Thursday, 2 January 2014

Alcohol-related violence: Can it be prevented?

With yet another teenager in a critical condition in hospital in NSW after being 'king-hit' (that so shouldn't be how we describe this violent act) in Kings Cross, the community is yet again debating what should be done about what appears to be a growing alcohol-related violence problem in this country. What makes this incident so much more distressing is that it happened just metres away from where Thomas Kelly was killed after being punched in a act of senseless violence just months ago. Even today, the NSW Government continues to refuse to make changes to licensing laws, i.e., restricting opening hours and limiting alcohol availability in these nightlife areas, and the community is beginning to lose patience ...

So is there an answer to the problem? Over the years I have been interviewed countless times on this topic and my answer has always been the same - if you want to reduce alcohol-related problems, including violence, increase the price of alcohol, reduce accessibility and remove alcohol advertising and sponsorship of sport. It's a simple answer for an extremely complex problem but is that really what the evidence says?

Over the past month I have been putting together a presentation on this very issue that I will be delivering to GPs during 2014 (at the HealthEd seminars), as well as another for those who work with young people (the Generation Next seminars). The convenor of both of these seminars, Dr Ramesh Manocha, contacted me at the beginning of December, just after the Daily Telegraph ran a front page story on a Monday morning with the headline - 'Sunday Bloody Sunday'. A national police operation had resulted in 540 people being arrested in NSW for alcohol-related offences, with more than 20 arrests per hour - or put more frighteningly, one person was arrested every 3 minutes! He said that he thought this would be a hot topic in 2014 - he couldn't have been more on the ball!

Just to make it clear that this is not a media 'beat-up' - there are 70,000 victims of alcohol-related violence in Australia each year. Some 14,000 people are hospitalized, almost 3,500 of them with brain injuries and research estimates that anywhere between 23-73% of all assaults in this country are linked to alcohol. This is not a small problem, it affects many Australians and if they haven't been a victim of alcohol-related violence themselves, there's a good chance they know someone who has ....

So before we look at how to deal with the problem - what is the link between alcohol and violence? Certainly heavy drinking and intoxication are associated with physical aggression but the fact is that the majority of drinkers do not become perpetrators of violence, so the link is not simple or straightforward. The evidence suggests that it is actually a result of a complex interaction of the following variables:
  • pharmacological effects of alcohol on the cognitive, affective or behavioural functioning of the drinker
  • individual characteristics of the drinker – age, gender, personality traits, predisposition to aggression, etc
  • effects of the drinking environment – a range of factors such as overcrowding in a venue, role and behaviour of venue staff, etc
  • societal attitudes and values, including a culture of drinking to deliberately become intoxicated
So if we look at these realistically there is very little we can do to impact on the first two variables - we can't change the effect that alcohol will have on the drinker and it's going to be extremely difficult to alter an individual's characteristics (although there are certainly things that we can do from a preventive perspective to target at-risk children and young people to reduce risk factors in this area). Therefore most of the research in this area has concentrated on making change to the drinking environment - i.e., making venues and the outside environments safer. Unfortunately, many (but not all) of the strategies identified in the research are often about reducing or limiting access to alcohol and are not supported by the hotel and alcohol lobby, and as a result governments are often too cowardly to support them.

The 'Newcastle Model' is often quoted as the 'gold standard' in this area and is most probably the most well studied strategy in this area in the country. Prior to March 2008, Australia's sixth largest city, Newcastle had the highest rate of alcohol-fuelled violence in NSW and its CBD attracted around 20,000 preloaded young drinkers each weekend from up to 100 kms away. As a result, a series of restrictions was placed on 14 licensed premises, most of whom were trading to 5am, including:
  • a mandatory, precinct-wide 3.30am closure 
  • a 1.30am lockout
  • from 10pm - no sale of shots, no sale of mixed drinks with more than 30mls of alcohol, no RTDs stronger than 5% alcohol by volume were permitted to be sold, and no more than 4 drinks were to be sold to any patron at one time
Some of the identified (and often quoted) benefits of the 'Newcastle Model' have included:
  • 33% fall in alcohol-related non domestic assaults, a 14 year low
  • 50% reduction in night time street crime
  • 26% reduction in related hospital ED admissions
So if it worked so well, why hasn't it been picked up and implemented across the country? Certainly the main reason is that the hotel and alcohol industries don't want it to happen. Over the past decade or so, there has been a general trend towards the liberalization of liquor licensing legislation across Australia, as well as a deregulation of the sale of alcohol. This has led to a substantial growth in the night-time economy (something governments don't want to lose - they can't afford to) and as the lobby groups fought hard to get these changes they certainly have no intention of losing some of what they have gained without a fight! And fight they have ...

