Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 5 February 2010

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Crucial study delivers mixed scorecard for drug treatment in England ...

Youth anti-drug campaign boomeranged say official evaluators ...

US experts recommend alcohol tax rises as an important public health measure ...

US task force says cutting alcohol outlets improves public health ...

The Drug Treatment Outcomes Research Study (DTORS): final outcomes report.

Jones A., Donmall M., Millar T. et al.
[UK] Home Office, 2009.

Over 10 years since the last attempt, in 2006 a national study assessed the progress of patients starting drug treatment in England. A year later drug use and crime were down and social costs saved, but wider life improvements were minor compared to treatment costs.

Summary The Drug Treatment Outcomes Research Study (DTORS) was commissioned by the government department with lead responsibility for drug policy and led by University of Manchester's National Drug Evidence Centre. Rather than setting up treatments to be tested on patients allocated by researchers, the study simply tracked what happened after patients presented in the normal way to usual drug treatment services. For this reason it was unable to compare the effectiveness Differences in outcomes can be and were compared but could not be used to conclude that services were differentially effective. of one treatment with another (caseload differences could invalidate such a comparison), but was able to shed light on the progress typically achieved during and after typical treatments.

In each of 94 areas during a four- to seven-week window between February 2006 and March 2007, the study recruited and interviewed 1796 adults seeking treatment for primary drug (not alcohol) problems. Interviewees had made face to face contact with staff at a representative sample of community or residential services offering interventions In the national schema,* known as 'tier 3' and 'tier 4' services as opposed to open access counselling and drop-in services.
intended to follow a systematically delivered treatment plan. Interviews were to be conducted as soon as possible (and at least within four weeks) after initial assessment. Respondents were to be included in the study whether or not they actually started treatment, and followed up regardless of whether they remained in treatment. For details of the caseload background notes. Below sampling and treatment details.

Of the 1796 patients interviewed initially, about half (886) could be interviewed three to five months later and 504 of these were interviewed again 11 to 13 months after their initial interview. Responses by these 504 to a researcher-administered survey could be used to track progress from the start of treatment through to the point (three months) when benefits were expected to be apparent, and then on to a year to see if these were sustained. Another 245 were only reinterviewed once six to 12 months after seeking treatment, too late to be interviewed again. 'Raw' findings from these samples were rebalanced to make them more representative of all adults recorded In the National Drug Treatment Monitoring System to which all structured tier 3 and tier 4 services are asked to submit returns on patients entering treatment. as having started structured treatment at services in England. Further adjustments were applied to account for ways the people who were followed up differed from those who were not.

Nearly 9 in 10 of the participants reinterviewed at three to five months had started treatment. Just over half (52%) had been prescribed medications with actions similar to the drugs they had been taking before treatment, generally the opiate-type medications methadone or buprenorphine, and generally too (75% of those prescribed) on a maintenance basis. Four in ten had instead/also been counselled, generally (71% of those counselled) at least once a week in one-to-one sessions, and about half (47%) also/instead in group sessions. Nearly 1 in 5 (19%) had been in residential rehabilitation for stays usually intended to last three to six months, almost as many (18%) had participated in structured day-care, and 1 in 10 had received inpatient detoxification. By the time they were interviewed a year after seeking treatment, very few (4%) had yet to start treatment. At both interview points, about three quarters (70% and 77% respectively) were still in some form of structured treatment, and around 70% had continuously been in treatment for at least three months and nine months respectively.


Drug use and other outcomes largely reflected in- rather than post-treatment progress. Main findings were that drug use fell substantially by the three–five month interview, reductions broadly sustained to one year. The proportions who in the past four weeks had injected any drug, or consumed heroin, cocaine, amphetamines, or benzodiazepines, were roughly halved, and reductions in respect of non-prescribed methadone or other opiates were considerably greater. By the one-year follow-up, a few people who had not used these drugs at treatment entry were now using cannabis or alcohol, somewhat curbing the still substantial net reductions. Across all drugs, many fewer respondents felt their use was causing problems. Taking the average past-week spend on drugs as a proxy for overall consumption, this fell rapidly the longer someone had been in treatment, flattening out after five to six months.

Crime too fell substantially. In the four weeks before seeking treatment, 40% of the sample had committed an acquisitive offence (mainly relatively minor), itself probably a reduction on prior offending. Within three to five months this had halved to 21%, then fell by a year to 16%. The reduction flattened out after about six months in treatment. Similar reductions were seen in serious crimes in particular. Even if offending did not stop, on average there was a substantial decrease in its volume and/or the costs associated with it.

In contrast, health and social improvements were modest. Mental health improved but remained below national norms, while throughout physical health matched UK norms. Though current health seemed unaffected, the number of people risking their future health (and those of others) fell substantially, most noticeably because three quarters (77%) who had recently shared injecting equipment before seeking treatment no longer did so a year later. The proportion recently experiencing overdoses more than halved (from 9% to 4%), probably associated with reductions in injecting and/or using several opiates together, or opiates with benzodiazepines or alcohol. Proportions in paid employment rose from 9% when seeking treatment to 16% about a year later, and those stably housed rose from 60% to 77%. These improvements did not result in fewer people receiving welfare benefits (throughout about 4 in 5); the number of benefits each beneficiary accessed actually increased. From 22%, the proportion of parents whose under-16 children all lived with them rose to 34%.

The authors concluded that treatment was associated with substantial reductions in drug use and offending, in harmful behaviours associated with problem drug use, and improvements in mental wellbeing and social functioning. Where comparable, outcomes from the DTORS 2006/07 cohort at least matched those recorded in a 1995 treatment cohort by a similar study. Despite doubling its caseload, the drug treatment system seems to have maintained and possibly improved effectiveness. Further work is needed to confirm whether gains are sustained after treatment ends. Clients presenting for treatment via criminal justice routes were retained as long and did as well those from other referral sources. However, criminal justice routes were no better at extending treatment to first-time entrants, and over half who came to treatment this way said they would have come anyhow, suggesting that resources might best be focused on the relatively few drug users who would not have entered treatment via another route.

