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ARCHIVED - WHO Facts on Alcohol and Violence: Youth violence and alcohol

WHO Facts on Alcohol and Violence: Youth violence and alcohol

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Harmful and HazardousFootnote 1 alcohol use are risk factors both for being victimized and perpetrating youth violence.Footnote 2 Youth violence takes many forms including bullying, gang violence, sexual aggression, and assaults occurring in streets, bars and nightclubs. The victims and perpetrators alike are young people, and the consequences of youth violence can be devastating. Across the world an average of 565 young people aged 10 to 29 die every day through interpersonal violence, with males at greater risk, and for each death there are an estimated 20 to 40 youth that require hospital treatment for a violence-related injury (1). The impact of youth violence reaches all sectors of society, placing huge strains on public services and damaging communities. Reducing harmful alcohol use and violence among young people should thus be considered a priority for policy makers and practitioners across a broad range of agencies, with public health professionals having a key role in leading partnerships and prevention. This fact sheet summarizes the role of alcohol in youth violence, the magnitude of the problem, risk factors for involvement in alcohol-related youth violence, prevention measures and the role of public health.

Links between alcohol and violence affecting young people

Box 1 : Gang violence

Youth gangs exist throughout the world and are frequently associated with violence. In Bremen (Germany), for example, youth gangs commit almost half of all police-reported violent offences (1). While most gangs comprise young males, for both sexes gang involvement is associated with higher levels of violence and alcohol use (e.g. Caribbean countries [15]). Qualitative research in the US found alcohol to be a central part of gang culture and to be strongly linked to violence. For example, fights between gang members erupted after drinking; alcohol was used prior to fights to build confidence; alcohol use occurred after fights as a seal of gang unity, and alcohol and violence were linked ritualistically during gang initiation processes (6).

Magnitude of alcohol-related youth violence

At a global level, uniform data for cross-national comparisons of youth alcohol consumption are scarce. However, a range of international and regional surveys (e.g. World Health Survey [16], WHO global school-based student health survey [17], the European Schools Survey on Alcohol and Other Drugs [18]) show levels and patterns of alcohol consumption vary widely between countries. Thus, the World Health Survey shows abstinence rates among 18-24 year olds to range from 6.7% in Latvia to 98.6% in the Comoros, with the percentage of heavy episodic drinkersFootnote 3  ranging from 0.2% in Lebanon and Malaysia to 20.1% in the Czech Republic (16). Particularly in the WHO European Region and the WHO Region of the Americas, young adults (aged 18-24) are more likely to engage in heavy episodic drinking than the general adult population (e.g. Brazil, Czech Republic, Spain, Dominican Republic [16]). Increasing consumption among young people elsewhere (e.g. Israel [19], Philippines [20]), is raising concerns that a youth culture of excessive drinking is spreading internationally. Further, while in most countries heavy episodic drinking is more common in males, alcohol consumption by females is increasing and in some countries heavy episodic drinking is now reported more by girls than boys (e.g. Australia, age 14-19; Lithuania, age 15-16 [16]).

Levels of youth violence also vary widely between countries. Mortality rates from homicide among 10-29 year olds range from 84.4 per 100 000 population (156.3 for males and 11.9 for females) in Colombia to less than 1 per 100 000 (males and females) in Japan and France (1). Globally, across all age groups, alcohol is estimated to be responsible for 26% and 16% of years of life lost through homicide by males and females respectivelyFootnote 4. This ranges from 18% for males and 12% for females in high mortality developing countriesFootnote 5 (where there is high mortality from other causes such as disease and famine) to 41% and 32% respectively in developed countriesFootnote 6 (16). While non-fatal violence is more difficult to measure cross-nationally, studies conducted in numerous countries identify links between non-fatal youth violence and harmful alcohol consumption by both perpetrators and victims. Findings include:

Risk factors for alcohol-related youth violence

A wide range of factors have been identified that increase young people's risks of becoming both victims and perpetrators of youth violence (see Box 2). While alcohol use is itself a risk factor for involvement in youth violence, many studies (mostly in developed countries) have specifically examined alcohol-related violence and its associated risk factors.

