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Liquor legislation, last drinks, and lockouts: the Newcastle (Australia) solution

Liquor legislation, last drinks, and lockouts: the Newcastle (Australia) solution



International Journal of Oral & Maxillofacial Surgery, 2017-06-01, Volume 46, Issue 6, Pages 740-745, Copyright © 2017 International Association of Oral and Maxillofacial Surgeons


Abstract

The aim of this study was to determine whether the regional implementation of prohibitive liquor legislation, introduced in order to limit the sale of and access to alcohol, can lead to a sustained reduction in the incidence of assault occasioning facial injury, as seen in patients presenting to a level 1 trauma hospital. A retrospective observational cohort study was conducted to document patients who were identified as an acute hospital presentation of assault occasioning facial injury. The period of study was 2003–2015; this ensured a similar period of time before and after the implementation of the legislation in 2008. A statistical analysis was undertaken to assess the rates of change in oral and maxillofacial (OMF) assault admissions pre and post legislation. The study found that pre-legislation numbers of OMF assaults increased at a rate of 14% per annum and then decreased at a rate of 21% per annum post legislation (31% relative rate ratio reduction). Similar trends were seen for all males, males aged 18–35 years, and males where alcohol was recorded at clinical presentation. The introduction of ‘last drinks’ and ‘lock out’ legislation has led to a significant and sustained reduction in assaultive alcohol-related facial injury in Newcastle.

Licensed premises are popular night-time establishments that are particularly favoured by a young adult clientele. Pubs, bars, and nightclubs act as places for socializing, the provision of entertainment, and the sale and consumption of alcohol. Regrettably, it has been recognized that these venues also serve as high-risk settings for alcohol-fuelled violence and injury. It has been well reported that a large number of assaults occur inside or within close proximity to hotels, bars, and nightclubs.

Alcohol-related physical aggression is a pressing public health concern. It can frequently result in either a head injury and/or a facial injury. It is noteworthy, however, that the relationship between alcohol consumption and occasions of violent behaviour is confounded by the fact that the majority of people who consume alcohol do not become either offenders or victims of violent crime, while the consumption of alcohol does not universally act as a predisposition to the perpetration of violent acts.

Research has demonstrated that in any given region, a relatively small number of liquor outlets can be responsible for a disproportionally high number of alcohol-related episodes of trauma. Towards the end of the late twentieth century, there began to develop, in many countries around the world, an intense public outcry and government scrutiny in relation to the serving practices of and trading hours kept by alcohol outlets. This concern was typified by formal complaints about levels of violence, damage to person and property, and broader elements of antisocial behaviours that were perpetrated by some patrons. Of relevance to the present study were the events that culminated in the application of the ‘Newcastle solution’ of 2008.

Newcastle is the second largest city in the state of New South Wales, Australia. It is widely acknowledged as Australia’s seventh largest city, serving an immediate urban population of approximately 530,000 inhabitants, within a total regional population of 900,000. Notably, several licensed premises located in the central business district (CBD) of Newcastle were identified as having a high incidence of patrons who were involved in interpersonal violence. As a result, effective March 21, 2008, the New South Wales state government Liquor Administrative Board restricted the trading hours and conditions of service of alcohol to patrons of 14 pubs in the Newcastle CBD. In particular, close of business (last drinks) was reduced from 5 a.m. to 3 a.m. (and by subsequent negotiation to 3.30 a.m.) and the admission of new patrons (lockouts) was limited to 1 a.m. (and by subsequent negotiation to 1.30 a.m.).

The purpose of the present study was to determine whether the introduction of liquor legislation imposed to restrict opening hours (last drinks) and in turn control the sale of alcohol, as well as limit the admission of new patrons (lock outs), can lead to a sustained reduction in alcohol-related facial injury.

Materials and methods

Study design and setting

To address the research purpose, a retrospective cohort study was designed and implemented to measure the frequency of persons being assaulted and having a resultant facial injury that required hospital attendance.

The study population was derived from all maxillofacial trauma patients who attended the regional level 1 trauma hospital and who were assessed and/or managed by the Department of Maxillofacial Surgery for a facial injury. The study was conducted over a 13-year period from January 1, 2003 to December 31, 2015.

