Pp. 863-873 in Philip Kolvin, ed., Licensed Premises: Law and Practice.  Haywards Heath, West Sussex, UK: Tottel Publishing, 2004.





Robin Room

Centre for Social Research on Alcohol and Drugs

Stockholm University, Sveaplan

106 91 Stockholm, Sweden



            Alcoholic beverages have been known to humankind for all of recorded history, and even before the European expansion of the last half-millenium fermented beverages were used in all parts of the world except Australia, Oceania, and north America north of Mexico.  Distilled spirits, invented in China and coming to Europe through Arabia, only escaped from the medicine chest into mundane use about 500 years ago, and came into use throughout the world as part of the European expansion.  In traditional societies, alcoholic beverages were often relatively expensive to make, in terms of time and resources. With the industrial production of alcoholic beverages, in an early stage of the industrial revolution, alcoholic beverages became progressively cheaper in relative terms.  In the absence of controls, the result was often an extended societal binge, as in the gin craze in 18th-century England (Warner, 2002; Dillon, 2003).


Consequences of drinking

            Recognition that drinking can bring pain and harm, as well as pleasure, also extends through recorded history.  The spectrum of harms from drinking is broad, affecting public health, safety, welfare, and productivity.  Alongside private and informal responses, governments have taken a wide spectrum of measures to reduce the harms from drinking.   Such measures have often included laws regulating public drinking places, which can be found already in the Code of Hammurabi 3800 years ago (Babor et al., 2003:117). 

In public health terminology, regulation of the production and sale of alcohol is often referred to as alcohol control (Room, 1984), by which is meant all regulation of the extent and conditions of alcohol availability, including a variety of measures such as excise taxation, licensing of premises and servers, and regulation of circumstances of sale such as permitted opening hours and days.

In the frame of public health and safety, alcohol policymaking starts from a consideration of the extent of and trends in problems related to drinking.  These include social problems as well as health problems, and acute problems as well as chronic. Considering only the health consequences, and after subtracting out protective effects on the heart, the World Health Organization’s study of the Global Burden of Disease in 2000 found that alcohol is the third most important risk factor for death and disability in developed societies such as the United Kingdom (Ezzati et al., 2002).   Two recent publications have brought together what evidence there is on problems from drinking for the United Kingdom (UK Cabinet Office, 2003; Academy of Medical Sciences, 2004).  For instance, it is estimated that alcohol accounts for up to 150,000 hospital admissions each year attributable to acute or chronic alcohol use, and up to one-third of Accident and Emergency (A&E) visits.  About 2.9 million British adults are reckoned to be dependent on alcohol.  47% of victims of violence in the British Crime Survey believed that their victim was under the influence of alcohol.  Between 30% and 60% of child protection cases involve drinking in the family.  From the limited data available, the levels of harm from drinking seem to be increasing.  Between 1970 and 2000, for instance, deaths between the ages of 25 and 64 from chronic liver disease, a great majority of which involve heavy drinking, have risen by 466%. Considered in terms of health and social service resources consumed by responding to alcohol problems, emphasis is often put on the burden on health services, which is certainly substantial.  But a Scottish study found that the health care costs accounted for only 21% of government service costs, with social work services accounting for 19% and criminal justices and fire services for 60% (calculated from Catalyst, 2001).


The relation of drinking levels and patterns to consequences: the individual and the population level

Both the level of drinking over time and the pattern of drinking affect the risks for the individual drinker. The contribution of different aspects of drinking varies for different consequences.  Thus risks of problems such as injuries and overdose deaths are primarily depend on drinking on a particular occasion. On the other hand, risks of liver cirrhosis or gastritis or other chronic health consequences of drinking reflect levels of drinking over time.  A pattern of relatively frequent light drinking seems to be protective for heart disease for those who are middle-aged or older.  Most of this benefit can be gained by drinking as little as one drink every second day. On the other hand, a pattern of recurrent bouts of heavy drinking seems to be bad for the heart (Britton & McKee, 2000).