Findings logo commentary For more detailed citations background notes. This account is based on:
• the featured report;
in-depth interviews with small, illustrative rather than representative This is not intended as a criticism. The samples were never intended to be representative but to enable the full range of factors, influences, views and experiences associated with the treatment of users of tier 3 and tier 4 services to be explored. samples of 32 treatment staff and 44 treatment-seekers who completed the second round of follow-up interviews;
• an economic sub-study estimating net financial savings for society associated with treatment and the degree to which each £ spent on treatment saved and improved patients' lives;
• earlier reports (1 2) describing the initial sample.
There is also a summary of the findings to date.

DTORS is the main contemporary study An alternative assessment has been published (http://dx.doi.org/10.1016/S0140-6736(09)61420-3), but this was based on data routinely collected by treatment staff, to whom patients sometimes tell a different story than the one they tell researchers, was concerned only with crack and heroin users, and focused on clients already in treatment for at least six months, or discharged before the study ended. enabling an assessment of how well the English drug treatment system is performing. Despite the study's problems ( below), it is also the best assessment we have. The scorecard includes substantial reductions in drug use, crime, and risk to health, but only small gains in employment and housing. Patients' health improved, but too little for this in itself to justify the cost of treatment. There were however cost savings for society as a whole. While these financial estimates shed light on the costs and benefits of making treatment available, substantial uncertainty over their magnitude make them less reliable than outcomes 'nearer the ground' such as drug use, crime and risk to health.

The study's importance makes it equally important to understand its strengths and limitations, particularly in relation to its predecessor, the National Treatment Outcome Research Study (NTORS), against which it is bound to be compared to assess whether things have improved since the mid-90s. How the samples were recruited is critical, and the differences complicate comparison between the studies. In essence, NTORS did not aim for a nationally representative sample; DTORS did, but suffered what cumulatively were serious setbacks for which it diligently sought to compensate, but which cast considerable doubt over the representativeness of the findings. For details background notes; summary below.

NTORS recruited its 1075 clients in 1995 using a similar methodology to DTORS: problem drug users approached usual treatment services in the usual way and their progress was tracked regardless of whether they remained in treatment. However, NTORS limited itself to methadone prescribing and inpatient/residential services, and the sample was not intended to be representative even of those types of services. In contrast, DTORS did aim to recruit a representative sample of people seeking structured treatment, including at day-care and non-residential counselling programmes.

In the event, DTORS too was unable to ensure a representative sample or achieve its 3000 target, and nearly three quarters of the sample could not be reinterviewed at the one-year follow-up. Especially in respect of the initial sample, this still left the study with the largest and probably the most representative drug treatment sample ever recruited in England. However, findings must be interpreted in the light of the sometimes substantial difficulties in recruiting and retaining them in the study. The representativeness of the initial sample also depended on treatment staff raising the study with all suitable new clients and gaining permission for a researcher to contact them, opening up opportunities for selective recruitment. Of those attendees staff identified as meeting the study's criteria, about two thirds were interviewed for the study; most of the remainder refused to participate. The degree to which these possible sources of bias could be adjusted for was limited, partly because there were large mismatches between the answers treatment-seekers gave to DTORS' researchers, and those they gave to treatment staff gathering information for the national database.

In the end the study started with 1796 treatment-seekers interviewed at 342 treatment facilities across 94 drug action team areas. From this starting point emerged the later follow-up samples, findings from which were subject to further layers of adjustment Using standard weighting techniques. to attempt to correct for the half of the starting sample not reinterviewed in time for the first follow-up, and the nearly three quarters not interviewed at the final follow-up, adding further substantial uncertainty to the findings. To assess effectiveness, such studies have to make assumptions about what would have happened if treatment had not been available. Implicitly (and in the case of the economic calculations, explicitly) the reports assumed that without treatment to seek, the drug users would have carried on as before. Perhaps, but perhaps not; given their motivation and the pressures they were under, some may have improved anyhow, though it seems unlikely that their progress would have been as great as it was without treatment doors to go through to actualise motivation and respond to pressures.

Especially given confirmatory research such as NTORS, these limitations do not seem sufficient to call in to question the general magnitude of the drug use, crime and health-risk reductions observed by the study, valuable dividends for the patients (over half prioritised ceasing drug use as a treatment objective) and for society. However, questions remain over the degree to which treatment contributed to these benefits.

Despite a sophisticated and careful analysis, much less confidence can be expressed in the '£2.5 for every £1' benefit-to-cost calculations, while gains in the patients' health-related quality of life would normally be considered too small in themselves to justify the cost of treatment. For each patient over about a year, seeking treatment was associated with an extra 0.05 (one twentieth) of a life-year adjusted for the quality of that life, at a treatment cost of £4531. Put differently, one quality-adjusted life-year was saved Assuming treatment was the cause and there would otherwise have been no improvements. at a cost of £90,620, considerably in excess of yardsticks Up to about £30,000 per year. for what constitutes a health gain sufficient to warrant the cost of medical treatment. Underlying this disappointing figure were at best modest improvements in physical/mental health and functioning. In terms of benefits for society as a whole, this result was turned around by adding savings in the costs of crime and in public health and social care services. Apart from poor and incomplete data, these rested on the questionable assumption that stolen/defrauded money and goods were lost to society, rather than transferred (albeit illegally) from one member of society to another. For details background notes.

While health and drug use and crime reductions remain important, reintegration through employment is now a national policy priority. Just predating this policy shift, DTORS showed how much needed to be done. First hill to climb was that though over three quarters were unemployed, just 1% of treatment-seekers prioritised employment as a treatment Though for more it may have been a life goal. goal. At follow-up, just under a fifth recalled receiving employment-related help from any source, let alone the treatment service itself. Not surprisingly, little (if any, given the numbers missing at follow-up) progress was made in gaining paid employment, and little too in laying the foundations for employment in improved mental health and stable housing, both impeded by poor access to specialist provision. For details background notes.

The in-depth interviews offer possible explanations for some of these findings. Expanded on in the background notes, a major theme was that delivery of a rounded and individualised service catering for the multiple needs of the clients was seriously impeded by high caseloads, competition between services, poor partnership working with mental health services, and restricted access to accommodation.

For governments concerned to contain welfare benefits, the same disappointing record of increased post-treatment access to these benefits was noted of patients starting treatment in 2009/10.