Males are more likely than females to be both perpetrators and victims of alcohol-related youth violence (23,25). However, in some countries harmful alcohol consumption has been associated with disproportionate increases in levels of violent behaviour among girls (e.g. Israel [21], Caribbean countries [15]), despite their overall levels of alcohol and violence being generally lower than male counterparts. Within the youth age category, levels of alcohol-involvement in violence increase with age throughout adolescence (e.g. Finland [22]), with recent experience of alco- hol-related violence peaking within the late teenage years and early twenties (16-19 year olds in England and Wales [26], 20-24 year olds in Australia [27]). Other factors that have been associated with increased risk of involvement in alcohol-related violence include low educational attainment (28), low college expectations (29), emotional distress in adolescence (30), involvement in other forms of antisocial behaviour, having delinquent (23) or alcohol-drinking (31) peers, and high levels of aggression-facil- itating personality characteristics (e.g. hostility and anger) (32).

Box 2: Risk factors for youth violence

Individual factors

Relationship factors

Community and societal
factors

Krug et al. 2002 (1)

Associations between alcohol and violence can also vary within societies by ethnicity. In the United States stronger links have been found between alcohol and fight- ing among Mexican-American youths than non-Hispanic White youths (33). In Israel, the relationship between alcohol consumption and being a perpetrator of bullying is stronger among Jewish youths, yet the relationship between alcohol and both being injured in a fight and carrying weapons is greater among Arab youths (21).

Levels of alcohol consumption among young people are strongly related to their risk of violence, with those who start drinking at an earlier age, drink frequently and drink large quantities at increased risk of being both perpetrators and victims (29,34,35,36). Research among schoolchildren in Switzerland found that having been drunk more than once was positively associated with perpetration of bullying and violence, yet reduced the risks of being a victim of bullying, particularly amongst socially integrated individuals (37).

Risks of committing alcohol-related violence are also affected by societal and individual beliefs about the effects of alcohol. Stronger links between alcohol and violence are seen in societies where alcohol is less integrated into daily life (38) and in individuals who expect alcohol to increase aggression (32). Much alcohol-related violence occurs at night, particularly at weekends (39), and often takes place in and around drinking venues (Box 3). Venue characteristics associated with a greater likelihood of violent behaviour include: low comfort levels (e.g. crowded, lacking seating and ventilation, hot and noisy); unattractive and poorly maintained premises; offer discounted alcoholic drinks; employ aggressive door supervisors; have a high proportion of intoxicated patrons, and have a permissive attitude towards anti-social behaviour (e.g. serving underage or drunk customers and allowing swearing and overt sexual activity) (8,40,41). Greater concentration of drinking establishments in an area is also associated with increased prevalence of violence (42).

Box 3: Alcohol and youth violence in bars

Qualitative studies have found that alcohol-related violence in bars and clubs is often reactive, triggered by events such as a split drink or an advance by one person towards another's sexual partner (43,44). Young men explain their aggressive responses to these events as necessary for defending their honour and retaining the respect of their peers; however fighting for fun is also a common reason given for initiating violence (45). Among young males participating in such violence, alcohol is believed to facilitate aggression by increasing confidence and willingness to take risks, making people more aroused and emotional, and reducing their ability to consider the consequences of their behaviour (44,45).

Impact

The consequences of youth violence are far reaching, affecting the health and well being of victims, relationships with family and friends, levels of fear within communities, and pressure on health and other public services. For victims, alcohol-related violence can be more likely to result in physical injury (22), with alcohol consumption often leading to more severe injury (46). In Wales, 72% of assault patients presenting at an Accident and Emergency department at weekend nights had some form of facial injury (47), while across the United Kingdom 8% of facial injuries sustained in assaults were inflicted with the paraphernalia of alcohol use (i.e. the use of glasses and bottles as weapons [46]). Such injuries can cause permanent scarring and emotional and psychological trauma (48). Further, victims of violence during adolescence report higher levels of alcohol consumption in later life (7). For perpetrators of alcohol-related violence, judicial penalties can also affect future prospects in terms of education and employment (49).

Health and criminal justice surveys frequently show young people to account for the largest proportion of treatment demands and criminal justice responses for alcohol-related violence (e.g. Norway [50], the USA [51]), with substantial economic costs. In the United States, the costs of violent crime related to harmful alcohol use among youth were estimated at US$ 29 billion in 1996 (1998 prices [52]). In England and Wales, violent crime is estimated to cost £24.4 billion annually (approximately US$ 44 billion; including medical treatment, criminal justice, lost earnings and physical and emotional costs to victims [53]). Half of this violence is alcohol-related and half is committed by youths aged 16-24 (54).