In recent years, it has become more clearly recognized that these patterns as described at the individual level are only part of the picture when the effect of alcohol consumption on the population as a whole is considered.  First, many of the problems from drinking do not occur to the drinker (Room, 1996).  Drinking-driving potentially affects other drivers, passengers and pedestrians.  Alcohol-fueled violence may hurt family members, acquaintances or strangers.  Time and resources spent out drinking may adversely affect children’s upbringing and the quality of family life.   Second, amounts of drinking in the population are heavily skewed, with less than 20% of the drinkers typically responsible for more than half of the consumption (Greenfield & Rogers, 1999).  What happens among the heavier drinkers may have a disproportionate influence on consequences.  Third, in thinking about the population as a whole there is a need to take into account that drinking is primarily a social behaviour.  How I drink today is likely to affect how you drink today or tomorrow.  If I buy you a round as part of a group at the pub, my expectation is that you will sooner or later buy one for me – and drink another one for yourself at the same time.  If I bring a bottle of wine to your dinner-party, the chances are you will bring one to mine the next time.  So there is a tendency for changes in drinking in a population to be linked.  The result of these three factors is that the risk levels based on individual-level data are not always a good guide to what will happen in the population as a whole as the amount of drinking changes (Skog, 1996).

For many chronic health consequences of drinking, such as liver cirrhosis, what seems to matter most at the population level, in predicting cirrhosis mortality in a given year, is the level of drinking in the previous few years.  For drink driving and violence, the dominant patterns of drinking in a population – how much of the consumption leads to intoxication – affects the rate of harm.  But customary drinking patterns in a population change only slowly over time (Simpura, 2001). Thus, while dominant patterns of drinking matter for comparisons of one drinking culture with another, they do not make much difference in comparisons over time within a given population.  In a given society, it seems that changes in rates of injuries track quite closely changes in the population’s overall level of consumption (Norström, 2002). 

For the middle-aged or older individual, the heart-protective effect is a relevant consideration in choices about drinking.  But the effect is apparently not important for alcohol policy and controls.  At the levels of drinking which are current in Britain and western Europe, a change in the population’s level of drinking does not affect the rates of heart disease mortality (Hemström, 2001).  It seems that any gains for those adopting protective drinking patterns are offset by losses for those who change to patterns more risky for the heart (Skog, 1996).

The conclusion is that, at the population level, both the level of consumption and the dominant patterns of drinking matter for problems from drinking.  In terms of patterns, an extra litre of alcohol per capita will have a greater effect on homicide, for instance, in northern Europe than in southern Europe.  But it is difficult to find examples of successful purposive efforts to change a population’s overall patterns of drinking (Room, 1991), although around drinking-driving seem to be an exception.  At a more micro level, this generally pessimistic conclusion is supported by the general failure of school education or public information campaigns to show lasting results (Babor et al., 2003; Foxcroft et al., 2003). This leaves governments with three main effective strategies for reducing the rates of problems in the population: reducing the level of drinking; reducing or eliminating drinking in specific risk situations, notably in connection with driving; and reducing the risk from drinking in specific situations, for instance by changing the environment of drinking.


The warrant for alcohol controls

It may well be asked, what warrant does a government have for acting to reduce rates of alcohol problems in the population?  Views differ, for instance, on whether and to what extent it is appropriate for a government to intervene to prevent suicide or other actions impacting primarily on the actor him- or herself.  Even for effects which are limited to the actor, however, society at large has an interest in what happens where there are health or welfare costs for society from the actions.  Beyond this, many problems from alcohol involve effects on others than the drinker.  In the case of such effects, there is wide social consensus that there is a warrant for action, including as needed governmental action.  There is no accurate accounting of the harm to others brought by drinking, but it is clearly very substantial.  As noted above, it includes very serious harms such as homicide, domestic violence and drink-driving casualties, but also a more broader penumbra of personal conflict and infringement and disturbance of the peace.  In a Canadian study, 45% of the population reported that they had experienced a problem as a result of someone else’s drinking in the preceding year.  This included 26% who had been disturbed by loud parties or the behaviour of people drinking, 21% who had been insulted or humiliated by someone who had been drinking, 17% who had been in serious arguments or quarrels as a result of someone else’s drinking, 8% with family problems or marriage difficulties due to someone else’s drinking, 7% physically assaulted by someone who had been drinking, and 3% who had had their property vandalized by someone who had been drinking (Eliany et al., 1992).   


