Summary of Alcohol and violence

Violence is one of the great scourges of humanity and alcohol fuels much of it.
Alcohol is a contributing cause of many violent incidents in Sweden that is often overlooked and under-reported. Official records show that the rates
of homicides and assaults in Sweden since the 1850s have closely tracked the population rate of alcohol consumption (see Figure 1). In this report we discuss evidence for alcohol having a direct causal contribution to violence and we also highlight effective but under-utilised strategies to reduce alcohol-related violence. While the World Health Organization (WHO) identifies public policies on alcohol as a ‘best-buy’ for violence prevention, such strategies have been mostly overlooked in Swedish violence prevention strategies.
We present evidence that alcohol use contributes to violence affecting people across the whole lifecourse and in many situations, including: violence between family members, intimate partners, friends, acquaintances and strangers, child maltreatment, youth violence, sexual violence and elder abuse.
Evidence from different types of studies shows that while alcohol does not provide a motive or excuse for violence, alcohol impairment can increase the probability that there will be a violent response to inter-personal conflict, frustration or a perceived threat.

Furthermore, people are more likely to be victims of aggression when they are intoxicated.
Many violent incidents are never reported. Furthermore, alcohol’s contribution to violence tends to be invisible or ignored. In anonymous surveys, however,
2.5% of Swedish men and 1.5% of women reported being physically assaulted in the previous year and, further, 0.3% of males and 1.8% of females reported
a sexual assault. While about 80% of the victims of public violence (e.g., assaults) are male, more females are victims of domestic and sexual violence. Furthermore, domestic violence victims, who are more likely to be women and children, may be more likely to under-report violence, and less likely to seek care for violence-related injuries.
A recent World Health Organization report identified many types of harm arising from violence beyond the immediate traumatic injuries. Serious longer term
effects impact physical, psychological, reproductive and sexual functioning in adults and deprivation or neglect in children. For instance, individuals who had experienced severe physical or sexual violence during their lifetime were about three times more likely to be diagnosed with heart disease. In general, female victims appear to be especially vulnerable to longerterm health consequences of violence.

Reviews of international studies indicate that alcohol has been consumed prior to assaults by between one-third and one-half of perpetrators of violence. In
Sweden, based on survey data for 2015, 57% of perpetrators of physical assault and 31% of victims were intoxicated. With an estimate of 317 000 cases of physical assault in 2015, this corresponds to 180 000 alcohol-related assaults in that year. For all types of violence in Sweden the perpetrator is male in 9 times of 10. The victims of physical assaults are mostly male while the victims of sexual assaults are predominantly female.
The evidence for a causal relationship between alcohol and violence was studied by triangulating the findings from three main research approaches:

(a) human and animal laboratory experiments,
(b) studies of alcohol use and violence in the general population, and
(c) studies of interventions where alcohol consumption has been affected by either stricter or more relaxed alcohol policies.

Human and animal experimental studies suggest that the pharmacological effects of alcohol cause changes in thinking, emotions, and physiology that increase the likelihood of aggressive behaviour (e.g., feeling overconfident, becoming angry with relatively minor provocation) and violence victimization (e.g., not recognizing unsafe situations, being less able to defend against, of flee from, attack). Biomedical evidence also suggests that alcohol counteracts the inhibitory functions of the brain which suppress aggressive impulses. There is also evidence that learned beliefs about alcohol and aggressive behavior (e.g., the belief that when ones drinks it is ‘normal’ to be more aggressive) can shape violent behavior after alcohol consumption, although the pharmacological or physiological effects of alcohol on the brain are more powerful determinants.
In the “real world” where experiments about violence are unethical or impractical, epidemiological studies of the general population demonstrate significant associations between alcohol consumption and violence. Intervention studies provide powerful tests of causal relationships by demonstrating that abrupt changes in general population drinking patterns predict changes in rates of violence.

The level of alcohol use in the general population is an important risk factor for violence. Swedish studies have found that a 1 litre increase in consumption is associated with a 7% increase in assaults all other factors being equal. Evidence that alcohol is a risk factor for violence is also strengthened by the consistency of the relationships observed across different types of violence, including intimate partner violence, elder abuse and child maltreatment.
Alcohol policy changes related to the price of alcohol (e.g., taxes), trading hours (i.e., hours of alcohol sales), minimum legal purchase age and the number
of liquor outlets have all been found to be related to rates of violent incidents. Greater restrictions on these are associated with reductions in violence while loosening of restrictions are associated with increasing rates of violence in Sweden and in other countries. Government alcohol monopolies, such as Sweden’s Systembolaget, can help resist commercial pressures to increase alcohol availability and affordability.
Violence can also be reduced through multi-component community level interventions. Successful examples of such interventions in Sweden include
responsible beverage service (RBS), particularly when RBS training is combined with community mobilization and stricter enforcement of licensing laws.
Examples of community interventions in Sweden include the reduction of violence among young people attending graduation parties and policing of alcohol
use in public places by young people.
Nearly everyone decries violence, at least publicly, and yet the difficulty lies in adopting meaningful interventions to actually reduce it. While many causes of violence are difficult to change (e.g. genetic, personality and cultural factors) this report finds that alcohol as a cause of violence stands out as being highly amenable to change through changes in alcohol policies.