finding for the discussion on alcohol use and risk concerns the discrepancy between BAC expected levels and BAC levels as provided by the breathalyzer test. Although research has demonstrated that self-reports on real time drinking contexts are more accurate than retrospective accounts (Monk, Heim, Qureshi, & Price, 2015), this study shows that, even so, people tend to do inaccurate calculations of BAC results. When analyzing Figure 1, two different estimation paths stand out. On one hand, individuals with BAC levels lower than 0.5 g/l seem to overestimate their expected BAC levels; on the other hand, individuals with BAC levels higher than 0.8g/l seem to underestimate them. The values in between reflect no estimation bias. This result is partially confirmed by previous research that found that while acute alcohol use or heavy episodic drinking were associated with higher underestimation values (e.g., Kuntsche & Labhart, 2012; Monk, et al., 2015; Northcote & Livingston, 2011), more moderate alcohol intoxication might not impact the reliability on self-report alcohol use (Kuitunem-Paul et al., 2018). These results should be further confirmed since at least two studies showed different results, demonstrating greater levels of underreporting in lighter drinkers when compared to heavier ones (Livingston & Callinan, 2015, Stockwell et al., 2014). These mixed results could also be attributed to the disparity of methods used for assessing alcohol consumption and estimation effects that goes from in-vivo vs retrospective studies (Monk et al., 2015), yesterday method vs recall pattern of use in the last 12 months (Stockwell et al., 2004), specific questions underlying national surveys (Livingston & Callinan, 2015) mand randomized control studies (Kuitunem- Paul et al., 2018). If alcohol underestimation seems to have an effect rather than documented on alcohol research, overestimation is less known. Considering the novelty of the result and the less pronounced slope of this effect, this discrepancy should be interpreted with caution. Nevertheless, this result seems to introduce an important question for alcohol use assessment: the idea that people can THE ROLE OF BREATHALYZER TEST 37 exacerbate their BAC estimation rather than uncover it. This intro- duces a challenge on explaining the reasons underlying estimation effects. Motives for alcohol underestimation have been attributed to implicit cognitions, social desirability (e.g., Greenfield & Kerr, 2008, as cited in Kuitunem-Paul et al. 2018; McGee, Boreham, & Blenkinsop, 2005) and recall period (e.g., Stockwell et al., 2004), but the overestimation curve challenges previous explanations. Given that, in the present study, individuals’ expected BAC levels were based on the amount of alcohol ingested and on mental and physical effects, this result could be associated with poor knowledge on drinking progressive effects and their association with the amount and type of alcohol used and mental and physical state and context. In a study conducted in the UK, Britton, O’Neill and Bell (2016) demonstrated how the increasing wine strength and cup serving size within the last 25 years has been associated with the underestimation of the amount of alcohol consumed. A recent study conducted in a sample of college students, concluded that estimation bias could be influenced by the type of drink ingested, since individuals tend to report higher underestimate bias with supersized alcopops compared with beer (Rossheim, Thombs, Krall, & Jernigan, 2018). This result led the authors to conclude the need to integrate information regarding alcohol units on the drink warning labels (Rossheim et al., 2018). Educating people to drink and minimize risks is also associated with the aim to promote self-knowledge on idiosyncratic response to alcohol intake. Real time harm-reduction strategies, considering pragmatic and non-judgmental premises, and based on non-dogmatic information of alcohol-related risks and pleasures could foster less discrepant correlates between BAC levels and effects. Previous research has described the potential of “nightlife venues as important educational settings for minimiz- ing the risks of alcohol and drug use” (e.g., Valente et al., 2018, p.205). Intervention in these settings is relevant and pragmatic considering that these environments are the space-times where heavy drinking patterns emerge. Mixed results have also been produced on differential reporting considering gender and age. Contrary to the present study, Livingston and Callinan (2015) found no gender-related differences and inconsistent patterns regarding age. Given the “rare” (Livingston & Callinan, 2015, p.162) status of analysis of demo- graphic differences in alcohol surveys, additional studies should 38 THE ROLE OF BREATHALYZER TEST be conducted. Even though, a key finding of this study questions a central idea alcohol epidemiology: underestimation of alcohol consumption is evenly distributed across the population (Rehm et al., 2010 as cited in Livingston & Callinan, 2015). Another important concern raised by either the overestimation as the underestimation bias, questions the use of self-reports as single measures for assessing alcohol use. Whether estimation bias has been an intentional behavior or not, breathalyzer tests could be a cost effective tool to produce more accurate epidemiological information and additional knowledge on self-report validity. A third result that should be outlined regards the two different patterns of behaviors found between the individuals that planned to drive and didn’t plan to drive during the data collection period. These differences were found in the drinking behaviors and intentional behaviors reported by individuals before and after conducting the breathalyzer test. First, these two groups differ significantly in the amount of alcohol ingested. Those who reported the intention to drive had lower alcoholic rates than the ones who didn’t. In the drivers’ group, the individuals with higher alcoholic rates were the ones who seemed to be more receptive to the breathalyzer result, reporting the intention to adopt protective behaviors to minimize alcohol-related harms, such as quitting the initial plan to drive or stop drinking. The opposite pattern of results was found in the group of individuals that didn’t plan to drive. Besides being, in average, the group with higher alcoholic rates, those who had higher alcoholic rates and might be more vulnerable to alcohol-related harms, seemed to be the ones who would continue to drink throughout the night, corresponding to a more intoxicating pattern of alcohol use. For many youth and young adults, drinking to intoxication is an important part of their social lives and leisure times. This social behavior described as “determined drunkenness” (Measham and Brain, 2005, p.269), “culture of intoxication” (Measham and Brain, 2005, p.278) and calculated hedonism (Brain, 2000, p.7) is strongly correlated with the emergence of a night-time economy. The normalization of excessive drinking patterns among young drinkers is associated to social bounding, searching for fun and pleasurable expe- riences and, many times, a way to transcend the rational world and formal responsibilities and to lose control (e.g., Fry, 2011; Griffin, Bengry-Howell, Hackley, Mistral, & Szmigin, 2009; Szmigin et al., 2008; Szmigin, Bengry-Howell, Hackley, & Mistral, 2011). THE ROLE OF BREATHALYZER TEST 39