Participants

To be included in the study, patients had to have (1) presented acutely to the emergency department between the hours of 6 p.m. Friday and 6 a.m. Sunday; (2) been assessed and/or managed for a facial injury (hard or soft tissue) by the oral and maxillofacial surgery (OMFS) service; (3) alleged that they had been assaulted (as recorded in their hospital record). Two subgroup analyses were performed: (1) patients aged between 18 and 35 years; (2) patients who had sustained their injury under the influence of alcohol and/or as a result of attendance at a venue associated with the consumption or sale of alcohol.

Patients were excluded from the study if they had presented with any non-alcohol/non-assault-related cause of facial injury, or had attended the hospital outside the defined study hours.

Variables

The primary predictor variables that were selected for the study comprised a heterogeneous set of factors that were grouped into logical categories: demographic (age and sex), classification (assault), aetiology (alcohol), and year (in particular pre/post legislation). The primary outcome variable was the presentation of a hard and/or soft tissue maxillofacial injury.

Data sources and analysis

The relevant information was retrieved and downloaded from the hospital electronic patient administration system ‘i.PM’. This is a State Ministry of Health (New South Wales Health) approved and supported software system.

Patient data entered under ‘emergency department presentations’ were retrieved for the period 2003–2015. All facial trauma presentations assessed and/or managed by the OMFS discipline and within the study time frame were sought. In addition, presentation comments (alcohol, assault, time, age 18–35 years) were used to further define the patient cohort. Blood alcohol testing was not undertaken at the institution and could therefore not be included in this study. Instead, subjective (self) reporting or objective (clinician) documentation was relied upon.

Statistical methods

For each year, aggregate counts and percentages within the population for the entire time period were recorded.

Segmented regressions were fit to allow different estimates of the slope of the line for the pre- and post-intervention periods; negative binomial and Poisson distributions were assumed (as appropriate for count data). The models included terms for time prior to intervention (in years, zero in 2008 and in the post-intervention period), post intervention time (in years, this variable was zero during the pre-intervention period), and an indicator for the pre/post intervention period (interpreted as the immediate effect of the intervention). The regression coefficient for time since start of follow-up was interpreted as the pre-intervention period slope, and the coefficient for the post-intervention time was interpreted as the change in the slope. When exponentiated, these coefficients were interpreted as incident rate ratios (RR). Robust standard errors were used to account for any slight deviations from the distributional assumptions of dispersion and potential heteroscedasticity.

Within a few of the male sub-populations, negative binomial models did not converge, and so Poisson models were fit without robust standard errors. Due to the low number of admissions within the female sub-population, regression modelling was not possible.

Admission numbers were recorded over time as crude (raw) data for the pre- and post-intervention periods. In addition, both crude rates and estimated presentation counts (with 95% confidence intervals (CI), as calculated for each segmented regression), which took into account changes over time, were recorded graphically.

SAS version 9.4 software (SAS Institute Inc., Cary, NC, USA) was used for all analyses.

Ethics

The study was granted an exemption in writing by the Local Health District and Hospital Ethics Committee (Institutional Review Board). All patients were de-identified and all data treated anonymously in the undertaking of this study.

Results

A total 152 patient attendances for assault occasioning facial injury with acute presentation to the emergency department from Friday 6 p.m. to Sunday 6 a.m. occurred over the 13-year study period. Of these 152 patients, 144 were male and eight were female. With regard to age, the cohort was dominated by males aged 18–35 years ( n = 113, 74%). The numbers of admissions by year, as well as the percentages within each population, are shown in Table 1 .

