III The Cost of Violence
IV Alcohol Consumption and Community-based Violence
V Presenting the Evidence
VI Policy Options for Prevention
VIII The Role of Public Health
--submitted by Carly Heung
From Evidence to Action provides background information and highlights policy directions from Alcohol Policy Network (APN). This series provides summary information from APN’s research report, Alcohol and Community-based Violence: A Systematic Review. Additionally, this research was selected for the Spring 2011 issue of the McMaster University Medical Journal, it can be found online under the title, Alcohol and Community-Based Violence: A Systematic Review of Evidence and Control Policies (http://www.mumj.org/Issues/v8_2011/articles/v8_29.pdf). This document serves to (1) provide a brief introduction to the growing link between alcohol and community-based violence, (2) summarize the research evidence and policy recommendations from APN’s research report, and (3) provide public health and health promotion intermediaries’ direction on how to put alcohol and violence control policies into operation.
Of the many psychoactive substances, alcohol is one of the most recognized, most commonly purchased, and most consumed. (1)(2) About 80% of Canadians aged 15 years and older report having consumed alcohol at least once in the previous year. (3) In Ontario, 82% of adults aged 18 years and older report having consumed alcohol at least once in the past twelve months. (4)
While alcohol consumption does not always lend itself to alcohol-related problems, harmful use and abuse of alcohol often leads to intoxication, impairment, and/or drunkenness. “Drunkenness is an important immediate situational factor that can precipitate violence.” (5) In an epidemiological review of 26 studies involving 9,304 violent cases, 62% of violent offenders were drinking at the time of their offence. (6)
III The Cost of Violence
Violence defined: Violence or violent behaviour is defined as intentional injury – inflicted by deliberate means or through physical force – that results in or has a high likelihood of resulting in injury 0. For an act to be considered violent, there must not only be harm but also intent to harm 0. Therefore, aggression and hostility are not classified as “violent”, as no actual physical harm has been carried out (e.g., verbal harassment).
In 2004, the total cost of violence in Canada from direct costs (health care costs arising from injuries) and indirect costs (costs related to reduced productivity from hospitalization, disability and premature death) were estimated to be $871 million. (9) While intentional injuries make up the large majority of injuries in Canada, intentional injury comprising of only violence accounted for 507 deaths and 8,050 hospitalizations in 2004. In Ontario, violence resulted in 167 lost lives, 2,025 hospitalizations, and $266 million in direct and indirect costs. (9)
The link between alcohol consumption and violence is well established, negatively impacting the individual consuming it and those around them. Findings from the 2004 Canadian Addiction Survey indicate that, “Close to a third of the respondents (32.7%) report having been harmed at least once in the past year because of someone else’s drinking.” (3) Of these respondents, 10.8% were pushed or shoved, and 3.2% were physically assaulted. (3)
IV Alcohol Consumption and Community-based Violence
Alcohol use and community-based violence disproportionately affects young people in the late-night economy. In developed countries, alcohol is recognized by the World Health Organization as the 3rd highest risk factor contributing to Disabilities Adjusted Life Years (DALY) (10). While the link between alcohol consumption and violent behaviour has been well established, the mechanisms – particularly the social and environmental influences – by which alcohol consumption leads to the escalation of community-based violence (Box 2) is not so clear. Identifying a causal pathway between alcohol and community-based violence is especially difficult because of the social setting.
Community-based violence defined: Community-based violence is a type of interpersonal violence that typically occurs between acquaintances or strangers outside of the home. (5) Other terms like ‘assaults’, ‘fights’, and ‘brawls’ have also been used interchangeably with community-based violence.
V Presenting the Evidence
A systematic review on alcohol and community-based violence identified 28 relevant studies published from 1999 to 2009 relating to six major categories of alcohol and community-based violence themes (7). The key findings on alcohol consumption, and the many direct and indirect ways it contributes to community-based violence, are presented below.
Evidence from research
Alcohol Outlet Density
Ecological studies have indicated a positive association between alcohol outlet density and rates of community-based violence. Among the different types of outlets, pubs and clubs showed the greatest strength of association with community-based violence.
Alcohol sales have been commonly used as a proxy measure for alcohol consumption. International studies have demonstrated that increased sales through alcohol outlets are correlated with higher rates of violence. In an Ontario study, the risk of hospitalization due to violent assault was found to be 13% higher with each doubling of usual daily alcohol sales of the closest Liquor Control Board of Ontario (LCBO) outlet. Emerging policy recommendations from alcohol outlet density and alcohol sales studies emphasize the importance of regulating alcohol availability.
High alcohol price reduces alcohol consumption while low alcohol price is correlated with high regional violence-related injury. In England and Wales, a “one-percent sustained increase in the price of alcohol above inflation will decrease violent injuries by nearly 2,200 a month” 0. Emerging policy recommendations from studies that monitored changes in alcohol pricing emphasize the importance of addressing alcohol pricing and taxation to reduce violent injuries.