While the study was unable to compare the effectiveness of the different treatment modalities, it did compare the progress of patients in these modalities. Across different outcomes, generally progress was about the same. Other issues analysed in the background notes were:

• Whether as assumed by English treatment funding and monitoring systems, three months really is a retention threshold beyond which the chances of lasting recovery take a step up. DTORS suggests improvements continue to at least six months, and other studies also offer little support for this assumption.
• Whether crack users really are harder to treat then heroin and other drug users. Few crack users recalled receiving a crack-specific intervention but still they did as well as anyone else in terms of retention and reintegration and if anything, crack seemed easier to give up than heroin. Findings are consistent with other studies showing that crack users do respond well to a range of non-specific psychosocial approaches. However, patients for whom crack was their primary drug problem were not singled out in the DTORS analyses.
• Were criminal justice clients different? In general, no or only slightly was the answer. Compared to the predominantly self-referred remainder of treatment-seekers, they had similar treatment histories, were currently just as motivated and ready for treatment, and did just as well. A third said they would not have come to treatment without legal pressure, but many more (over half) said they would have come anyway.
• Does treatment reduce crime by reducing drug use? DTORS found crime went down as the need to commit it to raise money for drugs also fell, but strangely there was no clear correlation between the criminal income of each participant at different stages in the study and the extent of their drug use.

Thanks for their comments on this entry in draft to Michael Donmall of the National Drug Evidence Centre at the University of Manchester and others on the DTORS research team. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 10 February 2015. First uploaded 18 January 2010

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Effects of the National Youth Anti-Drug Media Campaign on youths.

Hornik R., Jacobsohn L., Orwin R. et al.
American Journal of Public Health: 2008, 98(12), p. 2229-2236.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Hornik at rhornik@asc.upenn.edu. You could also try this alternative source.

Could the US government's biggest ever attempt to use the media to turn US youth away from cannabis actually have done the reverse? At best it was a disappointment; at worst, it counterproductively fostered the impression that 'Everyone's doing it'.

Summary Several previous documents (see evaluation web site and this Findings analysis) from evaluators appointed for the US Congress have assessed different stages of the US National Youth Anti-Drug Media Campaign as it ran from its inception late in 1999 to 2004. The featured report draws the threads together and reaches conclusions about its impact on the uptake of cannabis use and on related attitudes and intentions among the subset its 9–18-year-old targets The other major target were parents. Cannabis became a specific focus when in 2002 the youth component of the campaign shifted to what was called the Marijuana Initiative. aged at least 12 and a half.

Pothead poster featuring "My Anti-Drug" campaign strapline

Funded by nearly $1 billion appropriated by the US Congress, the campaign aimed to educate and enable America's young to reject illegal drugs, to prevent initiation of drug use (especially cannabis and solvents), and to persuade occasional drug users to stop. Youth-focused communications mainly broadcast through television and radio ads (but also through posters and cards illustrations) aimed to achieve these objectives by bolstering young people's resistance skills and confidence in their abilities to reject drug use, correcting mistaken assumptions about how 'normal' or accepted drug use was among their peers, promoting positive drug-free alternatives, addressing the benefits of not using drugs, and highlighting the negative consequences of drug use, including effects on academic and athletic performance. Main features of the study's methodology are described below.

Pot Quiz postcard

Data for evaluating the campaign derived primarily from annual reinterviews of national samples of 9–18-year-old youngsters and their parents. Initial interviews were conducted between November 1999 and June 2001 and the final round between mid-2003 and mid-2004. The sample was selected to provide a nearly unbiased national cross-section. About two thirds of young people agreed to join the study and supplied data at the initial interviews. Of these, 86% to 93% still eligible for the study were re-interviewed in subsequent rounds, totalling from about 8100 to 5100 young people in each round. The featured report focuses on children aged from 12 and a half to 18 This was because by the final round of interviews few children were under 12.5 years of age. To prevent analyses being complicated by children of different ages being sampled at each round, this was set as the lower limit. 18 years of age was the upper limit of the ages targeted by the campaign. However, the authors say that all the reported conclusions presented were supported by prior analyses of a broader age range of children. who either in the current interview or in the previous one had not Before the last stages of the study there were too few existing users of the drug to test impacts on persuading occasional users to stop. used cannabis.

Since the campaign was national, the researchers could not recruit comparison samples from areas not exposed to its messages. Instead they tested its impact primarily Also assessed was whether cannabis use and related attitudes and beliefs among young people changed over the course of the campaign. There was no change in the prevalence of cannabis use among people aged 12.5 to 18 between 2000 and 2004. A small but significant increase in anti-cannabis beliefs and attitudes was not accompanied by significant parallel gains in intentions not to use, social norms, or self efficacy. There were some significant year-to-year changes (including an anti-cannabis shift in intentions from 2002 to 2004) and a few significant changes for subgroups of the samples. by relating Relationships between exposure to the campaign and these cannabis-related measures were adjusted to take account of individual and household characteristics (some derived from the responses of their parents) which the study found to be related to exposure to the campaign and/or to the young person's cannabis use. The intention was as far as possible to statistically 'eliminate' influences which might create a spurious relationship between exposure to the ads and cannabis use, clearing the way for a more valid estimate of the possible impact of the ads themselves. how many times each young person recalled seeing or hearing anti-drug ads in general, or those from the campaign in particular, to their answers to various questions about cannabis. If the ads had been effective, the more intensely children had been exposed to them, the less likely non-users should have been to later try using cannabis. Associated with this should have been (then or later) a corresponding impact on attitudes and beliefs protective against cannabis use. These outcome measures included young people's lifetime or recent use of the drug, and whether they definitely intended Itself strongly predictive of whether they actually did not later use the drug. not to use it in the next year. The researchers also created an index Weighting the different components so they were closely related to intention to use. of the youngster's balance of positive versus negative attitudes/beliefs relating to the drug. Similarly constructed was a 'social norms' index based on their beliefs about how often their peers used cannabis, and about how negatively their friends, parents and other people in their lives would react if they knew the young person themselves were using the drug.

