Prevention in nightlife

1. Prevention in nightlife EMCDDA Conference Identifying Europe’s information needs for effective drug policy Lisbon, 6–8 May 2009 Amador Calafat IREFREA

2. Nightlife and use of drugs • “Research studies targeted at young people in the EU who attend dance music events consistently report much higher prevalence of drug use than that found in surveys of the general population. This appears to be the case in all of the countries where such surveys have been conducted” • Annual report 2006, EMCDDA

3. Cream Events Around The World • 350 events every year • Attended by almost 3 million people in last 5 years

4. PROBLEM AREAS IDENTIFIED • Health problems (injuries, hearing damage, mental disorders, heat stroke, drunkenness, …) • Violence • Unsafe and involuntary sex • Transport (e.g. drink/drug driving) • Social nuisance (noise, street drinking, vandalism,…) • Underage drinking • Crime or law offences

5. MEDICAL ASPECTS • During 'I love techno' (edition 2001), an indoor rave party attended by 37 000 people or during 'De Nacht', a traditional New Year's Eve dance party, data about medical problems (especially drug-related problems) were collected. • The incidence of medical problems during 'I love techno' the was 66.5/10 000 attendees, and in 'De Nacht' 70.0/10 000 attendees. Van Sassenbroeck DK, Calle PA, Rousseau FM, Verstraete AG, Belpaire FM, Monsieurs KG, Haentjens R, Allonsius J, Van Brantegem J, Haenen W, Buylaert WA. (2003). Medical problems related to recreational drug use at nocturnal dance parties. Eur J Emerg Med. 10:302-8

6. Transport when going out • Private car was the most frequent form of transport used when going out (37,5%) • Taking a lift (37%) from someone drunk or under the influence of drugs during the last month • driving when drunk (18%) last month • Driving under the influence of drugs (13%) last month • Drug use was related to crashes and traffic risk behaviours including having a lift from someone drunk or driving drunk or driving having taken drugs; drunkenness was related to risk behaviours but not to crashes (possibly because drunk people tend to use the private car less). Calafat et al, (2009)Traffic Risk Behaviors at Nightlife. Traffic Injury Prevention, 10:1–8

7. Sex risk behaviours and nightlife • Among people in nightlife being a current drug user was associated with sexual risk taking. • Thus in the last 12 months, regular cocaine users were 5.6 times more likely to have had multiple sexual partners, 2.7 times more likely to have had sex without birth control, and 5.1 times more likely to have paid for sex. Bellis, Hugues, Calafat et al (2008) Strategic use of substances by young people for sex and related behaviours and its implications for sexual health. BMC

8. Violence in the nightlife • Research consistently shows the peak time for violent offence is weekend nights and the peak location is in and around pubs and clubs (Allen, Nicholas, Salisbury and Wood, 2003). • In the United Kingdom one fifth of all violent assaults takes place in or around a pub or club and almost half of all incidents of violence and disorder occurred at weekend nights (Maguire and Nettleton, 2003) • Alcohol related aggression happens specially in a bar or club (Archer,1995; Leonard et al, 2002)

9. Violence in venues • A small number of licensed premises responsible for most disorder and assaults (Briscoe & Donnelly, 2001b, 2003; Graham & Wells, 2001, Jochelson, 1997) • The violence mostly males under 25 is triggered by conflict with staff, overcrowding, violating bar rules, offensive behaviour and conflict over interpersonal relationships (Chikritzhs, 2002; Homel et al., 2004; Macintyre & Homel, 1997)

10. Violent people prefer certain venues • People who were involved in fights while on vacation preferred different types of bars from those who were not involved in violence. • Those involved in violence were more likely to favour bars that sell cheap drinks while those that had not been involved in violence favoured bars with a friendly atmosphere, clean wash rooms and were easy to get home from. Hugues K, Bellis M, Calafat A, Juan M, Schnittzer S, Anderson, Z (2008) Predictors of violence in young tourists: a comparative of British, German and Spanish holidaymakers. Eur J Public Health, 18:569-74

11. Violence and intoxication • The intoxication level of those within the bar and bar policies that facilitates intoxication, like cheap drinks, is highly associated with aggression • Homel R., Clark J. The prediction and prevention of violence in pubs and clubs. Crime Prev Stud 1994; 3: 1–46 • Graham K., Osgood D. W., Wells S., Stockwell T. To what extent is intoxication associated with aggression in bars? A multilevel analysis. J Stud Alcohol 2006; 67: 382–90

12. Glass injury • A study on the risk of occupational glass injury in bar staff revealed that 41% of bar workers in South Wales have sustained bar glass injury. • Fifteen per cent of these had sustained five or more separate “sharp” injuries from broken glassware. • Shepherd JP, Brickley MR, Gallagher D, et al. Risk of occupational glass injury in bar staff. Injury 1994;25:219–20.