Preventing problems from drinking: the research literature on alcohol control

The idea of establishing an evidence base for alcohol control is not new.  For instance, a pioneer British study during the First World War of the effects of restricting the opening hours of pubs at the factory gates found that there were fewer accidents among men and during the first spell of work on a shift, since drinking before going to work had diminished (Collis, 1922).   But the modern tradition of studies of the effects of alcohol controls is a product of the last 50 years.  We here review briefly the evidence on particular strategies relevant to alcohol licensing and control.  A more complete review of the literature can be found in Babor et al. (2003).

Taxation.  As with other commodities, the consumption of alcohol is influenced by both price and income.  A substantial economic depression is a very effective way of drinking alcohol consumption down, but no-one would argue for this as a deliberate strategy.  Taxes on alcohol, which raise the price of alcoholic beverages relative to other choices for the consumer, are an effective strategy for reducing rates of problems from drinking – for instance, drink-driving casualties, cirrhosis and homicides  (Cook, 1981; Cook and Moore, 1993).  The tradition of relatively high alcohol taxes in Britain, recently considerably eroded (Academy of Medical Sciences, 2004), was not only a source of revenue for the Treasury but also effective in restraining the rates of alcohol-related problems.

Hours and days of sale.  British studies of the effects of extending hours of pub opening on health and drink-driving, which have been few and rather weak in design, have shown mixed results (Raistrick et al. 1999, pp. 134-136).  Elsewhere, there are a number of studies which demonstrate that changing either hours or days of alcohol sale  at a minimum redistributes when alcohol-related crashes and other violent events related to alcohol take place, which holds implications for rescheduling of police shifts and of public transportation (e.g., Smith 1988;  Nordlund 1985). More recent studies in Western Australia (Chikritzhs & Stockwell, 2003) and Iceland (Ragnarsdottir et al., 2002) have found an overall increase in such problems as injuries and drinking-driving incidents with lengthened hours of sale.

      Concentration and density of alcohol outlets. Cross-sectional studies suggest that alcohol-related problems, especially motor vehicle crashes, are more likely to occur where drinking places are more densely packed (Jewell & Brown 1995).  These results appear to extend to other pedestrian injury collisions (LaScala et al. 2000) and violent assaults (Alaniz et al., 1998; Stevenson et al., 1998).

Studies of the density of outlets have also found an effect of increased numbers of outlets on alcohol problem rates.  A time-series study of changes in the number of on-premise outlets in Norway as a whole in 1960-1995 found a significant relation to changes in the number of crimes of violence which were investigated by the police (Norström, 2000). The most dramatic change studied was in Finland, and its effects were also dramatic. In 1969, the number of off-premise sales points for beer up to 4.7% increased from 132 to about 17,600, and the number of on-premise sales points from 940 to over 4000 (Österberg 1979). The overall consumption of alcohol increased by 46%. In the following five years, mortality from liver cirrhosis increased by 50%, hospital admissions for alcoholic psychosis by 110% for men and 130% for women, and arrests for drunkenness by 80% for men and 160% for women (Poikolainen 1980).  

In general, it is clear that dramatic changes in the number of outlets can have a substantial influence on consumption and problem levels. But the overall effects of marginal changes where there are already a substantial number of outlets are much less clear.

Regulation of service. Responsible Beverage Service (RBS) programs focus on attitudes, knowledge, skills, and practices of persons involved in serving alcoholic beverages on licensed premises (Toomey et al., 1998).  In the absence of institutional support and regulatory oversight, stand-alone training in RBS appears to have few lasting effects.  But if supported by actual changes in the serving policies of licensed establishments and reinforced by local police, RBS training can reduce heavy consumption and high risk drinking (Howard-Pitney et al., 1991; Lang et al., 1998). A recent Swedish study found that a program combining stricter enforcement of alcohol sales laws and training in responsible beverage service had a significant effect in reducing the rate of violent crimes between 10 p.m. and 6 a.m. (Wallin et al., 2003). There are also promising results from a Canadian controlled trial of staff training in reducing pub-related violence (Graham et al., 2003). 

