From the Faculty of Public Health's 2015 Annual Conference in Gateshead. Author: Page, N.A.,

1. Violence-related injury and the real
price of alcohol in England & Wales
Paper presented at FPH Conference 2015
Dr Nicholas Page
Violence Research Group
Cardiff University
pageNA@cardiff.ac.uk

2. Alcohol price and violence
 A one-way relationship between alcohol price and violence has been shown
both nationally and internationally.
 Causation is understood as a two stage process:
Alcohol Price Alcohol Use Violence
(first stage) (second stage)
 A 1% increase in ‘real’ beer price (i.e. above inflation) has previously been
estimated to reduce violence-related A&E attendances in England & Wales by
5,000 per year.
Sources: Matthews et al., 2006; Wagenaar et al., 2010

3. Study aim and methods
Aim:
To investigate the influence of real alcohol price, both on-premises and
off-premises, on rates of violence-related A&E attendances in England
and Wales.
Methods:
A statistical model for violent injury was estimated which accounted
for regional variation in real alcohol price and controlled for the effects
of poverty, income inequality, youth unemployment and seasonal
effects.

4. Violent injury rates, per 1000 population
Dependent
variable
Monthly violent
injury rates (per
1,000 population)
based on adult
A&E attendances
from 100 A&E’s
across England and
Wales between
2005 and 2012.
0.00
0.25
0.50
0.75
1.00
east
eastmidlands
london
northeast
northwest
southeast
southwest
wales
westmidlands
yorkshire&humberside
region
monthlyviolentinjuryrate
per1,000population

5. Alcohol prices
On-premises Off-premises
Draught bitter (pint) Bitter 4 cans, 440-500ml
Draught stout (pint) Lager 4 bottles premium
Bottled premium lager Lager 12-24 cans, 440-500ml
Premium lager (pint) White wine – European, 75cl
Lager (pint) White wine – New world, 75cl
Bottle of wine, 70-75cl Red wine – European, 75cl
Wine glass, per 175-250ml Red wine – New world, 75cl
Liqueur, per nip Fortified wine, 70-75cl
Vodka, per nip Whisky, 70cl
Whisky, per nip Vodka, 70cl
Alcopop Brandy, 70cl
Alcopop, 275ml

6. Alcohol price indices
Eastern East Midlands London North East
North West South East South West Wales
West Midlands Yorkshire & Humberside
90
95
100
105
110
115
90
95
100
105
110
115
90
95
100
105
110
115
2006 2008 2010 2012 2006 2008 2010 2012
Date
Priceindex
Off-premises
On-premises

7. Violent injury and on-premises alcohol price
0.5
1.0
1.5
96 100 104 108 112
alcohol price index (on-premises)
Violentinjuryrate,per1000population
region
east
eastmidlands
london
northeast
northwest
southeast
southwest
wales
westmidlands
yorks&humberside
Linear trend – regional
variation unaccounted for.

8. Violent injury and off-premises alcohol price
0.5
1.0
1.5
90 95 100 105 110 115
alcohol price index (off-premises)
Violentinjuryrate,per1000population
region
east
eastmidlands
london
northeast
northwest
southeast
southwest
wales
westmidlands
yorks&humberside
Linear trend – regional
variation unaccounted for.

9. Regression results (random effects)a
Variable Total (β) Male (β) Female (β)
Intercept 2.563* 4.437* 0.884
Real on-premises alcohol priceb
-0.093** -0.099** -0.075*
Real off-premises alcohol priceb
-0.058* -0.077** 0.001
Income inequality 0.205*** 0.230*** 0.116*
Poverty 0.224*** 0.248*** 0.142**
Youth unemployment -0.092* -0.102** -0.074
Spring -0.056** -0.050* -0.066**
Autumn -0.094*** -0.084*** -0.114***
Winter -0.127*** -0.118*** -0.142***
F-statistic 27.823*** 30.814*** 13.770***
R-squared (adjusted) 0.192 0.208 0.105
a = standardized coefficients; b = log; *** = p<0.001; ** = p<0.01; * = p<0.05

10. Raising the real price of alcohol
Variable % change Month Year
Real on-premises
alcohol price
10%
increase
-3,550 -42,600
Real off-premises
alcohol price
10%
increase
-1,490 -17,880
Total -5,040 -60,480
 In 2014, 189,215 adults attended A&E’s for
treatment of violence-related injuries.
 Based on our estimates, a 10% real price increase
could reduce attendance by 32% per year.
Source: Sivarajasingam et al., 2015

11. Policy options
Minimum Unit Pricing (MUP)
 Most effective policy at reducing alcohol use among harmful drinkers
without penalising moderate drinkers.
 Targets cheap alcohol but wouldn’t effect price of on-premises alcohol.
Tax-based policy (accounting for alcohol strength)
 Would effect alcohol price in both markets.
 Would raise close to £1 billion in additional revenue which could be used
to offset costs to the NHS.
Sources: Griffith et al., 2013; Meier et al., 2010

12. Conclusions
 Raising the price of alcohol above inflation would reduce violence-
related A&E attendances in England & Wales.
 However, gender differences were identified; price of off-premises
alcohol was not related to violent injury among adult females.
 Importantly, associations between alcohol price and violent injury were
stronger on-premises.
 Policies intent on raising the price of alcohol should seek to increase
the price in both markets in order to achieve the greatest reductions
in violence.

13. Acknowledgments
 Clinical leads of all EDs that provided data for this study.
Co-authors:
 Vaseekaran Sivarajasingam, Kent Matthews , Saaed Heravi, Peter
Morgan and Jonathan Shepherd.
Further details:
Dr Nicholas Page
Research Associate
Violence Research Group
Cardiff University
Email: pageNA@cardiff.ac.uk
twitter: Nick Page @ Nick_Alan_Page

14. Violent injury and on-premises alcohol price by region
east eastmidlands london northeast
northwest southeast southwest wales
westmidlands yorks&humberside
0.5
1.0
1.5
0.5
1.0
1.5
0.5
1.0
1.5
96 100 104 108 11296 100 104 108 112
alcohol price index (on-premises)
Violentinjuryrate,per1000population

15. Violent injury and off-premises alcohol price by region
east eastmidlands london northeast
northwest southeast southwest wales
westmidlands yorks&humberside
0.5
1.0
1.5
0.5
1.0
1.5
0.5
1.0
1.5
90 95 100 105 110 115 90 95 100 105 110 115
alcohol price index (off-premises)
Violentinjuryrate,per1000population