This set of results seems to give important contributions to harm-reduction interventions targeting alcohol users. First, it seems that planning to drive at night is an important determinant of the amount of alcohol people plan to drink and then drive. Driving intentions or being a designated driver seems to be a restraining factor for preventing alcohol intoxication and related harms, being per se an indicator of less alcohol consumption. If in one hand, this result is consistent with previous research that attests to the effectiveness of setting to limit blood alcohol concentration and enactment as “a classic example of harm-reduction and of a public health approach” (Stimson & O’Hare, 2010, p.92) to reduce alcohol consumption among drivers (e.g., Fell & Voas, 2014; WHO, 2014; WHO, 2015); on the other hand, other alcohol-related harms seem to be less present in collective consciousness and be less of a determinant for influencing drinking behaviors. This result could also be attributed to the scarce or absent implementation of comprehensive interventions that, by not pathologizing excessive drinking, comprehend pleasure as one of the main reasons for drinking. According to Keane (2009) altering patterns of drinking requires a closer link between public health campaigns and alcohol intoxication understanding, pleasure playing a central role on this process. If health discourse understands intoxication as an expendable harm with no redeeming qualities, it will be unable to recognize its attractions as anything other than evidence of individual or cultural pathology (Keane, 2009, p.136). Considering this, pleasure-seeking dimension attributed to drunkenness (Jacques, 2018) by young drinkers must be a key-dimension highlighted in policies and practices implemented with the aim of promoting safer drinking behaviors to guarantee that these integrate culturally appropriate preventive strategies (Fry, 2011). Moreover, it seems that heavy drinking patterns are “not utterly unconditional and uncontrolled” (p.273) being bounded by concerns of health (as hangovers or physical performance interference), personal safety, security or more hedonistic dimensions such as desire to drive namely in individuals with performance cars (Measham & Brain, 2005). Additional studies should be developed in order to give further contributions to understand the underlying drinking and heavy drinking motivations in order to gain more accurate knowledge on drinking behaviors. This 40 THE ROLE OF BREATHALYZER TEST information is relevant to inform interventions and public health policies adapted to people needs and concerns in their everyday public drinking behaviors including its hazardous and pleasure dimensions.