In many jurisdictions in the U.S. and Canada, alcohol sellers or suppliers are legally liable for damages caused by patrons they served when already drunk or who are under age (“dram-shop” laws), and such liability has been shown to be effective in reducing drink-driving casualties (Wagenaar & Holder, 1991).  It has the further advantage of encouraging effective server training, and of making insurers deeply interested in house policies and practices on unlawful serving. It has been argued that this strategy could also be used as an extension of common law in Britain (Goodliffe, 2003).

Drink-driving countermeasures.  The evidence indicates that setting a low BAC (blood-alcohol content) level significantly reduces alcohol-related driving fatalities (Shults et al., 2001).  The present UK BAC level, 0.08%, is higher than the .05% level which applies in most of Europe.  An evaluation showed that further reducing the level in Sweden to 0.02% further reduced drink-driving fatalities (Borschos, 2000).

In recent years the greatest emphasis has been placed not on catching and punishing drinking drivers but on deterring drinkers from driving in the first place.  The most effective deterrence approach is through Random Breath Testing (RBT) (Shults et al., 2001; Henstridge et al., 1997), where motorists are stopped at random by police and required to take a preliminary breath test.  The evidence shows that highly visible, non-selective testing on a regular basis can have a sustained effect on drinking-driving and the associated crashes, injuries, and deaths (Stewart & Conway, 1999). 

There are a number of other drink-driving countermeasures which have also been shown to have effects (Babor et al., 2003).


Changes in British and Irish drinking

            The new millennium has brought increasing reports of widespread problems with alcohol-related public disorder on the streets of British and Irish cities (Chatterton & Hollands, 2003; Hobbs et al., 2003; Strategic Task Force on Alcohol, 2003).  The focus in news reports has been primarily on the drinking of young adults, with complaints that the central part of many cities in Britain has become a “no go” area on weekends for those wishing to avoid trouble.

            Problems with youth drinking are not unique to the British isles, although the problems are manifested differently in different European cultures.  Spanish authorities have complained about and tried to suppress el botellón, the custom of teenagers gathering in town squares to drink large amounts of mixed beverages such as cheap wine and cola (Baigorri et al., 2004).  A French study of young adults finds that many of them value intoxication, confining their drinking to weekends, and generally rejecting any pattern of regular light consumption, particularly of red wine, as tantamount to alcoholism (Freysinnet-Dominjon & Wagner, 2003).  However, it should be noted that British and Irish 15-year-olds, along with Danes of the same age, top the charts among 30 countries in Europe in terms of the proportion reporting regular intoxication (Hibell et al., 2000).

            There are also structural elements to the current situation in Britain and Ireland.  The problems primarily revolve around public drinking.  Although the proportion of drinking which is in pubs and restaurants has been slowly declining, it remains much higher in Britain and Ireland than anywhere else for which there is data (Babor et al., 2003:44; Academy of Medical Sciences, 2004).   In the following paragraphs, some  suggestions are put forward concerning structural elements which seem to be making the situation worse in Britain.

The British tradition of “tied houses” (where pubs were often owned by large operators, originally the brewers) has meant that the ownership is not on site, not living in town and not open to informal pressure from neighbours, and can lead to a situation where the lessee is being squeezed to maximize takings.  (In the US, for instance, tied houses, where the retail level is owned by the producers or wholesalers of alcoholic beverages, has been forbidden by both federal and state legislation since Repeal in 1934).  The Monopoly Commission's order in the 1980s to remove many of the pubs from brewer ownership means that there is now a new set of actors on the scene: the pubcos.  The "estates" of hundreds of pubs in common ownership were not broken up, simply commoditized and sold off.  Recent parliamentary hearings have shown how aggressive the pubcos have been as actors, often without the sense of social responsibility that the brewers retained from the days when the temperance movement was strong.  The pubcos are reported to exploit the lessees by attracting them in with misleading advertising and then mercilessly squeezing them, so that, according to the hearings, there is 1/3 turnover in lessees each year (UK House of Commons, Trade and Industry Committee, 2004).