Prevention

A range of prevention programmes targeting parents and children from infancy to adolescence have shown success in reducing youth violence, with most research conducted in high-income countries. Such programmes include: pre- and post-natal services; home visiting during infancy; parenting skills training; social development training for children, adolescents and gang members, and family therapy (1). In at least some cases (e.g. home visiting [55]), such programmes can also reduce future levels of alcohol consumption among young people.

Specifically for alcohol-related violence, interventions addressing access to alcohol can reduce both consumption levels and violence. Research in the United States indicates that increased alcohol prices through higher taxation can reduce the frequency of drinking and the chance of heavy alcohol consumption among young people (56). In the United States it has also been estimated that a ten percent increase in beer price would reduce the number of college students involved in violence by 4% (57). In Brazil (Diadema) the prohibition of alcohol sales after 23:00 helped prevent an estimated 273 murders (all ages) over a two year period (58); in Australia, extended licensing hours in public houses were associated with increased alcohol consumption and violence (59). Legislation on the minimum legal age of alcohol purchase can reduce access to alcohol for young people, and where such laws exist minimum ages range from 15 (e.g. the Republic of Slovenia) to 21 (e.g. the United States). While illegal underage sales can be common (60), they can be reduced through server training programmes and strict enforcement of age of purchase legislation (61) (e.g. test purchasing and penalties including license revocation). Few studies have measured the effectiveness of such interventions on violence and most research has been conducted in the United States. Restricting access to alcohol for underage youths in parts of the United States reduced disorderly conduct violations among 15-17 year olds (62).

Research in the United States has also found some evidence that programmes which alter social norms (i.e. correct misperceptions of peer drinking habits) can reduce harmful alcohol consumption levels among college students (63), and thus may be useful in reducing alcohol-related violence. At the individual level, alcohol consumption among those at risk of alcohol-related violence can be reduced through brief interventions. One intervention targeted at young males with alcohol-related facial injuries in an oral and maxillofacial surgery department resulted in significant reductions in consumption (65). Further, brief interventions delivered to male violent offenders in a criminal justice setting (magistrates' court), reduced participants' risks of injury through assault in the following year (as measured Accident and Emergency Department presentations) yet had no effect on re-offending (66).

Modifying drinking settings can also impact alcohol-related youth violence. For example, improving management and staff practice through training programmes (67), implementing codes of good practice, and strictly enforcing licencing legislation (68) creates environments less conductive to violence. In wider nighttime environments, the presence of large numbers of intoxicated individuals at the end of the night increases potential for violent confrontations (69). Here interventions such as provision of safe late-night transport (68), improvements to street lighting (70) and use of closed circuit television (71) have been shown to help reduce alcohol-related violence around licenced premises. Judicial interventions can also be used to deter individuals from anti-social behaviour, such as the use of fines for low-level alcohol-related offences (e.g. public drunkenness) and banning orders preventing offenders of alcohol-related aggression accessing drinking venues. However the effectiveness of such interventions has not been fully assessed.

Interventions that involve collaboration between different sectors and groups to implement an integrated package of prevention measures have successfully reduced alcohol-related violence in both high-income and low- to middle-income countries (Box 4). In some low- and middle-income countries, single-sector interventions such as legislation on the legal minimum age for purchase of alcohol, and efforts to strengthen and expand the licencing of liquor outlets could be of great value in reducing alcohol-related youth violence. For example, there is no legal minimum age of sale for alcohol in the People's Republic of China or the Republic of Gambia, and in the Republic of South Africa it is estimated that 80-90% of liquor outlets are unlicensed. Further, in many low- to middle-income societies a large proportion of alcohol consumed is produced at home, meaning strategies to increase alcohol price may be less effective and may switch drinkers to cheaper home produce (74). More research is needed in low- to middle- income countries to identify successful interventions for tackling alcohol-related violence and to examine opportunities to regulate production and sale.

