Tim Stockwell Centre for Addictions Research of BC, University of Victoria Preventing violence in and around late- night drinking venues: A review of the international evidence CARBC and BC Mental Health and Addictions Research Network public seminar, SFU Harbour Centre, Vancouver, 23 February, 2009.

‘Three bowls do I mix for the temperate; one to health, which they empty first, the second to love and pleasure, the third to sleep. When this bowl is drunk up, wise guests go home. The Fourth bowl is ours no longer, but belongs to violence; the fifth to uproar, the sixth to drunken revel, the seventh to black eyes, the eighth is the policeman’s, the ninth belongs to biliousness, and the tenth to madness and hurling the furniture. ’ Eubulus 375 B.C.

Bars, booze and violence in BC: A time to take stock? nBC Provincial health officers report on alcohol and public health, December 2008 nEvidence of increasing alcohol-related harm and violence nProposals before Vancouver city council to extend hours of liquor service: the right way forward?

Number of Liquor Authority and Agency/Private Liquor Stores, BC,

Age 15+ per capita alcohol consumption in BC and Canada, 1997/8-2007/8

Figure 17: % Serious Injury Crashes that Involve Alcohol, BC and Canada,

Figure 20: Provincial Net Income from the Control and Sale of Alcoholic Beverages, BC

 Physical availability  Affordability  Consumption +8%  Hazardous drinking  Hospital visits +3.4%  Alcohol-related crashes +11% In BC since 2002….

In Vancouver CBD nIn late 2003 hours of service for bars increased from 2 AM to 4 AM nNumber of liquor “seats” in entertainment district increased from 1000 to 6700 nMarked increase in calls for assistance, fights, assaults and stabbings reported by police

Apparent impact on late-night calls to VPD

Apparent impact on fights recorded by VPD

Apparent impact on assaults recorded by VPD

Two recent CARBC reviews on violence and licensed premises 1. For Alberta Gaming and Liquor Commission: n28 literature reviews and special reports (5 Canadian; 24 international) n39 descriptive and analytic studies (12 Canadian; 27 international) n30 intervention studies (3 Canadian; 27 international) 2. Crime Prevention and Community Safety (In press) Review of public health and safety impact of changes to opening hours of bars and restaurants (48 studies)

Ratings of Evidence O Limited investigation, inconclusive data  Evidence is contra-indicative  Warrants further research  Evidence for implementation.  Evidence for outcome effectiveness  Evidence for effective dissemination

Five guiding principles nEnsure retail prices are not too low nReduce intoxication levels nCreate stress-free drinking environments nSet clear house rules nEstablish credible deterrence against irresponsible practices

16 Dose-response relationships between alcohol consumption and harms n At the individual and population levels n For harms caused by both short and long- term effects of alcohol

Risk of Violent versus Accidental Injury for Different BAC Levels Risk of Violent versus Accidental Injury for Different BAC Levels Chi square for linear association p<.0001 Source: Macdonald et al, 2005

Operator Best Practices     Responsible Beverage Service ‘Safer Bars’ – violence prevention  Plastic/shatterproof glasses Food service with alcohol Manage the flow of late-night customers Screen for underage drinkers  Self breath testing machines

19 Freo Respects You RBS Project Lang et al, Australian J Public Health, 1998 n 8 ‘high risk’ intervention sites, 7 control n Feedback from police, risk assessment, RBS training, mystery shoppers n Patron exit BAC’s reduced, no change in house policies, age ID checking or service refusal n One premise changed house policies, refused service and # patrons with high BACs n Can work with strong management support n Collaboration: 23 changes to WA Liquor Act

20 The Safer Bars Project Graham et al, Drug and Alcohol Review, 2004 n Based on detailed studies of violent bars n Risk assessment: patron flows, atmosphere, screening, supervision, closing time n 3 hour training program: early intervention, clear house rules, team work, controlling anger, conflict resolution skills n 18 intervention sites – large Toronto clubs n 12 month reductions in violence vs. 15 control sites, best if low staff turnover.

