preventing alcohol-related violence: a public health approach

Copyright © 2007 John Wiley & Sons, Ltd 17: 250–264 (2007)DOI: 10.1002/cbm

Preventing alcohol-related violence: a public health approach

Criminal Behaviour and Mental Health17: 250–264 (2007)Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/cbm.668

JONATHAN SHEPHERD, University of Cardiff, UK

ABSTRACTBackground Studies of the relationship between alcohol and violent injury confi rm that while there is some evidence of a direct pharmacological association, many other factors are relevant to the frequency and severity of both violent perpetration and being a victim of violence. It is now widely recognized that offi cial police statistics are a poor indicator of the nature and extent of public violence.Aims Accident and emergency departments and trauma surgeons are not only in a position to provide more accurate information on the nature and extent of clinically signifi cant injury, but they can contribute substantially to violence prevention. This can be achieved through individually targeted interventions in conjunction with other clinicians on the one hand, and on the other through public health and community initiatives, in conjunction with other community agencies, including the police and local authorities. This article describes some of those initiatives and the evidence underpinning them. Copyright © 2007 John Wiley & Sons, Ltd.

Introduction

Interpersonal violence is an insidious and frequently deadly social problem which includes child maltreatment, youth violence, intimate partner violence, sexual violence and elder abuse (Krug et al., 2002). It occurs in the home, on the streets and in other public places, including institutions such as hospitals. Its fi nancial, social and human costs are enormous. The World Health Organization 2002 Report on Violence and Health (Krug et al., 2002) established violence as a global public health issue. Worldwide, the age-adjusted death rate from violence in 2000 was 28.8 per 100,000 population, but with variations according to regional and country income levels. In 2000, the rate of violent death in low- to middle-income countries was 32 per 100,000, more than twice that in high-income countries (14.4 per 100,000); there was variation between individual countries too (e.g. 1994 male homicide rate Colombia 147, Mexico 32, Cuba 12.6, all per 100,000). In Africa and the USA, homicide rates are nearly three times greater

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than suicide rates, with the position more or less reversed in Europe and Southeast Asia. Death represents only the tip of the violence iceberg, but information on non-fatal injury is much less complete (Krug et al., 2002). The type, severity and anatomical site of injuries also varies internationally, but the oro-facial region tends to be most commonly affected (e.g. UK: Shepherd et al., 1990a).

Alcohol and violence

The effects of alcohol on human aggression have been the focus of intense research effort whereas its effects on victimization have only recently attracted interest. A brief overview is given here, focusing on major meta-analyses and recent insights from psychology, substance misuse, epidemiology and criminology. The literature includes large numbers of studies of alcohol and violence which utilize only simplistic aggregate data and provide little reliable new knowledge (Shepherd, 1990).

Meta-analysis of 30 experimental studies of links between alcohol and human aggression concluded that alcohol does cause aggression, although its effects are moderated by methodological parameters (Bushman and Cooper, 1990). For alcohol versus control comparisons, effect sizes were smaller when the experi-menter was blind to conditions and were larger when an aggressive response was required than when a non-aggressive alternative was available. For alcohol versus placebo comparisons, effects were smaller for blind studies and larger for studies in which the confederate was free to retaliate against the subject. It was also concluded that it was possible that drinking habits moderate alcohol effects. Taking up this theme, in the context of links between assault injury and alcohol consumption, a recent innovative case crossover study utilized usual alcohol consumption during the last 12 months as a control value (Borges et al., 2004); the relative risk of injury in the hour after alcohol consumption, compared with no alcohol consumption during that time, was 4.33 (95% CI 3.55–5.27). Violence-related injuries were associated with higher relative risk, but those with alcohol dependence and high frequency of drunkenness had lower risks than those without alcohol dependence or with lower self-reported episodes of drunkenness respectively. Analyses of blood alcohol content on Emergency Department admis-sion tended to be confi rmatory. It was concluded that each episode of alcohol consumption results in an increase in short-term risk of injury, especially vio-lence-related injury, at its highest among the lowest usual users.