NSW Premier Barry O'Farrell spoke to the media this morning and once again defended his government's stance on not implementing the 'Newcastle Model' in Kings Cross (and other places) by stating that making these changes would have no effect on the individual who got drunk before they went out onto the town and was simply looking for a fight ... and you know, he's absolutely right! But really, would a person who set out to cause trouble be as attracted to a place like the Cross if he knew that he couldn't buy shots after 10pm and that all venues in the area closed their doors at 3.30am? I believe, as do many others, they are less likely to find the area attractive - unfortunately, that's what the industry groups fear!

But to be completely honest, there are a range of other barriers (many completely new phenomenon that simply didn't exist 10-15 years ago) that also contribute to this problem that won't be affected by simply shutting shop early and we mustn't forget them ... Some of these include:
  • When it comes to alcohol promotion and marketing, we're now competing with supermarket chains – no-one knows how to market like they do and the retail alcohol market is worth $14 billion a year!
  • As much as we talk about alcohol being much cheaper than it once was, it really isn't (both beer and spirits have actually gone up in price, with only wine showing a dramatic decrease in cost over time), although in terms of affordability (i.e., how much are we actually earning now compared to the price) we can afford to buy more alcohol today than we could in the 80s. What we don't talk about is that now we are encouraged to buy alcohol in bulk, with huge discounts offered by the supermarket chains when you buy more ... people do not tend to stockpile alcohol for the most part. Buy in bulk, drink in bulk! 
  • Pre-loading, side-loading and post-loading are all new phenomenon identified across all ages - drinking before you go out is the norm today
  • And let's not forget the relationship between alcohol and sport - this is locked in tight! Play sport or watch it - drinking is usually sold as part of the experience
If you remember, one of the variables that contributed to alcohol-related violence was societal attitudes and values. We need to make change to the drinking environment (it's certainly the simplest of the four variables to implement) but if we don't try to make cultural change at the same time, we are not going to get anywhere ... One of my great frustrations over the past few days while listening to coverage about the issue is that everyone keeps talking only about the 'binge drinking' culture - I'll be the first one to support that but let's also not forget the 'glorification of violence' culture that is growing, particularly in sport. Footballers bashing each other in the head (with headlines like 'Lands two punches - still standing') and cricketers verbally abusing each other (some people are going to call me a 'wowser' here but really verbal abuse is just one step away from throwing a punch) and it is being justified and even celebrated by commentators and the public alike ... And let's not forget the Ultimate Fighting Championship (UFC) - if you truly want to be horrified, take a look at some of the videos on their website ...

So as an individual, and particularly a parent, what can you do in a simple way to start the process of cultural change? Here are my four simple tips:
  • Not everyone will choose to drink - and many of those who do, don't always drink a lot. Make sure to take a close look at your own drinking behaviour and try to identify the messages you're modelling …
  • Footballers are footballers – they aren't gladiators. This move towards the idea of a Roman arena that is heavily promoted, particularly in the NRL is dangerous. Young people need to be made aware that a punch on a football field is still violence and it can be deadly. It is not sport!
  • Most people who get punched do not get back up again without an injury - the violence we see on the TV, in movies or in video games does not reflect what really happens. I'm certainly not saying we should shield them from watching anything but having regular discussions about what they are seeing is vital ...
  • Most importantly, bullying is not acceptable in any form - talk about the consequences and make your values clear
When Thomas Kelly died last year I was quoted many times as saying that his would become the face of the alcohol-related violence issue and would result in some sort of change. I had no idea that we would have so many more faces to add to the list of those affected by this senseless violence in such a short period of time ... Of course it's a binge drinking issue and increasing the price of alcohol, reducing accessibility and removing alcohol advertising and sponsorship of sport will make a difference (Mr O'Farrell, you should be ashamed of yourself - implement the Newcastle Model, or at the very least, elements of it, in Kings Cross and other high risk areas!), but we also need to address other cultural issues or we will simply be wasting our time.

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