Regulatory Best Practices      Raise or maintain prices [& Tax on alcohol content] Raise the minimum legal drinking age      Restrict happy hours/discounting Restrict days and hours of service Mandatory third-party insurance Enforcement of liquor laws  Restrict density of liquor outlets

Set taxes and prices according to ethanol content

Principle of using price to control alcohol use is well-established Meta-analysis by Gallet (2007): Identified 132 studies, and concludes:  A 10% increase in price leads to an average of a 5% decrease in consumption Meta-analysis by Wagenaar et al (in press): Identified 112 studies worldwide ( ) with 1007 estimates and conclude:  A 10% increase in price leads to a 4.4% decrease in consumption and 2.8% for heavy drinkers

Low alcohol beer There are 38 varieties of beer in Australia containing between 2.5% and 3.5% alcohol. We have found 3 in BC liquor stores.

Increasing Market Share of Low Alcohol Beer (<3.8%) in Australia Source: Australian Associated Brewers

Tax per Drink for Canadian Beer

Price incentives for drinking different strength coolers in BC, 2005/6 Strength N of brands Mean alcohol content % Cooler market - 5+ % alc Mean $’s per SD Mean $ per L of drink % % % Total

Set effective minimum drink prices and index to cost of living

Cheapest alcohol in BC Liquor Stores per standard drink, August 2008  >6% 75 cents  7% 71 cents  40% 86 cents  11.5% 91 cents  >20% fortified 62 cents Minimum mark-ups in BC not increased since 1994 for beer, 1995 for wine and 1998 for spirits, recommendation to update not accepted

Recent moves to apply minimum pricing to alcohol in Canada  Minimum prices of $2.50 per drink set in both Alberta and Nova Scotia in 2008  6.5% increase for packaged beer in Ontario, November 2008  Recommendation from BC provincial health officer in December 2008

Longer hours, more civilised drinking?

32 Impact of changes to trading hours of bars and restaurants Stockwell and Chikritzhs (in press), Crime Prevention and Community Safety n 48 studies over four decades, mostly from the UK, USA, Australia and Canada n Only 14 included both baseline and control measures, all peer-reviewed n Of these 11 reported significant impacts on at least one outcome in predicted direction n 4 of these high-quality studies focused on violence – all found significant impacts

Impact of extended trading hours on rates of assaults in Perth Hotels, Extended Trading Premises Other Premises Assaults/Month Source: Chikritzhs and Stockwell (2002), Journal of Studies on Alcohol

Targeted regulation of high risk licensed premises

Kalgoorlie, Western Australia

Assaults and drink-driving offences linked to Kalgoorlie licensed premises

37 NSW Alcohol Linking Program Wiggers et al, Drug and Alcohol Review, 2004 n All 400 licensed bars in 2 police districts n For 6m all officers recorded if alcohol involved and location of last drink n Safety audit of high risk bars and feedback by police n 15% reduction in violent incidents 3 months post intervention compared with control districts

Enforcement of liquor laws regarding intoxication: need for credible deterrence

Classic US Study: Law enforcement versus server training % Service refusal for ‘pseudo patrons’ (McKnight and Streff, 1992) Server Training 1986Enforcement

Avoid high concentrations of late-night liquor outlets in one district

Relationship between alcohol-related assaults and number of bars and restaurants in Melbourne, Australia (Livingston, 2007)

Community mobilisation 0 to  0 to   Early intervention with children and adolescents  Public education campaigns Alcohol education in schools  Collaboration between police, licensees and civic authorities (e.g. Accords)

43 Police-Licensee Accords n Signed agreements usually covering RBS, happy hours, door charge and police support n May involve staff training n Self-regulation and, to a degree, targeted law enforcement n Some short term tangible benefits in violence reduction n Benefits not consistent and maybe short- term n Accords can be fragile

A sustainable and effective regulatory system to prevent alcohol-related harm nAccurate and well-publicised monitoring nCredible deterrence and graded penalties nIncentives for violence prevention nOpportunities for local community input nEffective controls on physical availability nPricing policies to promote health and safety nClear legislation to support effective enforcement