13. Crystal Clear • Raise awareness of Bottle and Glass related injury • Encourage leaving glasses and bottles in clubs • Reduce glass related injuries

14. INTERVENTIONS • Venues • Code of practice and other agreements • Bar staff and management training programs. House policies • Opening hours • Collaboration with emergency rooms, with police,… • Physical and contextual • Community interventions • Education (in school, peer education, patrons education, …) • Emergency rooms, medical and first aid provision assistance, • Control availability (sale to minors, prices, happy hours, …) • Licensing /Law enforcement // Underage drinking • Context, environments, neighbourhood (transport, lighting, …) • Drink and Driving programs • Pill testing • Policing, collaboration with the industry,… • Alternatives programs, youth policies,… • Cultural approaches • Campaigns

15. Venue environmental factors that can be addressed • Permissive atmosphere is a very important factor (Homel, 1994, Graham et al 2006) • overcrowding and bumping (Macintyre and Homel, 1997) • smokiness (Homel and Clark, 1994) • bad and loud music (Home and Clark, 1994) • activities such dancing or pool games (Graham et al 1980; Quigley et al 2003). • overt sexual activity (Homel et al, 2004; Graham et al,2006) • Transport (Calafat et al, 2009)

16. Outside Clubs • Police handing out of Lollipops Some Interventions for Noise

17. Safer Nightlife Guidelines England Denmark Spain New Zealand New South Wales

18. Prevention of overcrowding • Air conditioning and ventilation • Availability of drinking water • Further measures to combat overheating • e.g. chill out areas, DJ choice of music • Other environmental factors • e.g. secure fixtures, glass collectors, regular checking of electrical systems, safe noise levels • Door supervisor registration • General security measures • e.g. searching at entry, safe storage of seized drugs and weapons, CCTV, washroom attendants • Staff training • Medical and first aid provision • Drugs information and advice • Additional measures for large events • Independent research and monitoring

19. Responsible Beverage Service (RBS) • Typical objectives are: • Learn to identify and refuse service to obviously intoxicated persons • Learn to identify and refuse service to underage • Contribute to a harm reduction strategy related to alcohol: • cleanliness and maintenance of premises • Removal of potentially harmful objects • sufficient but subtle lighting and moderate noise level; • availability of seating; crowd control, • availability of food and non-alcoholic beverage choices; • limiting specials, such as “happy hours,” “two-fers,” events. • etc

20. Minimum requirements for RBS training • Cover all basic information with servers • Actives techniques (e.g. role playing) should be used, • Focus on both managers and servers. Managers should be targeted because they are responsibles of supervising the servers, so they should be familiarised with the techniques. • Include policy development for managers. Managers should develop written house policies. This increases the chances to implement RBS at the establishment. • the minimum length for the most effective RBS is a minimum of four hours. • Mosher JF, Toomey TL, Good C, Harwood E, Wagenaar AC. (2002) State laws mandating or promoting training programs for alcohol servers and establishment managers: an assessment of statutory and administrative procedures. J Public Health Policy. 23(1):90-113

21. Evaluation of RBS • Mixed results. • It is possible to reduce alcohol related problems by RBS (Gliksman, McKenzie, Single et al,1993) • There is no effect or limited effects according a review (Graham, 2000) • Results do not support that the RBS training alone has produced effects on alcohol. Clearly enforcement was better. But it was probably effective in the reduction of violence (Wallin, Andréasson, 2005).

22. Cochrane review • 20 researches covering a range of interventions involving server training, health promotion initiatives, a drink driving service, a policy intervention and interventions that targeted the server setting environment. • There is no reliable evidencethat interventions in the alcohol server setting are effective in preventing injuries. The effectiveness of the interventions on patron alcohol consumption was found to be inconclusive. There is some indication of improved server behaviour but it is difficult to predict what effect this might have on actual injury risk. • Lack of compliance (low paid, high turnover of staff, stressful work,…)with interventions seems to be a particular problem; hence mandated interventions or those with associated incentives for compliance, may be more likely to show an effect Ker. K and Chinnock. P (2008) Interventions in the alcohol server setting for preventing injuries, The Cochrane Collaboration

23. Community or multi component approach • Integral or multi component approach will probably be more effective than the implementation of separate interventions. • The most effective community model would combine education, coordination and enforcement (Homel) (Holder. HD, Gruenewald. P.J, Ponicki. W.R, Treno, A.J., GRube, J.B., Saltz, R.F., et al (2000) Effect of community-based interventions on High Risk drinking and alcohol-related injuries, JAMA 284: 2341-47; Wagenaar. A.C, Murray. D.M and Toomey. T.L (2000) Communities mobilizing for change on alcohol (CMCA): effects of a randomized trial on arrests and traffic crashes, Addiction 95:209-217