Table 1
Number (%) of oral and maxillofacial admissions.
Year All Female Male Male 18–35 years old
All Alcohol recorded All Alcohol recorded All Alcohol recorded All Alcohol recorded
2003 9 (5.9) 0 0 0 9 (6.3) 0 8 (7.1) 0
2004 6 (3.9) 1 (1.6) 0 0 6 (4.2) 1 (1.7) 5 (4.4) 1 (2.2)
2005 13 (8.6) 5 (7.8) 0 0 13 (9.0) 5 (8.3) 10 (8.8) 4 (8.9)
2006 8 (5.3) 2 (3.1) 0 0 8 (5.6) 2 (3.3) 8 (7.1) 2 (4.4)
2007 18 (11.8) 10 (15.6) 0 0 18 (12.5) 10 (16.7) 13 (11.5) 7 (15.6)
2008 13 (8.6) 5 (7.8) 0 0 13 (9.0) 5 (8.3) 10 (8.8) 4 (8.9)
2009 20 (13.2) 6 (9.4) 1 (12.5) 1 (25.0) 19 (13.2) 5 (8.3) 14 (12.4) 3 (6.7)
2010 18 (11.8) 11 (17.2) 0 0 18 (12.5) 11 (18.3) 15 (13.3) 9 (20.0)
2011 16 (10.5) 11 (17.2) 3 (37.5) 1 (25.0) 13 (9.0) 10 (16.7) 10 (8.8) 7 (15.6)
2012 12 (7.9) 3 (4.7) 0 0 12 (8.3) 3 (5.0) 10 (8.8) 3 (6.7)
2013 7 (4.6) 1 (1.6) 2 (25.0) 0 5 (3.5) 1 (1.7) 4 (3.5) 1 (2.2)
2014 9 (5.9) 6 (9.4) 0 0 9 (6.3) 6 (10.0) 6 (5.3) 4 (8.9)
2015 3 (2.0) 3 (4.7) 2 (25.0) 2 (50.0) 1 (0.7) 1 (1.7)
Total 152 (100.0) 64 (100.0) 8 (100.0) 4 (100.0) 144 (100.0) 60 (100.0) 113 (100.0) 45 (100.0)

The rate of change (RR) per 1-year increase was calculated for the pre-intervention period and the post-intervention period and is outlined in Table 2 . The rates of change for the pre-intervention versus post-intervention periods were compared (relative RR), and the instantaneous change between the pre- and post-intervention slopes (ratio of the intercept for the pre-intervention slope and the post-intervention slope when year = 2008) was examined.

Table 2
Rates of change for oral and maxillofacial admissions.
Oral and maxillofacial admissions Period RR (95% CI) P -value
All Pre-intervention 1.14 (1.03–1.26) 0.0111
Post-intervention 0.79 (0.72–0.85) <0.0001
Difference (Post vs. Pre) 0.69 (0.60–0.79) <0.0001
Instantaneous change (Post vs. Pre) 1.87 (1.26–2.79) 0.0020
All, specified as alcohol-related Pre-intervention 1.57 (1.14–2.16) 0.0058
Post-intervention 0.83 (0.71–0.97) 0.0195
Difference (Post vs. Pre) 0.53 (0.37–0.75) 0.0004
Instantaneous change (Post vs. Pre) 1.26 (0.45–3.56) 0.6578
Male Pre-intervention 1.14 (0.99–1.32) 0.0696
Post-intervention 0.76 (0.67–0.86) <0.0001
Difference (Post vs. Pre) 0.67 (0.55–0.80) <0.0001
Instantaneous change (Post vs. Pre) 1.89 (1.06–3.35) 0.0298
Male, specified as alcohol-related Pre-intervention 1.59 (1.15–2.19) 0.0050
Post-intervention 0.79 (0.62–1.00) 0.0454
Difference (Post vs. Pre) 0.50 (0.33–0.74) 0.0006
Instantaneous change (Post vs. Pre) 1.32 (0.41–4.26) 0.6427
Male 18–35 years old Pre-intervention 1.11 (0.95–1.30) 0.2038
Post-intervention 0.80 (0.69–0.94) 0.0061
Difference (Post vs. Pre) 0.73 (0.58–0.91) 0.0046
Instantaneous change (Post vs. Pre) 1.72 (0.87–3.39) 0.1158
Male 18–35 years old, specified as alcohol-related Pre-intervention 1.47 (1.11–1.96) 0.0079
Post-intervention 0.86 (0.67–1.10) 0.2316
Difference (Post vs. Pre) 0.58 (0.40–0.85) 0.0053
Instantaneous change (Post vs. Pre) 1.15 (0.34–3.85) 0.8193
RR, rate ratio; CI, confidence interval.

From 2003 to 2008, the numbers of oral and maxillofacial admissions increased significantly, at a rate of 14% per year. From 2009 to 2015, the number of admissions decreased significantly, at a rate of 21% per year ( Fig. 1 a). These rates were found to be significantly different (RR 0.69, P ˂ 0.001; i.e. an approximate 31% relative RR reduction) and a significant change between estimated numbers for pre-intervention and post-intervention for 2008 (instantaneous change) was also seen (RR 1.87, P = 0.002).

