Internationally proven community alcohol crime and harm reduction programmes feasible in Britain

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Internationally proven community alcohol crime and harm reduction programmes feasible in Britain

Though unable to securely document outcomes, three projects have shown that British communities can generate the kind of coordinated action which new reports from the USA and Sweden have shown curtail alcohol-related violence and injury, creating substantial cost-savings for society.

FINDINGS Rather than targeting risky drinkers, all the projects targeted high-risk neighbourhoods, aiming to modify features of the social and physical environment which generate alcohol-related violence and disorder.

UK flag UK From 2004, parallel projects Jointly known as the UK Community Alcohol Prevention Programme. in Glasgow, Cardiff and Birmingham sought to generate action locally to promote responsible service of alcohol in bars and shops, enforce licensing and allied laws, limit alcohol outlets, and to modify the environment and transport services to improve safety. Awareness-raising initiatives aimed to stimulate support from residents, politicians, licensees and local services. The projects were among only five in the UK found to meet international criteria1 for 'multi-component' programmes which simultaneously bring a range of influences to bear on alcohol problems.

The featured report2 documented how all three were able to generate activity of the kind they sought. In the absence of a systematic evaluation, official statistics and data gathered by the projects themselves was used to assess whether this activity had reduced alcohol-related problems – problematic, because the projects' effects could not easily be isolated and the figures fluctuated due to factors other than the real levels of crime or injury.

Perhaps clearest was the impact in Birmingham, where in the targeted area (a transport corridor crossing three suburbs) the project started with a clean slate in terms of existing community organisation. Birmingham too seems to have had the strongest enforcement component, shown by research ( In context) to be the greatest single influence. Trading standards staff visited all the area's alcohol outlets, alerting staff to their responsibilities and warning of future 'sting' operations to test whether outlets would sell to underage youngsters. Police recorded reports of licensing infringements, followed up with an advice visit, and mounted highly visible operations similar to those used in relation to illicit drugs.

Possibly as a result, offences such as vehicle crime, domestic burglary and robbery in the area fell by over a third compared to just 9% in a neighbouring area, and public place wounding fell by 30% compared to 17%, though the numbers involved were small. Unlike elsewhere, after the project was established few premises sold to underage test purchasers and most asked for proof of age.

USA flag USA The US project targeted two poor neighbourhoods relatively crowded with alcohol outlets and blighted by crime and alcohol-related problems. A robust Staggered implementation at the two sites and before and after measures benchmarked against the rest of the city offered multiple checks on whether the interventions were responsible for any improvements.evaluation3 documented reductions in violent crime and injuries, among the priorities for UK projects.

Local community organisations prioritised control of alcohol outlets to tackle underage drinking and alcohol-related violence. Training in responsible beverage service was taken up by 40–70% of outlets after personal and persistent approaches by project staff and police. Shop managers were warned that police would mount test purchases by underage youngsters. An accompanying officer immediately initiated proceedings against offending outlets. Given this backing, there was a clear reduction in sales, prompting replication city-wide. Similar operations were not undertaken in bars where, without enforcement backing, staff training on its own did not lead more premises to refuse service to drunk patrons. The bottom-line finding was that across both sites, the interventions were followed by significantly greater falls than in the rest of the city in assaults According to both police and medical records. and injuries Before the waters were muddied by city-wide implementation, there was also a greater reduction in injuries specifically related to drinking or drug use. due to traffic accidents. Some of the relative reductions were substantial – over a third for assaults and traffic accidents. Given the social costs imposed by such incidents, the project was likely to have been cost-beneficial.

Swedish flag SWEDEN The Swedish report4 showed that such programmes can indeed save society money. It attached monetary values to an earlier finding5 that a city-centre programme targeting licensed premises reduced violence Represented by reports to the police. by 29%. The resulting estimate was that it saved society 39 times more than it cost, primarily due to reduced criminal justice expenditures. The calculations were subject to potential error but even when savings were limited to police work, the most securely estimated element, they were seven times greater than costs. A dip in quality of life after being the victim of a crime meant that the interventions also gained one quality adjusted life year (QALY) for each 3000 Euros spent, well within the Swedish yardstick of 54,000 Euros.

