Sven Andréasson, MD

Swedish National Institute of Public Health

& Department of Public Health Sciences,

Karolinska Institutet

Club Health 2010, Zurich, 7-9 juni 2010

Preventing alcohol

related violence:

cost – effectiveness

Community

coalition

Media Enforcement

Surveys Training Follow-up

The STAD model for violence prevention at

licensed premises

Media Advocacy

Public opinion regarding drunk patrons in bars

and restaurants

0

20

40

60

80

100

120

Doormen should refuse

entrance for intoxicated or

drug-influenced patrons

Service to intoxicated

patrons should be reduced

Make obviously intoxicated

patrons leave the premises

Pe

rce

nta

ge

All n=565 Non-frequent visitors n=264 Frequent visitors to bar/-pub, nightclubs n=212

95

53

30

0

10

20

30

40

50

60

70

80

90

100

1996 1999 2001

% s

erv

ed

Intoxicated

Psudopatrons served

JA

N 1

998

JU

LY

1997

JA

N 1

997

JU

LY

1996

JA

N 1

996

JU

LY

1995

JA

N 1

995

JU

LY

1994

JA

N 1

994

400

300

200

100

0

Police reported violent crime in Stockholm city

1994 – 2000; number of offences

Intervention area

Control area

JU

LY

2000

JA

N 2

000

JU

LY

1999

JA

N 1

999

JU

LY

1998

JA

N 1

998

JU

LY

1997

JA

N 1

997

JU

LY

1996

JA

N 1

996

JU

LY

1995

JA

N 1

995

JU

LY

1994

JA

N 1

994

400

300

200

100

0

Police reported violent crime in Stockholm city

1994 – 2000; number of offences

Intervention area

Control area

Intervention begins

Reduction in

assaults by 29%J Stud Alcohol, 2004

Causal chains

Problem indicator

shows high value

Important determinant

shows high value

Baseline

Assaults in or

near bars & clubs

High level of

alcohol

intoxication

Intervention

RBS-training

and

enforcement

Indicator of preventive

intervention

Problem indicator

shows reduced value

Important determinant

shows high value

Follow-up

Reduction in

assaults

Reduced level of

alcohol

intoxication

Health economic analysis

1. costs of the program, minus…

2. savings in various societal sectors, compared to…

3. health effects measured in QALYs

Number of violent crimes 1998-2000: 7,368

Preventive effect of the restaurant project: 29%

� Number of prevented violent crimes: 3,009 cases

Costs

1. Administration; (salaries project staff, travels, computers,

cleaning, etc.)

2. Studies; baseline & two follow-up studies (training and

salaries to actors/young people)

3. Community Mobilization; minutes of meetings (numbers;

participants), mean wages/payroll taxes

4. RBS training; costs of training (572 participants * 500 SEK),

production loss (572*wages)

5. Law enforcement; visits/inspections (251*45 min*2

policemen & 2 officers), notification letters (72*1 hrs*200 kr)

Survey among victims of violence

• Randomly selected from the National Police Board’s

register of violence, during 2003 in Stockholm City

• 604 victims were selected; serious assaults (n=83),

other assaults (n=288), unlawful threat (n=152), and

assault/threat towards officials (n=81)

• Response rate: 35 %

Survey of victims: monetary effects

of violence

1. Judicial system (police, court, sanction/prison)

2. Production (mainly sickness absence)

3. Health care (emergency transport/treatment, inpatient care,

outpatient care, psychotherapy, drugs)

4. Other damage (personal assistance/belongings)

Combined with data from the Police Board, Public Prosecutor,

Courts Administration, Federation of County Councils,

Association of Pharmacy

(e.g. prison 2,364 SEK/day, emergency trspt 2,311 SEK)

Survey: health effects from

violence

The respondents were asked to classify how the

violence had affected their health by:

1. five dimensions of health (mobility, self-care, usual

activities, pain, anxiety/depression)

2. three levels (no problems, moderate problems,

extreme problems

3. ‘before violence’, ‘two weeks after’, ‘at present’

� gained quality-adjusted life-years QALYs

The average cost of a violent crime(euros)

Type: Assault Threat Other

20,145 21,382 10,870

Sex: Male Female

17,684 20,912

Education:Compulsory Secondary University <3yr University ≥3 yr

9,119 10,141 16,368 32,274

Results (euros, discounted values)

Costs

• Project administration 492,050

• Mapping/follow-up 27,632

• Community mobilisation 33,723

• RBS training 220,906

• Law enforcement 21,517 -795,828

Savings

• Judicial system 24,393,381

• Loss of production 4,728,370

• Health care 1,565,686

• Other damage 626,274 +31,313,711

• Net saving +30,517,883

Results: health gainsQuality adjusted life years (QALY:s)

Average health status (max 1.0):

- before the violent crime: 0.8647

- two weeks after: 0.6776

-12 months after: 0.8729

Gained health: 3,009 prevented crimes

* (0.8647 – (0.6776+0.8729)/2)

� 3,009 * (0.8647 – 0.77525)

� 3,009 * 0.08945 ���� 270 QALYs

Sensitivity analysis

• Low response rate (35%)

• Costs not considered, e.g. Family, restaurant

• Main result: 1:39

• IF only police costs for non-respondents �1:18

• IF entirely ignoring the survey (2,001*3,009) �1:7

Conclusion

• Cost-saving 1:39

• Health gains 3-4 lives in normal health

• CBA of Alcohol law inforcement Michigan �1:45

• ”Investing in RBS is a wise use of societal resources;

i.e. monetary savings, health gains, & welfare gains”

National dissemination

Through the Police authorities

Through the County administrations

Moving on to illicit drugs: an environmental approach to drug use and drug prevention

Acknowledgements

• Co – authors

Anna Månsdotter, Eva Wallin, Malin Rydberg

& Lars Lindholm

• Publication: European Journal of Public Health

2007