Nearly all the young respondents recalled seeing or hearing at least some the campaign's ads, but there was marked variation in the extent of this exposure. Yet this variation was essentially unrelated to their current attitudes and beliefs about cannabis use, including intentions to use. More significantly, greater exposure in any given year of the campaign was not associated in the following year with fewer youngsters starting to use the drug, nor with attitudes and beliefs protective against cannabis use. If anything, the reverse was the case; in respect of exposure to the campaign itself, one of the associations was neutral and the remaining four in the 'wrong' direction. These included a possibly chance Especially if multiple outcomes tend not to covary, the more are measured, the more likely it is that some will reach the threshold for a statistically significant difference purely due to chance variations in the samples rather than any real impact of the interventions being tested. For example, by convention, if a difference would happen only 1 in 20 times by chance, it is considered a non-chance occurrence possibly due to the intervention. But if, say, 20 independent outcomes are measured, more often than not one would cross this threshold purely by chance. To cater for this, it is recommended1 that researchers consider raising the threshold (in the example, according to some adjustment methods to as high as 1 in 400) before each of the outcomes is considered to have reflected a statistically significant difference.

1 International Conference on Harmonisation Of Technical Requirements for Registration of Pharmaceuticals for Human Use. "ICH harmonised tripartite guideline statistical principles for clinical trials." Statistics in Medicine: 1999, 18, p. 1905–1942.
statistically significant trend for social norms to become more favourable to cannabis the more ads the child recalled experiencing, and a non-significant tendency for more exposure to be followed by a greater chance that the child would try cannabis during the following year. The picture was the same when the sample was broken down in to different sub-groups to test if certain children responded well to the campaign. Among these 80 tests of ads in general and the campaign ads in particular, 20 reached statistical significance, all but one in the 'wrong' direction. Results from the second half of the study period, when cannabis had become a specific target, were similar.

The researchers concluded that while the campaign had successfully reached the children it targeted, there was no evidence that this exposure had the intended impacts on their cannabis uptake, and it may have promoted more pro-cannabis attitudes and beliefs.

Findings logo commentary Despite unprecedented funding and government backing, this most high-profile of campaigns seems to have left its young targets unmoved or possibly nudged in the opposite direction to that intended, an object lesson in the difficulty of constructing persuasive messages in respect of one of the least dangerous drugs, and the risk that the attempt could backfire. It should however be remembered that parents did in some respects react as intended to the parental strands of the campaign. Also, other health promotion mass media campaigns (including some targeted at substance use) have been unable to demonstrate the intended effects on behaviour, though the evidence tends to be weak, especially in respect of young people. For example, smoking has been a major target, but just four Other studies involved advertising campaigns combined with health promotion activities of a different kind. methodologically strong studies of campaigns aimed at young people were found by reviewers up to 1998. Of these, only one – which employed a dubious strategy No adjustment was made for the fact that communities were allocated to be intervention and non-intervention sites yet the results were analysed as if individuals had been allocated. to analyse its results – found any impact on smoking. A later review of US studies still found few in which media campaigns were 'uncontaminated' by other initiatives, though these few studies often found reduced smoking in youth and adult target populations. Among the most convincing of recent studies was one which linked local variation in the intensity of a national US anti-smoking campaign to the initiation of smoking by teenagers and young adults.

After the period reported on in the featured study, the campaign again changed tack, adopting the label Above the Influence to signify the incorporation of messages encouraging children to avoid or resist peer influences which promote substance use. The campaign's own monitoring suggests this has avoided its predecessor's counterproductive impact on social norms related to cannabis use. But at the time of writing this latest revision of the campaign had yet to be subjected to the kind of independent evaluation which was unable to support the earlier versions.

However, it remains possible that the earlier campaigns really did have the intended impacts, but these were not picked up by the featured study. Details in background notes. In summary, there seems little to support arguments that the ads stuck in the mind of children most likely to use cannabis, creating the illusion that seeing the ads caused pro-cannabis effects. From the study's broader findings, it also seems unlikely that there were counterbalancing positive impacts on the more high-risk children or (these were excluded from the featured report) children who had already tried the drug. Two studies (details in background notes) in the same two medium-sized cities, either of the campaign itself, or of anti-cannabis ads specially developed to target high sensation-seeking teenagers, suggested that such teenagers may respond as intended, even if their less sensation-hungry peers are unmoved. Due partly to methodological problems and to the limited nature of the samples, these are not a persuasive counter to findings from the national study. What cannot however be excluded is the possibility that the outcomes in that study might have been partly due to differences between children who recalled lots and those who recalled few ads, rather than purely due to their exposure to the ads.

Another set of arguments accepts that the campaign was ineffective, and tries to explain why. Again, for details see background notes. Meta analyses and reviews (1 2) combining the results of relevant studies across health promotion offer clues to success factors lacking from the youth-oriented strands of the National Youth Anti-Drug Media Campaign: media campaigns are most effective when they publicise and reinforce an associated regulatory or law enforcement initiative; promoting new behaviours is easier than trying to prevent or stop problem behaviours; adults have responded better than children. It is also important (as some studies directly relevant to the featured campaign showed) to pre-test and adapt the campaign to the reactions of samples of the intended targets – a process which the US government admitted was inadequate Announcing the Marijuana Initiative on 23 May 2002, the Executive Office of the President Office of National Drug Control Policy said: "... we are implementing a number of changes, effective immediately:
1. Prior to being aired, all TV ads will undergo rigorous testing.
2. ..."
at least until the cannabis-specific phase.

The most far-reaching argument, advanced by the study authors themselves, and for which there was some evidence, is that no matter what deterrent impact the campaign's explicit messages may have had, these were (possibly more than) counterbalanced by an implicit message that drug use was hard to resist and common among children of the same age as the viewer or listener, a sometimes powerful influence promoting substance use. Why else, the young viewers might subliminally have reasoned, would the government be so keen to warn us about drugs and think we need help to resist?

The featured study had to rely on 'messy' real-world data. Others have been able to exercise greater control in examining how children react to the same or similar ads. They too support the simple explanation that the campaign seemed ineffective because it was, and also show how it might have been counterproductive. In one study nearly half the tested ads were seen as less effective in deterring youth substance (in particular, cannabis) use than simply watching a neutral TV programme. An offshoot of this study found that watching ads which graphically portrayed the 'gateway' message ('soft' drug leads to 'hard' drug use and addiction) left children feeling more positive about cannabis and more likely to use the drug, it seems because those most likely to use tended to "move towards disbelieving that regular marijuana use has negative consequences".