As Hobbs and his colleagues (2003) detail, city councils and planners have also contributed to the situation by encouraging the “nighttime economy”, seen as a way to resuscitate deindustrialized city centers.  However, instead of the lively cultural center which was hoped for, the result has often been an oversupply of "enormous city bars", "vertical drink factories", as they are described in parliamentary debate (UK House of Lords, 2004).  It is much more difficult for servers and other staff to keep track of customers and ensure good order when the drinking area is large and crowded. The situation has been exacerbated by the abolition of the concept of “need” as a constraint on new pub licenses, and the "use classes order" from the 1970s, which ties the hands of local planners so that they have been unable to resist further growth of pubs in central districts. 

The regulatory system has also often become non-functional.  The licensing justices system has often been co-opted by the trade, and it remains to be seen if this will happen with the new regulators.  As elsewhere, licenses have become more and more viewed as a property right, well-defended by legal teams.  The police have until recently regarded alcohol trouble as routine and everyday, and not something which could be affected by their policies and priorities.  The international experience is that alcohol regulation tends to work better when there are specific alcohol control inspectors whose job it is to hold down alcohol-related troubles, rather than making enforcement a part of general police work.

There is no other English-speaking society, and it is difficult to think of any society, where the alcohol industry (the producers and the pubcos, particularly) has more political power than in the UK.  Transferring licensing to DCMS from the Home Office has enabled the industry to exercise even more control over what happens in licensing.  But even without that, what happens routinely in the UK would be seen as shameful elsewhere (Room, in press-a, -b).   


Bringing liquor licensing and regulation together with evidence-based promotion of public health and safety

            There is an imperfect fit between what those involved in liquor licensing decisions may want to know and what is available in the literature on alcohol controls.  The gap between the content of alcohol control legislation and the research literature has been documented in the U.S. (Wagenaar & Toomey, 2000), and is undoubtedly at least as great in Britain and Ireland.  The studies are sometimes done because a change was controversial in a particular jurisdiction, and funding an evaluation was a way of defusing the controversy. Other studies have been opportunistic, where a researcher seizes the chance to do a “natural experiment” study (“natural” here means that the researcher did not have a voice in the circumstances of the change, so that the study’s design is often constrained).  Often studies have made use of available data, such as per-capita consumption data or mortality registers.  Since research is usually a national government responsibility, its topical focus is not necessarily attuned to the concerns of local jurisdictions.

            Nevertheless, the growth of the literature evaluating the effects of alcohol controls has been a substantial achievement involving a number of national traditions, and lessons from it can applied, with suitable caution, across jurisdictions.  An evidence-based resource worth considering for use at the community level is a U.S. publication (Grover, 1999) reviewing environmental approaches to preventing alcohol problems in the community.

            It is notable how small the contributions from Britain and Ireland have been to this international literature.  British social alcohol research was systematically dismantled at the time of the Thatcher government, with the result that there is little tradition now in Britain of the kind of research-involved prevention and policy studies on alcohol problems that can be found in Australia, Canada, the U.S., the Nordic countries, the Netherlands, or Poland.  Without such a tradition, there is no cumulation of knowledge about what works and (more important) what doesn't. 

The modern British approach to liquor licensing appears to have been to muddle through on the basis of presumptions and good intentions, with little concern about the evidence base for actions, and no investment in monitoring and evaluating what the actual results of a policy or official action are.  Sometimes it appears that a deliberate blind eye is turned to the evidence (Room, in press-a, -b).  This is actually a considerable backsliding from the position 70-90 years ago, when Britain was a world leader in studies of the effects of alcohol controls (e.g., Carter, 1919; Shadwell, 1923; Catlin, 1931).

            In the current situation of serious problems with drinking on the streets of British and Irish cities, perhaps it is time for a change of approach.  Much can be learned from local experiments and policy changes during and after the period of changeover to the new licensing law.  Studying what happens may involve setting up local data-collection systems for collection of data by the licensing board, police, A&E services, and health and welfare services.  Such data collection may be used for studying the effects of a specific change, but it also potentially becomes a means of reflexive monitoring, by which problems can be identified and responded to as they occur.  Studies of the effects of a specific change or action need to be analyzed and published, so that other localities can learn from the experience.  In this way, a cumulative literature of evaluations of the effects of licensing and alcohol control measures can be built up.  As it once before was (Room, 2004), evidence-based practice needs to become the watchword for licensing and regulation in Britain and Ireland.     



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