Number of oral and maxillofacial admissions: (a) all patients; (b) all patients where alcohol was recorded; (c) males aged 18–35 years where alcohol was recorded.
Fig. 1
Number of oral and maxillofacial admissions: (a) all patients; (b) all patients where alcohol was recorded; (c) males aged 18–35 years where alcohol was recorded.

The rates of change for oral and maxillofacial admissions where alcohol was recorded were found to be significantly different pre and post intervention (57% increase per year, P = 0.006, and 17% decrease per year, P = 0.02, respectively; RR 0.53, P < 0.001) ( Fig. 1 b). The instantaneous change between the rates (pre vs. post at 2008) was found not to be significant (RR 1.26, P = 0.658).

Admission numbers for females were too small to compare trends over time. The rates of change for oral and maxillofacial admissions for all males were found to be significantly different pre and post intervention (14% increase per year, P = 0.07, and 24% decrease per year, P < 0.001, respectively; RR 0.67, P < 0.001). The instantaneous change between the rates (pre vs. post at 2008) was found not to be significant (RR 1.32, P = 0.643).

The rates of change for oral and maxillofacial admissions for males aged 18–35 years were found to be significantly different pre and post intervention (11% increase per year, P = 0.204, and 20% decrease per year, P = 0.006, respectively; RR 0.73, P = 0.005). The instantaneous change between the rates (pre vs. post at 2008) was found not to be significant (RR 1.72, P = 0.116).

The rates of change for oral and maxillofacial admissions for males aged 18–35 years where alcohol was recorded were found to be significantly different pre and post intervention (47% increase per year, P = 0.008, and 14% decrease per year, P = 0.232, respectively; RR 0.58, P = 0.005) ( Fig. 1 c). The instantaneous change between the rates (pre vs. post at 2008) was found not to be significant (RR 1.15, P = 0.819).

Discussion

This study identified, both statistically and clinically, a 31% relative rate reduction in alcohol-related facial injury in a cohort of patients who presented acutely to a level 1 trauma hospital following the introduction of local prohibitive liquor legislation. Similar trends were observed for all males, males aged 18–35 years, and males where alcohol was specifically recorded at the time of clinical presentation.

There were 2450 attendances for facial injury over the 13-year study period. One hundred and fifty-two (6.2%) of these fulfilled the study inclusion criteria. Remarkably similar percentages have been documented from periodic audit cycles of the hospital OMFS department, which have indicated that 6.3–7.0% of the facial trauma patient cohort sustained their injury at a bar, nightclub, or pub.

The literature supports the premise that the majority of assault victims who attend accident and emergency departments present with a facial injury, and that these are predominantly young men (72%) who have been drinking in a pub or club late at night.

To date, four significant epidemiological studies have investigated the effect that the Newcastle solution (restrictions on pub sales and closing times) has had on the incidence of assault. These studies have documented outcomes at 12 months, 18 months, 5 years, and 7 years, respectively, after the introduction of the legislation. Overall, the studies consistently concluded that there has been a 33% reduction in the incidence of assaults reported to the Regional New South Wales Police Force (Newcastle City local area command) and in turn recorded by the New South Wales Bureau of Crime Statistics and Research (BCSR-NSW).

Sydney is the capital of New South Wales, Australia, and has a resident population of 4.8 million (June 2014). On February 24, 2014, the same state government introduced a similar prohibitive legislative change to the liquor service in the Sydney CBD (‘party precinct’). In response to this initiative, Fulde et al. undertook a 2-year retrospective analysis of patients injured by serious assault (as well as major trauma, including vehicular, pedestrian, and falls), initially with reference to alcohol, and then with consideration to high alcohol time (HAT). The emergency department attendance data for St Vincent’s Hospital (serving the CBD catchment) suggested that there was an overall reduction in alcohol-related serious injury from 318 to 246 (22.6%) as a result of the intervention. This trend was further corroborated by the neurosurgical service of that hospital, which reported a 57% reduction in patients who had sustained an alcohol-related serious head injury, from 26 to 11. In keeping with these trends, the BCSR-NSW revealed a corresponding 32–40% drop in assaults across the Sydney CBD entertainment precinct.