These studies suggest that among young people most likely to use cannabis, focusing on harmful consequences was a difficult strategy to carry off with any credibility in respect of a drug where clear-cut examples are hard to find. Apart from the unintended 'Everyone's doing it' message, some other features may also have undermined the campaign's effectiveness. A major theme implied that the choice young people faced was between cannabis use and other valued activities and identities, yet the experience of many will have been that usually no such dilemma presents itself. In turn this theme rested on the theme that cannabis use detrimentally dominates young lives, a depiction which all but a few could deflect as 'nothing like them' or their friends. Finally, there were explicit urges to independence of mind ("We need to stand up for ourselves and become independent thinkers"); if taken to heart, these might as easily have led to rejection of the government-sponsored messages as their acceptance.

Thanks for their comments on this entry in draft to Robert Hornik of the University of Pennsylvania. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 05 February 2010. First uploaded 14 January 2010

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The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms.

Elder R.W., Lawrence B., Ferguson A. et al.
American Journal of Preventive Medicine: 2010, 38(2), p. 217–229.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Elder at rfe3@cdc.gov.

The review which led a national US task force to recommend alcohol tax rises as an important public health measure to curb excessive alcohol use and related harms. US and UK politicians remain wary for reasons which can't just be dismissed as populism.

Summary This systematic review of alcohol tax policy interventions for reducing excessive alcohol consumption and related harms was conducted for the Guide to Community Preventive Services according to the Guide's rigorous common template. The Guide is maintained by the US government's Centers for Disease Control and Prevention, which appoints a task force of independent public health and prevention experts to oversee the reviews and make recommendations (these are the ones based on the featured review) to promote the health of the US population based not just on effectiveness, but also other potential benefits and harms and real-world applicability.

Given evidence that alcohol taxes feed through to retail prices, the review included studies not just of tax levels, but also the impact of price, with the provisos that the study was of an acceptable quality, published in English, and conducted in a high-income economy. 73 research papers met the review's criteria. Most related prices or taxes to a society's total alcohol consumption; on the basis of clearly established links between consumption, excessive drinking, and harmful consequences, these studies were considered relevant to the review's remit. Remaining studies assessed relationships with excessive or underage drinking or alcohol-related harm, most commonly traffic accidents. Some studies were of tax/price rises, others of cuts, and others still of different levels in different jurisdictions. Regardless of the design of the study, nearly all found that higher alcohol taxes or prices were associated with falls in indices of excessive drinking or alcohol-related illness or injury. Details below.

Of the 50 studies relating price to overall consumption, 38 calculated price elasticities. The extent to which an increase in price results in a proportionate change in consumption. For example, a price elasticity of -1 means that when price rises by 10%, consumption of the same commodity falls by 10%. Elasticities are rarely so rigid because (among other factors) people buy for reasons other than price and may be prepared to pay more to sustain consumption. As a result, a 10% increase in price might result in just a 5% fall in consumption, a price elasticity of -0.5. Nearly all the 38 studies found negative elasticities, indicating that higher prices were associated with lower per-capita consumption. In both the USA (-0.63) and elsewhere (-0.68), the typical elasticity meant that as price rose by a given %, consumption fell by about two-thirds as much. In another 12 studies, elasticities could not be calculated, but generally higher prices were associated with lower consumption.

Another 16 studies used survey data on how much individuals said they drank. Most included young respondents often underage for drinking, and all but two were conducted in the USA. Generally higher prices or taxes were associated with a lower prevalence of youth drinking, though only four out of nine studies found at least some statistically significant results. Among adults and the general population too, tax and price rises were associated with a lower rate of heavy drinking (usually typified as 'binge' drinking) and related harms. There were some indications that impacts were greatest among population groups who drink most often to excess, such as young men.

Half the 22 studies of alcohol-related harm concerned motor-vehicle crashes and/or consequent fatalities. Generally these found significant falls as tax or price rose, impacts comparable Because tax is only part of what determines price, numerical values for tax elasticities were lower (by about a factor of 10) than for price. to those on alcohol consumption. Liver cirrhosis was the other main cause of death investigated. All five studies found higher prices associated with fewer deaths, though impacts varied considerably. Some other causes of death were also estimated to fall. The three studies which looked at this found higher alcohol taxes were associated with decreased violence – and specifically violence to children – to a degree comparable to impacts on alcohol consumption, while two found higher prices curbed the spread of sexually transmitted diseases.

Consistency across high-income economies in North America, Europe, and the Western Pacific suggest that in such economies the link between overall alcohol consumption in a society and tax/price is broadly applicable. Findings on alcohol-related harms derive primarily from North America but are likely to be broadly applicable across high-income countries. Sectors of the population with least disposable income would be expected to be most sensitive to price, but the review was unable to test this expectation. It was also unclear whether heavier drinkers are more or less sensitive than lighter drinkers.

According to the World Health Organization, tax rises are the most effective and cost-effective measure to reduce alcohol-related harm when at least 1 in 20 of the population is a heavy drinker, and a US analysis found net costs savings for society due to the injury prevention impact of a 20% tax rate.

The review noted that while raising alcohol taxes provides government revenue, it may be resisted by the alcohol industry and consumers; public support increases when revenues are devoted to alcohol prevention and treatment. It acknowledged equity concerns that higher alcohol taxes may have the greatest economic impact on poorer people, but argued that: in the USA these taxes would still constitute a very small part of the tax burden; inequality could be redressed elsewhere in the tax and benefits system (such as in the availability of healthcare services for uninsured and other vulnerable populations); and poorer citizens can be expected to benefit most in health terms from reductions in excessive alcohol consumption.

The reviewers concluded that these results constitute strong evidence that raising alcohol taxes is an effective strategy for reducing excessive alcohol consumption and related harms. The impact is expected to be proportional to the size of the consequent price rise. For example, a 10% increase in alcohol prices has typically resulted in a 3% to 10% fall in consumption. Impacts will probably also depend on factors such as disposable income and the demand elasticity for alcohol among different population groups.

Findings logo commentary As the review comments, the proposition that as alcohol price rises, consumption falls, is one of the most well established in the alcohol use prevention armoury, and plausibly in line with general economic theory and data about the response of demand to price. Given its findings, the Task Force on Community Preventive Services recommended "increasing taxes on the sale of alcoholic beverages".

Convincing as it was, the review did not always clearly separate tax from price; tax obviously influences price but in complex ways which mean that a general rise in tax will not lead to the same proportionate rise in prices across different types of drink sold under different licensing conditions. Especially when it comes to the harms from a given amount of drinking, the assumption that primarily North American studies are an adequate guide to expected impacts in other drinking cultures is open to question. Even within Europe, a given consumption change has impacts which differ greatly across nations. Another general gap in the analysis was that it was unable to explicitly account for the potential impact of drinkers switching to other beverages if one type of drink increases in price.