After an upsurge in violence when on-licence outlets expanded, Stockholm County Council initiated the programme to curb serving of drunk patrons in the central district. Test purchases by apparently drunk actors generated support for responsible beverage service training, later made a condition of licence renewal for late-night venues. Liquor law enforcement (especially the ban on serving drunk patrons) was stepped up by police and the licensing board, largely in the form of warning letters rather than formal proceedings. Resulting reductions Inevitably the calculations incorporated arguable assumptions, but the magnitude of the gains were such that substantial benefits seem certain. in violence were estimated on the basis of before and after trends in the intervention district compared to the next most similar area. Benefits grew in line with the unfolding of the programme, reinforcing the case that this was an active ingredient. Once again, enforcement was thought to have been the main influence. Even in the comparison area, underage sales fell after activists organised test purchases and notified offenders to the police, who banned some from selling alcohol.

IN CONTEXT Reviewers6 have concluded that the 'environmental' approach7 (controlling the geographic, retailing and social environments in which alcohol is distributed, sold or consumed, and stepping up enforcement) tested in these studies can be more effective than trying to affect individuals through education or persuasion. However, impacts sometimes remain modest, partly because the scope for local action is limited by national or regional laws.

Police or licensing authority action backed by ultimate legal sanctions can on its own have a major impact, but requires other components to amplify and sustain its effects. Publicity makes authorities aware of the need for action and licensees aware of the potential consequences of failing to comply, while local lobbying helps gain support for the required intensity and persistence of effort.8 9 Possibly enforcement works because it stimulates defensive management actions10 such as firm and clear policies on adhering to regulations and a system for monitoring staff compliance. Commercial considerations often mitigate against such policies, but can also generate them if otherwise the business faces closure or costly restrictions.

British research includes a landmark study11 based on test purchases by underage youngsters which suggested that many vendors' primary concern was not to avoid underage selling as such, but to avoid successful prosecution for selling to children who were clearly underage. In Cardiff,12 the main lessons of a programme to curb alcohol-related city-centre violence and disorder seemed to be that intensive implementation is needed to have a major impact. Planning and licensing decisions which increase the density of drinking outlets, and competitive and financial pressures driving the policies of large club or pub chains, can counter the benefits. However, benefits remained and were probably enough to create substantial cost-savings for society. Though not formally evaluated, similar enforcement-led programmes13 stimulated by the 2004 English national alcohol strategy have encouraged licensee compliance and appear to have reduced alcohol-related crime and disorder. Sales to underage youngsters have also been curbed by recent test purchase14 operations15 allied with trading standards and/or police follow-up.

PRACTICE IMPLICATIONS The UK report argued for environmentally-based community projects on the grounds that these probably represent the best chance for minimising harm in the face of national deregulation and promotion of alcohol consumption. Yet the leverage local projects can exert depends partly on the tools made available by national laws and policies to the projects and to the authorities they seek to influence, tools abolished or weakened or by deregulation. Given adequate powers, local lobbying and coordination can maximise their potential and tackle factors beyond the reach of the law.

So a crucial issue is how far national UK frameworks provide the required support and legislative tools. New British alcohol strategies and laws and attendant funding do provide a basis for projects similar to those featured, particularly the powerful tool of test purchases to expose underage service. But at the same time (less so in Scotland) they limit the scope for licensing authorities to respond to community concerns. Click here for summaries of the situations in England, Wales and Scotland.

Flexibility is essential because the impacts of commonly used tactics depend on the environment with which they interact; a different mix works best in different situations.1 10 The ideal16 is when national support and regulations afford localities the required tools within an accountability framework which motivates effective action, but which also gives localities discretion on what to target and how.

There are however some general principles. Regardless of the interventions built upon them, test purchasing and the construction of a database linking untoward incidents to particular premises are important in motivating and targeting action and assessing its impact. The visible and credible possibility of enforcement action against alcohol outlets must be persistently maintained if it is to have anything but a fleeting impact. Attention should be paid both to alcohol consumption and the factors17 (such as crowding, transport problems, divorcing alcohol from food, poorly kept or managed premises, glasses easily transformed in to weapons, inadequate training and monitoring of staff) which potentiate violence and disorder.