24. An integral or multi component prevention approach combines some or all of the following interventions: • Community awareness and community mobilization (involvement and cooperation with important stakeholders like municipalities, pubs and clubs, party-organisers, health/addiction services, and police) • Training -RBS, preventing violence,..- bar staff (from doormen to managers) and other stakeholders • House policies • Improving the safety and the health of the Nightlife areas and venues (healthy settings) • Education for nightlife visitors about decreasing the risks of drug and alcohol use • Law enforcement

25. Stockholm Prevents Alcohol and Drug Problems. STADT • The community alcohol prevention program related to alcohol consumption at licensed premises starts in 1996 in the northern part of central Stockholm and a control area in the south. • Main intervention included community mobilization, training of servers in RBS and stricter enforcement of existing alcohol laws. Wallin, E., Andréasson, S. (2005). Effects of a community action program on problems related to alcohol consumption at licensed premises. In Stockwell, T., Gruenewald, P.J., Toumbourou, J.W., Loxley, W. (Eds), Preventing Harmful Substance Use: the Evidence Base for Policy and Practice. West Sussex: John Wiley & Sons

26. STADT Results • a decrease in alcohol related problems at licensed premises • increase of licensed premises that refused alcohol to intoxicated patrons (from 5% in 1996 to 47% in 1999 and 70% in 2001) • increased refusal to serve minors (from 55% in 1996 to 59% in 1999 and 68% in 2001) • During the project period the assaults decreased the 29% in the project area and slight increase in the control area

27. Some other examples of Community programs • Surfers Paradise Safety Action Project (Australia) • marked reductions in violence and crime (inside and outside venues) and in practices that promote the irresponsible use of alcohol as well as improvements in security practices, entertainment, handling of patrons, and transport policies. • Community Trials Project (Salinas, California) • lowered the rate of nighttime traffic injuries and the number of admissions to hospitals due to traffic accidents.

28. . Community mobilisation as a way to apply multiple interventions and generally put pressure on bars to ‘clean up their act’ does seem to have a substantial impact. But questions remain regarding how to make mobilization happen outside of funded research projects and how to sustain gains made by communities Graham. K (2000) Preventive interventions for on-premise drinking: a promising but under researched area of prevention, Contemporary drug problems 27, 593-668.

29. Alternative Evening Entertainment Programme • Very common in Spain (Open Till Dawn, The night is young,…) • Conducted on the same hours as the nighttime scene (e.g. till 3 in the morning) to prevent alcohol and new drug use among young people, while generating healthy leisure and free time alternatives through workshops, sports, etc.

30. Evaluation of alternative programs • In a evaluation of the alternative program (OPEN TILL DAWN) in Spain there were not results in use of drugs, change of attitudes or behaviors in relation to the control group (Secades, 2003) • According to a review of programmes made by Norman (1997) there is no evidence that organising artistic activities, sports, leisure,…, will be, by itself, successful in decreasing the use of drugs. • In a review of 45 evaluated programs of different types (Hansen 1992), nearly all the programs were giving positive results with the exception of the programs that provide alternative experiences (developing experiences incompatibles with the use of substances).

31. EDUCATION OF PATRONS

32. EXTENDED LIQUOR TRADING HOURS More evidence that drink driving incidents and traffic accidents coincide with extended liquor trading (ELT) and around closing times* • Other research suggests ELT has little impact on positive BAC traffic fatalities** • A small number of licensed premises responsible for most disorder and assaults(Briscoe & Donnelly, 2001, 2003; Jochelson, 1997) • Chikritzhs et al., 1997; Palk & Davey, 2005; Smith,1988; Newton, 2007 • ** Vingilis et al., 2005

33. Law enforcement • Uniformed police officers visit pubs 2 to 3 times a week at an english seaside resort. 20% of reduction in recorded public disorders offences in intervention area. No reduction in control area. (Jeffs, B.W., Saunders, W.M. (1983). • ‘Tackling Alcohol Related Street Crime’ TASC in Cardiff a broad and multifaceted intervention implemented largely by the police (Maguire et al, 2003), produced reductions in violence at the relevant premises.

34. Some of these programmes are “turnkey”, or “ready to implement”, and have been measured and evaluated. They can be easily adapted to national cultures and contexts EUROPEAN FORUM for RESPONSIBLE DRINKING (EFRD)

35. Industry Activities

36. Recommendations (1) 1. To concentrate more efforts in risky alcohol use because it generates most of the problems 2. Greater accountability for law enforcement. - needs political and social support - easiest to implement when there are local awareness of problems (vandalism,…) 3. Community approaches tend to produce the largest and most significant effects. - more expensive - need political support - problem with sustainability

37. Recommendations (2) 4. Intervention in venues - many possibilities - not very evaluated - more effective when non compliance can be sanctioned. 5. Classical measures like taxation, random breath testing of drivers, enforcement of purchase age laws are evidence based and effective. 6. Education to patrons not useful specially alone. 7. Codes of practice and other coordination efforts of industry are promising but there is no evidence. - The problem is the compliance and sustainability.

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