FINAL CONSIDERATIONS By adopting a flexible approach to drinking behavior and alcohol-related problems, harm-reduction seeks to promote individual and societal change one drink at a time. (Marlatt & Witkiewitz, 2002, p. 881) The aim of this study was to contribute knowledge on a complex (Calafat et al., 2013) and neglected domain of research, alcohol use in nightlife environments (e.g., Labhart, Anderson, & Kuntsche, 2017). In these settings, breathalyzer tests seem to be a valuable tool both to complement research, by contrib- uting to gain knowledge in alcohol use phenomena intersected with gender specificities, alcohol estimation bias and collective consciousness on drinking and driving harms. Nevertheless, the extension of the use of the breathalyzer test for intervention should be further analyzed. Preliminary data show that in individuals who intend to drive, the intervention could have an important impact. Nonetheless, this may not be the case for the rest of the party goers, who could be more resistant to intervention, given the importance of intoxication in people’s lives. In this sense, this result asks for a greater effort from public health authorities to develop interventions that, by having a deeper knowledge on drinking patterns and intoxication boundaries in the pleasure-ori- ented hegemonic drinking cultures, consider other alcohol-related harms in addition to drinking and driving. In this framework, non-moralizing approaches to the use and abuse of alcohol can be particularly relevant and should be further invested by “public or private funding agencies with an interest in nightlife, namely government institutions, municipalities, clubs and bars” (Valente et al., 2018, p.205). Although acknowledged, the moralization of alcohol use and abuse could have a detrimental effect on validity of knowledge produced on the sub- ject, a result from alcohol estimation and social desirability bias. This study also contributes to gaining knowledge on intervention effectiveness by grasping the role of mediating dimensions THE ROLE OF BREATHALYZER TEST 41 between test results and post interventions reporting behavioral changes, namely pre-set driving intentions. Addressing this medi- ation could be important to clarify the possible pernicious effects of this tool on increasing alcohol use that has been observed in previous research (e.g., Calafat et al., 2013). Considering the scarce knowledge produced on this domain, additional studies on the dimension of planned behavior, in an analogy to the preloaded alcohol phenomena, should be conducted. Qualitative designs could be a major contribution to explore these dimensions. Additionally, breathalyzer tests could be a valuable tool for assessing validity of self-reports and specific differences considering data collection contexts, sociodemographic characteristics or alcohol patterns and rates. The limitations of this study are associated with the cross-sectional design and data collection methods that were used (convenience sample, nightlife environments and the use of breathalyz- ers4). Given that the study was time and resource limited, it was not possible to implement a quasi-experimental longitudinal study for assessing behavior change. Social desirability could contribute to introduce inconsistencies between behavior and behavioral intentions, even in a non-judgmental interventional setting. These results cannot be generalized to other settings, considering the convenience sampling, the data collection time (holiday and sum- mer time) and specificities of the party setting analyzed (e.g, tour- istified area, variability of supply nightlife activities, high-den- sity party area). Data collection setting and respondents’ altered states of consciousness could have also introduced error on questionnaire completion. Correspondence concerning this article should be addressed to: Helena Moura de Carvalho, APDES Agência Piaget para o Desenvolvimnto, °100 apartado 1523, 4411-801, Arcozello, Vila Nova de Gaia, Portugal; Telephone: +351-227-531-106/7; Email: [email protected]. Funding: Study developed under the scope of SafeIn Porto, project founded by Porto Municipality and implemented in

4 Although breathalyzers like the ones used in this study do not guarantee 100% accuracy, no relevant differences were found when compared to blood tests in clinical context (Andersson, Kron, Castren, Athlin, Hok and Wiklund, 2015). Nevertheless, its use in natural contexts may diminish their reliability. 42 THE ROLE OF BREATHALYZER TEST close collaboration with Porto Municipality and Movida by APDES. Research conducted under the scope of RECI. Research in Education and Community Intervention, is co-founded and acknowledged by the Portuguese national funding agency for science, research and technology (FCT) as a Research and Development Unit (UID/Multi/04587/2013).

AUTHORS CONTRIBUTION: Helena M. Carvalho contributed to the statistical analysis and to the manuscript writing. Christiana Vale Pires contributed to the study design and to the manuscript writing. Jose López- Guerrero contributed to the study design and to the manuscript writing. Marla Pinto contributed to the study writing and revised the manuscript.

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