Alcohol Sale Hours
Extending alcohol sale hours does not always increase the level of violence, however, when it does, it is usually because of increased levels of intoxication from higher volume of alcohol consumed and because of crowding. Emerging policy recommendations from studies that assessed the restriction and extension of alcohol sale hours emphasize the importance of restricting hours and days of alcohol sales.
Research on bar violence found that the frequency of violence incidences increases with the level of intoxicated patrons. Furthermore, the literature consistently shows the peak time for violent offending is weekend nights while the peak location is in and around pubs and clubs. More importantly, both physical and social factors are associated with violence in high-risk pubs. Emerging policy recommendations from studies assessing the bar environment emphasize the importance of modifying the drinking environment as well as increasing policing and enforcement.
Emergency Department Injuries
Emergency Department studies found that alcohol-related violence accounted for more injuries than any other causes (e.g., vehicle crashes, falls, poisoning, or burns). Of those with violent injuries, 22% were intoxicated, as opposed to 8% of those involved in motor vehicle crashes 0. Emerging policy recommendations from Emergency Department studies emphasize the importance of implementing a violence management system.
VI Policy Options for Prevention
These findings suggest that the majority of problems associated with alcohol attributable violence can be addressed by controlling the availability of and harmful use of alcohol. Table 1 illustrates four major categories of alcohol and community-based violence control policies emerging from the research literature: regulation, taxation, service provision, and education including policy options, activities and effect (see effectiveness rating scale below). (7)
TABLE 1: Alcohol and Community-based Violence Control Policies
Policy option: Regulate alcohol availability through the following activities:
- Limit alcohol outlet density ++
- Limit the opening of new outlets +
- Permanently close or heavily fine outlets that repeatedly violate liquor laws ++
- Regularly review operational liquor licensing policies (?)
- Impose strict mandatory insurance requirements to operate a licensed establishment ++
Policy option: Restrict hours and days of alcohol sales through the following activities:
- Restrict hours in which retail alcohol sales are permitted ++
- Restrict days of alcohol sales ++
- Consider the effects other municipalities (i.e., border towns) have on alcohol sales and control measures ++
Policy option: Address pricing and taxation through the following activities:
- Increase the full price of alcoholic beverages +++
- Price alcohol based on the percentage of alcohol +
- Introduce a tax levy +++
Policy option: Increase policing and enforcement through the following activities:
- Target high risk areas +
- Target late-night venues +
- Mandate evaluated server and security staff training ++
- Significantly increase the number of provincial liquor inspectors ++
Policy option: Modify the drinking context through the following activities:
- Address the physical characteristics of venues where alcohol is sold +
- Limit the number of intoxicated patrons within such venues +
Policy option: Implement a violence management system through the following activities:
- Develop a violence management system that will collect Emergency Department injury data (?)
Policy option: Utilize education and persuasion strategies through the following activities:
- Develop evidence-informed educational campaigns as part of comprehensive health promotion interventions +
Policy option: Support provincial strategies through the following activities:
- Support a Provincial Alcohol Strategy (?)
- Support a Provincial Violence Prevention Strategy (?)
*Adapted from Babor et al.(13) and Stockwell (14): Effectiveness rating scale: + for modestly effective; ++ for moderately effective; +++ for most effective; and (?) for unknown effectiveness(13).
VIII The Role of Public Health
Policy recommendations point to the increasing need for public health to address alcohol-related harms, as it relates to community-based violence. Alcohol is readily available, and there is a high density of retail alcohol sales outlets across the province, especially in downtown urban areas. Despite this, many incidents of community-based violence can be prevented. Public Health can work with relevant stakeholders and government departments to reduce population alcohol consumption by affecting favourable changes in alcohol and violence control policies (see Table 1).
Many of the control policies in Table 1 were recognized by Babor et al. and Stockwell as being among the most effective at reducing alcohol-related harms. (13),(14) However, even best practice policies should be considered in conjunction with public opinion and political readiness when framing developments in alcohol policy. “There is generally strong public support for current alcohol control policies and intervention efforts. Most Canadians feel that current alcohol tax levels, the legal drinking age, and the current operating hours of alcohol outlets are appropriate and should not be changed, and also that alcoholic beverages should not be sold in convenience stores. The majority favour increased prevention, treatment and server intervention programming.” (15) Public health can work with relevant stakeholders and government departments to mandate server and security staff training programs like the Centre for Addictions and Mental Health’s (CAMH) Safer Bars program. However, it is important to keep in mind that even environmental control measures like a Safer Bars program would likely have only a modest effect on people who binge drink regularly.
