Alcohol, Violence and Injuries: The view from Accident and Emergency Departments

Hutchinson, I.L., Magennis, P., Shepherd, J.P. and Brown, A.E. (1998) ‘BAOMs United Kingdom Survey of Facial Injuries, Pt. 1: Aetiology and the Association with Alcohol Consumption’, British Journal of Maxillofacial Surgery, Vol. 36, pp 3-13.
Aims: To determine the age and sex distribution, timing, causes, geographical location, and nature of facial injuries in the UK and to determine the association of these factors with alcohol consumption by the patient or any other involved person. Design - A 12-section proforma was completed on all patients with facial injuries covering their age and sex, time and day of injury and presentation, the cause and type of injury and where it occurred, the treatment the patient received, any other injuries, and alcohol consumption by the patient and any other involved person. The total attendances for the study week and the catchment population for each A&E department were recorded. Setting - 163 of the A&E departments in the UK served by 137 of the UK's oral and maxillofacial departments. Subjects - All patients who presented with facial injuries to these 163 A&E departments in England, Scotland, Wales and Northern Ireland over the study week from 09.00 hours on Friday 12 September 1997 to 08.59 hours on Friday 19th September 1997. Results - 6114 patients with facial injuries presented over the week, out of a total of 152 692 A&E attendances. The male:female ratio was 68:32. This rose to 79:21 in assault cases. The mean age of all patients was 25.3 years, of males 23.2 years, and of females 29.8 years. Forty per cent of the facial injuries were caused by falls. A large proportion of these happened to the under-5 age group in the home. Eleven per cent of all falls were associated with alcohol consumption. Twenty-four per cent of the facial injuries were caused by assault. The commonest sites for assault were the street followed by public drinking establishments. More women than men were assaulted at home. Fifty-five per cent of assaults were related to alcohol consumption. Eight per cent of assaults were with bottles or glasses. Five per cent of the facial injuries occurred in road traffic accidents (RTAs). Fifteen per cent of RTA victims had consumed alcohol. The 15-25 age group suffered the greatest number of facial injuries caused by assault and RTAs and had the highest number associated with alcohol consumption. At least 22% of all the facial injuries in all age groups were related to alcohol consumption within 4 hours of the injury. In the over 15 age groups, alcohol consumption was associated with 90% of facial injuries occurring in bars, 45% on the street, and 25% in the home. Assault, RTA and alcohol consumption conveyed an increased risk of serious facial injury. Conclusions - Campaigns should be instituted to educate young people about the link between excessive alcohol consumption, assault, road traffic accidents and serious facial injury.

Langley, J., Chalmers, D. and Fanslow, J. (1996) “Incidents of Death and Hospitalisation from Assault Occurring In and Around Licensed Premises: A Comparative Analysis” Addiction, Vol. 91, No. 7, pp 985-93.

Macdonald, S, Cherpiter, C, Borges, G, Desouza, A, Giesbrecht, N and Stockwell, T (2005) “The criteria for causation of alcohol in violent injuries based on emergency room data from six countries”, Addictive Behaviours, Vol. 30 (1) pp. 103-113.
This paper is based on data using similar methods collected from patients at 30 emergency rooms (ERs) in six countries. These data were analyzed with the goal of determining whether alcohol is a likely cause of violence through an application of criteria outlined by Bradford Hill [Proc. R. Soc. Med. 58 (1966) 295]. Analyses were conducted by comparing various measures of alcohol involvement in violent versus accidental injuries. The results supported temporal sequence of events and specificity. The odds ratios of violent versus accidental injury for a blood alcohol concentration (BAC) over 80 mg% were significant for each country, ranging from 2.77 for Mexico to 9.45 for Canada, which supports both the strength of associations and the consistency of findings. No third variables were found from the logistic regression analysis that better explain the relationships between alcohol and violence. A significant dose--response relationship between BAC level and violence was also found. All analyses conducted point to a causal role of alcohol in injuries related to violence.

Shepherd, J. (1994) “Violence crime: The role of alcohol and new approaches to the prevention of injury” Alcohol & Alcoholism 29(1), pp 5-10
Almost all evidence of a link between alcohol consumption and violence is available only in the form of aggregate data. This is unsatisfactory and case-control investigations and studies which relate injury severity to blood alcohol levels are needed. In the few closely controlled studies which have been performed, increased risk of injury in assault has been linked with binge consumption of more than about 8 units, and above average weekly consumption only in those over 25 years. Raising the minimum purchasing age for alcohol to 21 years, learning to drink responsibly with parents, especially fathers, and the adoption of tempered glassware are all achievable objectives which would reduced alcohol-related injury. The use of sobriety-checkpoints (breath testing though not by the police) and other situational prevention programmes need to be evaluated in relation to reducing injury sustained in violet crime. Proactive, community policing has been shown to reduce levels of alcohol-related violent crime, in contrast to more reactive, defensive and confrontational policing. The concept of ‘capable guardianship’ to establish and maintain social control of young delinquents needs to be extended, particularly near known foci of violence such as bars and adjacent fast-food outlets and taxi-ranks.

Shepherd, J.P. and Brickley, M.R. (1996) “The Relationship Between Alcohol Intoxication Stressors and Injury in Urban Violence”, British Journal of Criminology, Vol. 36, No. 4, pp 546-566.
The relationships between alcohol consumption and intoxication, stressors and injury in urban violence were investigated in parallel case control and cohort studies of injured people presenting at a large Accident and Emergency Department. Alcohol intoxication and consumption were assessed using the breath analysis and diary method stressors were assessed using the Holmes and Rahle Life Style Score for the periods up to one week; more than one week but less than one month; more than one month but less than one year; and more than a year prior to injury, and injury severity was calculated by means of four injury severity indices. The Glasgow Coma Score was recorded as a measure of the effect of alcohol on brain function. Cases could not be differentiated from controls on the basis of experience of major life events or minor stressors in the period prior to injury, or on the basis of age, employment status, social Glass or the types of relationship formed with peers or sexual partners. Cases drank more during an average weekend than controls, drank more on each weekend drinking session than controls, and were more likely to binge drink (consume more than ten units) compared to controls. Consumption of more than ten units of alcohol in the six hours prior to assault and blood alcohol levels of greater than 160 mgm per 100 mi were associated with injury. A predominance of facial injuries was found. While blood alcohol concentration and injury severity were significantly related to levels of alcohol consciousness, there was no significant relationship between injury severity and blood alcohol concentrations. The results of this study suggest that heavy binge drinking increases vulnerability to injury.

Warburton AL, Shepherd JP (2006) “Tackling Alcohol Related Violence in City Centres: Effect of Emergency Medicine and Police Intervention, Emergency Medicine Journal, January, 23 (1),
To identify correlates of alcohol related assault injury in the city centre of a European capital city, with particular reference to emergency department (ED) and police interventions, and number and capacity of licensed premises. Marked decreases in licensed premises assaults resulting from targeted policing were enhanced by the intervention of ED and maxillofacial consultants. Capacity of licensed premises was a major predictor of assaults in the city centre street in which they are clustered. City centre assault injury prevention can be achieved through police/ED interventions targeted at high risk licensed premises, which should also target the streets around which these premises are clustered.