Switching drinks can undermine tax rise impacts

If drinkers switch drinks, price rises may substantially curb consumption of the now more expensive drink, yet the impact on overall alcohol consumption will be less. If the elasticity for alcohol as a whole is estimated from the elasticities for each beverage, the result will be to overestimate the impact of price and tax rises. Adjusting for product switching is however complex; details below.

UK data (1 2) shows that often pairs of beverages substitute for one another, but sometimes the opposite happens; as consumption of one falls or rises in response to its price, so does consumption of the other. But overall a major meta-analytic A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. synthesis of relevant studies found that taking in to account the prices of other beverages significantly weakened the link between price and consumption of any given beverage. This analysis argued that "interdependencies in demand across alcohol beverages" should be taken in to account in making decisions on tax. Some of the studies incorporated in the featured review (for example, one which contributed six of the 38 elasticity estimates) did not take account of price competition between different beverages, somewhat weakening confidence in the review's conclusions about the impacts of price (and therefore tax) on overall consumption. Another major meta-analysis found that across all the studies which gave a figure for alcohol consumption as a whole (therefore taking in to account any switching), elasticity averaged -0.51, indicating that as price levels rise, consumption falls by about half as much. Heavy drinking was cut too but less so than drinking overall.

Some tax or price policies are designed to limit the ability of consumers to switch to products which offer more alcohol for less money. Among these is 'volumetric taxation' – setting tax levels solely on the basis of alcohol content and uniformly across all types of drinks. In the Australian context this was estimated to cost just $0.58 million but to save $57 million in health costs due to reduced drinking, leading to a net cost saving of $56 million Australian dollars, about 28 million. Despite costing less than current policies, it would also avert the loss of an extra 11,000 years of life adjusted for disability, making it the most cost-effective and cost-beneficial of the tested interventions. This analysis does seem to have "... the change in consumption for each beverage was then estimated by summing the change in quantity derived from the change in its own price and the changes in price of the other alcohol drinks." accounted for price competition between different types of drink.

Switching was also accounted for in a mathematical model based on English data. Price rises applied across all products in the on- and off-trade were estimated to substantially reduce average consumption, partly due to limited switching between drinks because price increased across the board, and partly because all consumer groups are targeted equally. Raising the price only of low-priced products led to much smaller falls in consumption (for example, under 0.5% for a 10% rise compared to over 4% if this were applied to all drinks) because limited market segments are affected, and there would be some switching between drinks. Alcohol-related harms were estimated to fall along with overall consumption.

Minimum price per unit now UK policy

Another proposal which avoids switching is to set a minimum price per unit of alcohol across all types of beverages. The mathematical model mentioned above was used to estimate that a minimum price of £0.40 would curb consumption by 5.4%, most notably among heavier drinkers, and save a life a day by the tenth year of the policy, when hospitals would be relieved of nearly 6300 alcohol-related admissions a year. It would also cut crime, absence from work, and loss of employment, totalling nearly 950 million social cost savings at a cost to the Treasury of around 120 million.

Given the broad agreement among studies and reviewers, the major questions are not over the validity of the findings, but over whether governments mindful of the opinions of the drinking public and the importance of drink-related industries will raise alcohol taxes/prices sufficiently to realise the potential public health gains. This is especially the case in Britain, which compared to other European nations already has among the highest alcohol taxes, and where drink prices are relatively high compared to other commodities. After government resistance in England and Wales and initial parliamentary rejection in Scotland, now across most of the UK setting a minimum price per unit is government policy and in the case of Scotland has been provided for in law, though nowhere has it yet been implemented. Details below.

In 2009 the UK House of Commons Health Committee advocated a minimum per unit price allied with duty increases on high-alcohol products. At the time no UK-wide political party potentially in a position to implement such policies was planning across the board tax rises or minimum pricing. In opposition, Conservative party plans were to raise alcohol taxes, but only on high-strength beers and ciders and drinks preferred by teenagers, an option similar to that estimated to have very minor effects on overall consumption, but one which might alienate few adult voters. In government with the Liberal party, policy changed with the release of the 2012 national alcohol strategy for England and Wales. This included a commitment to rapidly set a uniform minimum price per unit for alcohol across all drinks, the level The prime minister's foreword gives the example of 0.40. of which will be subject to a consultation which was announced in November 2012.

Scotland, where drink problems are the most severe of the UK nations, moved considerably earlier than the rest of the UK to implement price rises in the form of a minimum per unit price, though at the time of writing the plans have yet to be implemented. As long ago as 2009 Scotland's national alcohol strategy committed the government to a minimum price per unit of alcohol and included plans to ban the sale of alcohol as a loss-leader. These plans faced challenges from within the Scottish parliament, which in November 2010 rejected the minimum pricing element of the Scottish National Party's Alcohol Bill. Following the May 2011 elections which left the Scottish National Party with an overall majority in the parliament, another attempt was made in the form of the Alcohol (Minimum Pricing) Bill placed before the Scottish parliament in October 2011 which was later passed and in June 2012 became the Alcohol (Minimum Pricing) Scotland Act 2012. This enables the government to issue regulations setting a minimum unit price, which government says it intends to set at £0.50. Unless after five to six years renewed by government subject to parliamentary approval and on the basis of a report on its impacts, this provision will automatically be withdrawn. It remains possible that opponents will use UK devolution and/or European Union free trade laws to obstruct this provision.

Public and politicians ambivalent over expensive drink

The stuttering and in some political quarters reluctant progress to accepting a minimum unit price in the UK illustrates the difficulty democratic administrations face in imposing expensive drink on majority-drinking populations and also in facing up to the power of sections of the alcohol industry opposed to such plans. In the USA too, public health has in practice not been the overriding consideration. Given the evidence that tax rises would raise revenue and cut public service costs, in 2009, 25 cash-strapped US states sought to increase alcohol taxes. Despite a trend to appease public and political opinion by planning to divert new revenue to address alcohol-related harm, just six succeeded in getting the bills passed by their legislatures, reportedly defeated by alcohol-industry lobbying.