The more effective methods of mitigating the negative effects of drinking include setting minimum-drink prices, having a government monopoly control the sale of alcohol, reducing the percentage of alcohol in products, conducting random breathalyzer tests, raising the minimum age required to purchase alcohol, having high government taxes on alcohol, bringing in graduated drivers' licenses with strict alcohol policies, and lowering legal blood alcohol limits for drivers. (13) Public health plays a critical role in preventing current control policies from being dismantled. Increases in the minimum alcohol purchase age over the past 20 years have been related to fewer fatalities among young people. Maintaining the status quo on having a government monopoly on the sale of alcohol in regulating the availability of alcohol has become more important than ever. Public Health can work with relevant stakeholders and government departments to maintain the status quo or improve current alcohol control policies.
Ultimately, the challenge for Public health is in changing public attitudes around the acceptability of intoxication. Increasingly, the underlying issue of harms associated with alcohol and community-based violence is the drinking culture. Like the National Alcohol Strategy, Reducing alcohol-related harm in Canada: Towards a culture of moderation: Recommendations for a national alcohol strategy (2), Ontario can build an alcohol strategy that not only works towards a culture of moderation, but also ingrains common messaging around responsible drinking. Such movement will result in positive effects in reducing alcohol-related community-based violence.
Funding of this publication generously provided by the Ontario Agency of Health Protection and Promotion through the Ontario Public Health Association.
Recommended Citation: Heung, C., LeMar, J., Rempel, B. (2010). From Evidence to Action: Reducing Harm from Alcohol and Community-based Violence. Alcohol Policy Network, Ontario Public Health Association: Toronto.
Acknowledgements: Special thanks to Carly Heung, a graduate student in the Master of Public Health program at the University of Waterloo, for researching and compiling the majority of this document, and the following individuals for their valuable editorial work and contributions:
- Jason LeMar, Coordinator, Alcohol Policy Network, Ontario Public Health Association
- Benjamin Rempel, Manager, Alcohol Policy Network, Ontario Public Health Association
For further information please contact:
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2. National Alcohol Strategy Working Group. (2007). Reducing alcohol-related harm in Canada: Toward a culture of moderation: Recommendations for a national alcohol strategy. Retrieved August 1, 2009, from www.nationalframework-cadrenational.ca/uploads/files/FINAL_NAS_EN_April3....
3. Adlaf, E. M., Begin, P., & Sawka, E. (Eds.). (2005). Canadian addiction survey (CAS): A national survey of Canadians' use of alcohol and other drugs: Prevalence of use and related harms: Detailed report. Ottawa: Canadian Centre on Substance Abuse.
4. Ialomiteanu, A.R., Adlaf, E.M., Mann, R.E. & Rehm, J. (2009). CAMH Monitor eReport: Addiction & Mental Health Indicators Among Ontario Adults, 1977-2007 (CAMH Research Document Series No. 25). Centre for Addiction & Mental Health, Toronto. Retrieved March 19, 2010, from www.camh.net/Research/camh_monitor.html.
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7. Heung, C., LeMar, J., Rempel, B., Ray, J. (Ed.). (2010). Alcohol and Community-based Violence: A Systematic Review. Alcohol Policy Network, Ontario Public Health Association: Toronto. Retrieved March 25, 2010, from www.apolnet.ca/resources/pubs/rpt_Alcohol_and_Violence-2010.pdf.
8. Rutherford, A., Zwi, A. B., Grove, N. J., & Butchart, A. (2007). Violence: A glossary. Journal of Epidemiology & Community Health, 61(8), 676-680.
9. SMARTRISK. (2009). The Economic Burden of Injury in Canada. SMARTRISK: Toronto, ON, p.14.
10. Rehm, J., Baliunas, D., Brochu, S., Fischer, B., Gnam, W., Patra, J. et al. (2006). The costs of substance abuse in Canada 2002. Ottawa: Canadian Centre on Substance Abuse.
11. Sivarajasingam, V., Matthews, K., & Shepherd, J. (2006). Price of beer and violence-related injury in England and Wales. Injury, 37(5), 388-394.
12. Macdonald, S., Cherpitel, C. J., DeSouza, A., Stockwell, T., Borges, G., & Giesbrecht, N. (2006). Variations of alcohol impairment in different types, causes and contexts of injuries: Results of emergency room studies from 16 countries. Accident; Analysis and Prevention, 38(6), 1107-1112.
13. Babor, T., Caetano, R., Casswell, S., Edwards, G., Giesbrecht, N., Graham, K., Grube, J., Gruenewald, P., Hill, L., Holder, H., Homel, R., Osterberg, E., Rehm, J., Room, R., & Rossow, I. (2003). Alcohol: No ordinary commodity - research and public policy. Oxford: Oxford University Press.
14. Stockwell, T. (2010). Operator and Regulatory Best Practices in the Reduction of Violence in and Around Licensed Premises: A Review of Australian and Canadian Research. Centre for Addictions Research BC. Victoria, B.C.
15. Alcohol Policy Network. (2006). Priorities 2006: Developments in alcohol policy since 1996. Toronto: Ontario Public Health Association.