In the UK guidance on local strategies18 is available and a new database19 features examples. International lessons on community alcohol interventions have also been usefully encapsulated.20 These include: devolve decision-making to the community while supplying research-based knowledge; rapid feedback of results motivates participants and keeps projects on track; recruit influential and respected local leaders; considerable lead-in time is needed to build the social and organisational infrastructure for community action, and projects need a few years to fully deliver; project staff must expect and permit adaptation not just of methods but also aims in response to the community's strengths and self-perceived needs; success comes easier in communities where the project's aims are already high on the agenda; community norms and alcohol availability restrictions have their greatest impacts in self-contained, stable communities whose residents and businesses cannot easily escape their impact; a key element is the surer detection and sanctioning of transgressors brought about by the more intensive use of existing legal powers; however, these legal powers must in the first place have the potential to be effective.

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

1 Thom B. et al. Multi-component programmes: an approach to prevent and reduce alcohol-related harm. Joseph Rowntree Foundation, 2007.

2 FEATURED STUDY Mistral W. et al. UKCAPP: an evaluation of 3 UK Community Alcohol Prevention Programs. Final report for the Alcohol Education & Research Council. University of Bath and Avon & Wiltshire Mental Health Partnership NHS Trust, 2007.

3 FEATURED STUDY Treno A.J. et al. The Sacramento Neighborhood Alcohol Prevention Project: outcomes from a community prevention trial. Journal of Studies on Alcohol and Drugs: 2007, 68(2), p. 197–207.

4 FEATURED STUDY Mnsdotter A.M. et al. A cost-effectiveness analysis of alcohol prevention targeting licensed premises. European Journal of Public Health: 2007, 17(6), p. 618–623.

5 Wallin E. et al. Alcohol prevention targeting licensed premises: a study of effects on violence. Journal of Studies on Alcohol: 2003, 64(2), p. 270–277.

6 Giesbrecht N. Alcohol, tobacco and local control: a comparison of several community-based prevention trials. Nordisk Alkohol- & narkotikatidskrift (Nordic Studies on Alcohol and Drugs): 2003, 20(English suppl.), p. 25–40.

7 Holder H.D. Prevention of alcohol problems in the 21st century: challenges and opportunities. American Journal on Addictions: 2001, 10, p. 1–15.

8 Holder H.D. Community prevention of young adult drinking and associated problems. Alcohol Research & Health: 2004/2005, 28(4), p. 245–249.

9 Toomey T.L. et al. Environmental policies to reduce college drinking: an update of research findings. Journal of Studies on Alcohol and Drugs: 2007, 68, p. 208–219.

10 Grube J. et al. Preventing impaired driving using alcohol policy. Traffic Injury Prevention: 2004, 5(3), p. 199–207.

11 Willner P. et al. Alcohol sales to underage adolescents: an unobtrusive observational field study and evaluation of a police intervention. Addiction: 2000, 95(9), p. 1373–1388.

12 Maguire M. et al. Reducing alcohol-related violence and disorder: an evaluation of the 'TASC' project. Home Office, 2003.

13 Home Office. Alcohol Misuse Enforcement Campaign 2: communications toolkit. Home Office, 2004.

14 Department of Health [etc]. Safe. Sensible. Social. The next steps in the national alcohol strategy. HM Government, 2007.

15 Local Government Association. Unfinished business: a state-of-play report on alcohol and the Licensing Act 2003. LGA, 2008.

16 Giesbrecht N. Community-based prevention of alcohol problems: addressing the challenges of increasing deregulation of alcohol. Substance Use & Misuse: 2007, 42(12–13), p. 1813–1834.

17 Plant M.A. et al. Safer bars, safer streets? Journal of Substance Use: 2007, 12(3), p. 151–155.

18 London Drug and Alcohol Network and Alcohol Concern. Local alcohol strategy toolkit. LDAN and Alcohol Concern, 2004.

19 Alcohol Concern. HubCAPP: Hub of Commissioned Alcohol Projects and Policies.

20 Graham K. et al. Community action research: who does what to whom and why? Lessons learned from local prevention efforts (international experiences). Substance Use and Misuse: 2000, 35(1&2), p. 87–110.

Last revised 01 November 2008

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