One reason why public and politicians may remain unconvinced is that studies concerned primarily with harm fail to account for the benefits drinkers feel they get (the reason why they are prepared to pay) from drinking. Sometimes studies do account for the minor (relative to the overall harms) medical benefits of low-level regular consumption, but these are not why most drinkers drink. An industry-funded review found research indicating that moderate drinkers "experience a sense of psychological, physical, and social well-being; elevated mood; reduced stress (under some circumstances); reduced psychopathology, particularly depression; enhanced sociability and social participation; and higher incomes and less work absence or disability", benefits which have "barely begun to be incorporated into epidemiologic research and analyses." Against this it can be argued that neither do studies account for all the negatives related to drinking such as family break-up, low-level abuse, and family and personal distress.

Neglect of benefits from drinking was one of the criticisms made by a prominent alcohol expert and sociologist of attempts to establish a total cost (or cost reduction due to policy changes) to society of alcohol-related harm. He argued that though the constituents such as lives saved, crimes not committed, and illnesses avoided, may in themselves be a good enough reason to curtail the availability of alcohol, amalgamating these 'apples and pears' and attaching a monetary value to them is such a value-laden and imprecise exercise that it is of propaganda value only in determining policy. The British exercises in particular were dominated by productivity gains due to less drink-related unemployment, calculations which, the critic reasoned, unrealistically assumed no countervailing benefits. Yet in the absence of full employment, vacancies left by drinkers will usually be filled by someone else, ending perhaps via a chain of job changes in someone currently unemployed gaining a job.

Neither can the equity arguments which weigh with some politicians be dismissed. Faced with price rises, drinkers do not generally cut back enough to avoid spending more. Minimum pricing or alcohol-content taxation would reduce or eliminate the option of switching to cheaper drinks. The impact of a greater proportion of the family budget being diverted to drinking is likely to be felt most sharply among the poorest. The featured review and others argue that this aggravation of inequality could be redressed by selective use of the tax revenues, and that the poorest may also gain most in health. However, these potential and/or future mitigations are set against an almost certain and immediate impact on the emptiest pockets.

Thanks for their comments on this entry in draft to Randy Elder of the US Guide to Community Preventive Services, Petra Meier of the University of Sheffield and Peter Anderson of Maastricht University. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 28 November 2012. First uploaded 22 January 2010

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Effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms.

Campbell C.A., Hahn R.A., Elder R. et al.
American Journal of Preventive Medicine: 2009, 37(6), p. 556–569.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Hahn at rhahn@cdc.gov.

The review which led a national US task force to recommend limiting the concentration of retail alcohol outlets as an important public health measure to curb excessive alcohol use and related harms. In much of the UK though, licensing law severely limits the scope for action.

Summary This systematic review of whether the geographical density of retail alcohol outlets affects excessive alcohol consumption and related harms was conducted for the Guide to Community Preventive Services according to the Guide's rigorous common template. The Guide is supported by the US government's Centers for Disease Control and Prevention, which appoints a task force of independent public health and prevention experts to oversee the reviews and make recommendations (these are the ones associated with the featured review) to promote the health of the US population based not just on effectiveness, but also other potential benefits and harms and real-world applicability. Below the theory behind the review and some methodological details.

Reducing outlet density is thought to curb excessive alcohol consumption and related harms by increasing the distance people need to travel to and fro to buy drink, relieving competitive pressures and increasing prices, reducing exposure to alcohol marketing, and potentially by strengthening anti-drinking social norms. Concentrations of pubs and other premises serving alcohol can also lead to concentrations of people drinking excessively, fertile ground for aggression and violence, while drink bought in off-licenses and drunk at home may be associated with domestic violence and suicide attempts. A possible counterproductive impact is that more and longer car journey to buy drink may generate alcohol-related crashes.

The review searched for studies capable of testing these theories which had been published in English and conducted in high-income nations. Among the 88 reports, none concerned studies of the effects of policies directly intended to alter outlet density, but unlike some predecessors, the review included studies of interventions which would have the effect of changing the number of sites where alcohol can legally be obtained, even if this was not the explicit intention. Because these are most capable of attributing effect to cause, most weight was given to studies which compared alcohol-related outcomes before and after a density-related change. Studies which simply related outlet densities in different areas to alcohol consumption/harm were also analysed, but suffer more from the possibility that density was not a causal factor. For example, it could be that outlets cluster where drinking is particularly heavy rather than the reverse, or that some other factor (such as a strong local drinking culture) affects both outlet density and alcohol consumption/harm.

Most studies found that greater outlet density was associated with higher alcohol consumption and more related harms, including illness, injuries, crime, and violence. This convergent evidence derived from studies which directly evaluated outlet density (or changes in density) and those evaluating policy changes which indirectly had a substantial impact on density such as privatisation of government off-premises monopolies, the reverse process, local bans on alcohol sales and the reverse, and licensing regulation changes. Studies assessing the relationship between alcohol outlet density and motor-vehicle crashes produced mixed results. Selected details below.

The four studies of national or local licensing policy changes consistently indicated that more permissive licensing increased the number of on- and off-licence alcohol outlets, which in turn led to increased alcohol consumption, in two studies most notably among heavy drinkers. A US study also found substantial proportionate rises in night-time single-vehicle crashes among men of legal drinking age. Privatisation of previous government off-licence monopolies usually results in a substantial increase in outlets, but also changes in alcohol price, opening hours and marketing which complicate attribution of impacts to outlet density. The 11 privatisation initiatives studied to date typically resulted in a 42% increase in sales of the privatised beverage with (where this was reported) no impact on other drinks, meaning consumption overall increased. Just one study documented the reverse process – the re-monopolisation of sales of medium-strength beer in Sweden; among 10–19-year-olds indicators of heavy drinking fell, as in most age groups did motor-vehicle crashes. A more drastic curtailing of outlets is achieved through local bans of on- or off-licence sales or consumption, creating 'dry' localities. In isolated communities these can substantially reduce alcohol-related harms, but where alcohol is available in nearby adjacent areas, travel to and from these areas may lead to serious harms.