Box 4: Multi-component programmes

The DESEPAZ programme in Colombia

In response to increasing levels of violence in the city of Cali, the Mayor led the development of the DESEPAZ programme, comprising a partnership of demobilized guerrillas, labour union representatives, church members and private sector leaders. This involved the development of an accurate information system for measuring violence and a wide range of measures to: improve law enforcement (including education and training for police); increase communication between citizens and law enforcement agencies; and improve education and employment for residents and particularly high-risk youths. Recognising the important role of alcohol in violence, alcohol sales were restricted with closing times imposed on bars and nightclubs. Both hospitals and traffic authorities reported reductions in injuries following this intervention (72).

The Queensland Safety Action Projects in Australia

The Safety Action Projects targeted aggression and violence in nightclubs and nightlife areas in three Australian cities (Cairns, Townsville and MacKay). The projects focused resources at three levels: improving state regulation; developing a mechanism for community support of regulation, and facilitating self-regulation among bar and club management. Interventions within this included strict enforcement of legislation by licencing authorities and police; development of community forums and task forces regarding nightlife issues; conducting risk assessments at drinking venues, and implementing codes of practice. The intervention led to observed reductions in arguments (28%), verbal abuse (60%) and threats (41%) in drinking premises. The changes within drinking venues that were most associated with reductions were: improved comfort (e.g. availability of seating), increased public transport, less overt sexual activity and fewer highly drunk men (68).

The role of public health

The public health approach to violence prevention uses a wide range of data and research to provide a better understanding of the extent, causes and risks of violence and to implement effective interventions through collective action. For alcohol-related youth violence, priorities for public health include:

Policy

Both the harmful and hazardous use of alcohol and violence have been recognized internationally as key public health issues requiring urgent attention. At both national and international levels, health organizations have a key role in advocating for policies that address the relationships between alcohol use and violence and in doing so promote prevention initiatives that will improve public health. The World Health Organization (WHO) runs comprehensive programmes on both issues to instigate and conduct research, identify effective prevention measures, and promote action by Member States to implement successful interventions and align policy towards reducing hazardous and harmful drinking and violence.

For alcohol, this includes collating and disseminating scientific information on alcohol consumption, developing global and regional research and policy initiatives on alcohol, supporting countries in increasing national capacity for monitoring alcohol consumption and related harm, and promoting prevention, early identification and management of alcohol use disorders in primary health care (75). A World Health Assembly resolution on Public health problems caused by harmful use of alcohol (WHA58.26 [76]) of 2005 recognizes the health and social consequences associated with harmful alcohol use and requests Member States to develop, implement and evaluate effective strategies for reducing such harms, while calling on WHO to provide support to Member States in monitoring alcohol-related harm, implementing and evaluating effective strategies and programmes, and to reinforce the scientific evidence on effectiveness of policies.

For violence, this includes the WHO Global Campaign for Violence Prevention. Launched in 2002, the Campaign aims to raise international awareness about the problem of violence (including youth violence), highlight the role of public health in its prevention, and increase violence prevention activities globally, regionally and nationally. The approach to preventing violence is set out in the WHO World report on violence and health (1). World Health Assembly resolution WHA56.24 (77), of 2003 encourages Member States to implement the recommendations set out in the report, and calls on the Secretariat to cooperate with Member States in establishing science-based public health policies and programmes for the implementation of measures to prevent violence and to mitigate its consequences. Complementary to this, the Violence Prevention Alliance has been established to provide a forum for the exchange of best practice information between governments and other agencies working to reduce violence around the world.

For further information please consult:

www.who.int/violence_injury_prevention
www.who.int/substance_abuse/en
www.who.int/substance_abuse/terminology/who_lexicon/en

Or contact:

Department of Injuries and Violence Prevention
Dr Alexander Butchart (butcharta@who.int,
fax: + 41-22-791-4332, telephone + 41-22-791-4001)

Department of Mental Health and Substance Abuse
Dr Vladimir Poznyak, (poznyak@who.int, fax + 41-22-791-4160,
telephone + 41-22-791-4307)

World Health Organization
20 Avenue Appia
CH-1211 Geneva 27,
Switzerland

John moore university, Centre for Public Health
Prof mark Bellis (m.a.bellis@livjm.ac.uk,
fax + 44-(0)-151-231-4515, telephone + 44-(0)-151-231-4511)
Centre for Public Health
Liverpool L3 2AV
UK

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2023-06-07