Stockwell and Chikritzhs chronicled 13 international liberalization studies of alcohol trading hours and concluded that these were associated with a higher degree of alcohol-related harm. In contrast to such measures, licensing restrictions have been introduced by a number of authorities with the purpose of attempting to reduce the incidence of interpersonal violence and, in particular, those episodes that result in homicide. Two notable South American studies have both found that the legislated restriction of bar trading hours has been responsible for a statistically significant reduction in homicides occurring in or near these establishments.

There have been some attempts to profile the typical ‘weekend’ assault offender, commonly apprehended between 6 p.m. and 6 a.m. on Fridays and Saturdays. Those charged with assault occasioning bodily harm during these times are invariably males aged 18–25 years who have drunk a mixture of beer, wine, and spirits, ranging from 16 to 22 standard units and customarily consumed within a licensed premises. It has also been claimed that, in addition to these patron characteristics, the context of alcohol consumption makes some contribution to the prevalence of alcohol-related assault. Several studies have investigated the drinking environment that underpins alcohol-based assault and in particular the characteristics of what constitutes a ‘bad bar’ and a ‘permissive decorum’.

The World Health Organization in association with the Centre for Public Health at John Moores University in Liverpool, UK, published a monograph in 2009 to consider the strategies that can be delivered in “Preventing violence by reducing the availability and harmful use of alcohol”.

In addition to the restriction of the hours per day that alcohol is available for sale, the literature has also shown that measures to reduce the number of serving outlets or to increase the prices of or taxes on alcoholic beverages have also been successful in curbing violence.

Well-established research in the OMFS field has demonstrated a relationship between the excessive consumption of alcohol, the occurrence of interpersonal violence, and the presentation of a facial injury. Typical of the published works is the investigation that was undertaken by Lee and Snape. Their study considered the role that alcohol plays in relation to the occurrence of facial fracture. Significantly, nearly 50% of their study cohort had an alcohol-related presentation. Of these, 78% were due to alcohol-precipitated episodes of interpersonal violence, typically being perpetrated by males aged 15–29 years. Similar conclusions have been reported in studies undertaken in the UK.

A strength of the present study is that the observations regarding liquor prohibition in Newcastle were linked to hospital health care data, unlike previously published epidemiological studies, which have made no such attempt. The study hospital is the tertiary referral (level 1) trauma hospital for the city of Newcastle and captures all public, as well as a significant proportion of private, facially injured patients. The OMFS service deals almost exclusively with the assessment and management of all facial injuries in the region (although it shares fractured noses with the otorhinolaryngology–head and neck service).

A weakness of this study is that it was not possible to successfully restrict for post code (zip code) 2300 (for Newcastle) and 2303 (for Hamilton, as a control). However, it is reasonably assumed that the Newcastle CBD is the ‘party precinct’ for Friday and Saturday night alcohol-based venues and entertainment for 18–35-year-olds. Furthermore, it is acknowledged that some patients who sustained injuries during the study period may not have attended hospital acutely (or at all) and that some patients may have been treated privately; some of these data may not have been available to the authors. The data also exclude those requiring non-surgical (conservative) management, as well as those managed under local anaesthetic (not admitted) and those managed under local anaesthetic in the intensive care unit (perhaps in association with a sustained head injury). In addition, it is unknown whether this information is translatable to other associated episodes of (alcohol-based) interpersonal violence, which for example may result in head injury (neurosurgery service) or hand injury (hand surgery service), although this is clearly an area for further study. Further investigation is also required in relation to the effects of geographic displacement of violence, alcohol ‘pre-loading’, and the potential associations with illicit substance abuse.

Irrespective of these acknowledged concerns, the lack of inclusion of such data would tend to bias the results presented to the null, and in turn would make the significant results found in this study more robust.

In conclusion, this study favourably linked previous epidemiological observations (which have upheld the success of the Newcastle solution) to the local tertiary referral hospital health care data. The implementation of ‘last drinks’ and ‘lockout’ strategies supports the contention that such legislation can result in a significant and sustained reduction in assaultive alcohol-related facial injury and moreover may have implications on a wider international basis.

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