The review also included studies linking alcohol-related outcomes to differences in outlet density not explicitly linked to any particular initiative or policy. Most weight was placed on studies of changes in density over time. These consistently found higher density related to higher consumption but impacts on harms were sometimes complex. In one US study, more densely clustered on-licensed premises were associated with more traffic accidents but the reverse was the case for off-licensed premises. The few studies of violent incidents found these more numerous where outlets are densely clustered, in one study, not entirely due just to increased drinking, but other factors presumed to include the congregation of drinkers. A particularly sophisticated study in California found changes over time in the concentration of on-licence bars in the focal area and in neighbouring areas were both related to the number of serious assaults in the focal area, the more so in areas with relatively high proportions of men in the population. Relative to the aggravation of violence associated with growing poor minority populations, the effect was small, but appreciable in urban areas with many bars and pubs. Studies of differences between areas not tracked over time were consistent with outlet density contributing to alcohol consumption and related harms, especially violent crime, but possibly with the exception of injuries.

The reviewers concluded that regulation of alcohol outlet density can help control excessive alcohol consumption and related harms, but cautioned that most studies were of the opposite process (ie, de-regulation) and derived from North America and Scandinavia. Also the mechanisms leading from increased density to adverse consequences are unclear; it could for example be that high density areas attract prostitution and drug dealing, and that these activities are related to public health and violence and might directly be tackled. Lacking too were studies of the costs and benefits of limiting alcohol outlet density. Alcoholic industry interests are likely to lose economically and can be expected to be oppose further regulation.

Findings logo commentary Regulating outlet density is one of the ways of restricting the physical availability of alcohol. By making it harder and less convenient to obtain and consume alcohol – effectively, increasing the 'price' in terms of time and effort – these low-cost measures are thought to harvest savings in drink-related harm which can be expected to be much greater than their costs. Except at the extremes and in special circumstances, evasive tactics such as home/illicit production and smuggling do not counterbalance the benefits.

On public health grounds, the Task Force on Community Preventive Services which assessed the review's implications thought it sufficient to warrant a recommendation for regulatory action (such as licensing and zoning) to limit alcohol outlet density. But a major weakness in the evidence was the absence of studies of policies explicitly intended to alter outlet density, and only outlet density; initiatives which affect density as a by-product of other changes make it difficult to attribute outcomes to the density element. All but a few studies documented the impacts of increased outlet density. The implicit assumption is that the reverse process would lead to similarly dramatic cuts in consumption, but this remains to be adequately demonstrated.

Aware of the limitations, in the US context the task force nevertheless felt the circumstantial evidence weighty enough to support regulatory action. However, US and UK drinking and geographical contexts are quite different. The USA has a stronger tradition of more or less 'dry' areas, and total abstinence, a rarity in Britain, is not uncommon. Within this context, US legislatures have been able to make dramatic departures from low-level availability or the reverse, departures whose impacts are magnified in communities whose size or isolation make them difficult to sidestep. Compared to the featured review, an almost contemporary review was less convinced about the impact on consumption of non-dramatic, gradual changes in density, and remarked that little was known about density fluctuations in countries like the modern UK with plentiful outlets. In such regions, the studies which have been done found mixed impacts on consumption which were unlikely to affect alcohol-related chronic health problems except (perhaps via price falls due to competition) among socially marginalised drinkers.

Where alcohol outlets are already plentiful, and in the UK in particular, density concerns relate more to the bunching of on-licence outlets reaching the point where they coalesce into an 'entertainment' district blighted by alcohol-related nuisance such as violence, disorderly conduct, noise, fouling from vomit or urine, and litter. As well as the sheer volume of alcohol consumed, mechanisms include the aggregation of young drinkers and sharpened competition between outlets. This may be seen not just in terms of price, but also in special offers encouraging rapid and heavy drinking, preparedness to attract and embrace the heaviest drinkers, and to engage in more risky serving practices such as underage sales. Except for outright violence, focused as it was on public health, the featured review had little to say about these concerns. There are in any event very few relevant studies.

As the featured review commented, such concerns raise the issue of when density becomes dense enough to constitute bunching which risks an escalation in alcohol-related nuisance, an issue addressed by a study in Melbourne. When an otherwise typical district hosted up to about 30 of the Australian equivalent of pubs, there was little increase in violence presumed Police records of assaults taking place between 8pm and 6am on Friday and Saturday were considered 'alcohol-related'. to be alcohol-related, but as outlets increased beyond this threshold, the rate of violent incidents rose steeply. In respect of on-licence establishments devoted to drinking, the same principle may apply elsewhere. Such an effect partially hampered a major project in Cardiff intended to curb violence and disorder related to licensed premises. One of its least successful strands was the attempt to influence licensing and planning decisions. In major violence hot spot in the city, other strands were overwhelmed by decisions which increased the density of drinking outlets.

In the UK there is some evidence that the relationships most clearly revealed by dramatic density-related alterations elsewhere have been operative in more gradual, long-term trends. What seems the most recent analysis found that as the number of off-licenses rose between 1952 and 1991, so too did beer consumption. Given inconsistent and sometimes negative relationships with other beverages, it was unclear how expansion of the licensed trade affected alcohol consumption as a whole.

Official regulation of outlet density cuts against the grain of market economies. Prospects for density controls as a means to curb alcohol-related harm depend on the degree to which legislatures prioritise these harms against the untrammelled response of supply to demand and the right of legitimate industries to promote their products. UK nations uniformly concede the primacy of the market in determining whether demand is sufficient to warrant a new or revised licence, but differ in the counterbalancing weight given to social and health concerns. Details in background notes; main points below. Faced with the most severe drinking problems in the UK, Scotland has gone farthest. Unlike other nations, alongside crime, disorder and antisocial behaviour, public health is a consideration in Scottish licensing decisions, and licensing boards are required to monitor density-related problems or impending problems and take action by banning new premises or the type likely to aggravate the situation. In England and Wales such initiatives are expressly forbidden. The most licensing authorities can do is identify areas where the concentration of (normally on-licence) premises is already giving rise to serious problems of nuisance and disorder. In such areas, but only if cogent objections on these grounds are received, the presumption would be that new licences or variations in licences which would aggravate the situation will be refused. This option has been used by about a fifth of authorities. Rather than curtailing density, in England and Wales much more emphasis is being placed on tackling the problems to which density may contribute by enforcing laws and supporting multi-agency campaigns relating to alcohol and resultant crime and disorder.

Thanks for their comments on this entry in draft to Robert Hahn of the US Centers for Disease Control and Prevention. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 04 February 2010. First uploaded 04 February 2010

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