The acute effects of alcohol on aggression are moderated by individual differ-ences and contextual factors (Giancola et al., 2003). Alcohol plays an important role in the intergenerational transmission of family violence (Giancola et al., 2003). Violence typology has prompted research on problem drinking in the context of intimate partner violence (IPV) perpetration and victimization (e.g. Kantor and Strauss, 1987; Leonard, 1993). Problem drinking has been found to

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be a signifi cant predictor of both violence perpetration and victimization for men and women (White and Chen, 2002). Consistent with this, the longitudinal Pittsburgh Youth Study concluded that offences committed under the infl uence of alcohol were more prevalent among heavier alcohol users, more serious offenders, more impulsive youths, and youths with more deviant peers (White et al., 2002). However there were no signifi cant interaction effects.

Another major longitudinal study, the Seattle Social Development Project (Hill et al., 2000), provides evidence of four distinct trajectories of binge drinking during adolescence: early heavy binge drinking, increasing binge drinking, late onset binge drinking and non-binge drinking. Furthermore, these different tra-jectories signifi cantly predicted positive and negative outcomes in adulthood after controlling for demographic characteristics, early proxy measures of the outcome and adolescent drug use. With regard to beverage type, longitudinal interrelation-ships between specifi c beverages, physical symptoms and psychological distress have confi rmed that physical impairments due to alcohol – in large part respon-sible for the increased risk of victimization in violence (Shepherd, 1998) – operate similarly for beer, wine and spirits, for males and females and for adolescents of all ages (Hansell et al., 1999).

Links between patterns of alcohol misuse and crime have been studied in the New Zealand Birth Cohort Study, taking into account confounding factors through the use of fi xed effects regression analyses (Fergusson and Horwood, 2000). Increasing alcohol abuse was associated with signifi cant increases in rates of violent crime, although control for observed and non-observed confounding indicated that much of this association was attributable, effectively, to factors which were common to both. Alcohol abuse remained signifi cantly related to violent offending.

Markowitz (2000) studied the implications of alcohol consumption on violent crime, and provides possible explanations for the association between alcohol consumption and violent crime in terms of a utility-maximizing framework. She developed a model where violence is in the utility function but not a choice variable in the traditional sense. Violence is an expected or unexpected conse-quence of alcohol consumption. A person maximizes utility and chooses the level of alcohol consumption if violence is expected. If no violence is expected then a level of alcohol consumption is chosen without regard to the effect of violence on utility.

There are three favoured explanations as to why alcohol and violence are linked:

1. A psychopharmacological relationship, in which alcohol can alter behaviour by increasing excitability and/or boosting courage (Fagan, 1993);

2. Alcohol use as an excuse for aberrant behaviour, disinhibition and violence (Fagan, 1993);



3. Unknown common factors that result in both drinking and violent behaviour (Fagan, 1993), including personality variables, such as impulsivity and high risk taking.

There is, however, no consensus on the link (Reiss and Roth, 1993). Studies that have found a link between alcohol consumption, drug abuse and violence in the perpetrator of violence are legion (Ragghianti, 1994), and there are many which also fi nd alcohol in the victim as well (Gerson, 1978; Collins, 1982).

While evidence in the epidemiological and criminological literature for a causative link between alcohol consumption and violence remains questionable, evidence of a causal link emerges in the economics literature. Several studies, for example, have found an inverse relationship between alcohol consumption and alcohol prices. Using the National Family Violence Survey in the USA, Markowitz and Grossman (1998, 2000) studied the effects of state beer taxes on child abuse, and of the price of alcohol on spousal abuse and physical assault by teenagers (Markowitz, 2000). Matthews et al. (2006) found evidence of a causal, negative link between beer prices and treatment for assault injury. In a time-series ana lysis in the USA, Cook and Moore (1993) found a pathway from alcohol price to alcohol consumption to acts of violence resulting in violent injury.

Measuring violence

Measurement of violence has traditionally been the remit of crime statisticians, using police records and information obtained from national crime surveys. The British Crime Survey, as an example, is an annual survey of 40,000 randomly selected households in England and Wales (Mirrlees Black et al., 2001). Such crime surveys do not, however, provide measures at community, town or city levels, and exclude important sectors of the community such as prisoners or the homeless. Furthermore, crime surveys usually do not include violence towards children and young people (Shepherd and Sivarajasingam, 2005).

Police records are even more incomplete. International and national crime surveys in Sweden, the UK and the US all demonstrate low police recording rates (Farrington et al., 1994). British Crime Survey data, for example, show that 75% of ‘moderately serious’ violent offences do not appear in police records (Mirrlees-Black et al., 2001). Nowhere is this under-recording more obvious than in data from trauma services (Shepherd et al., 1989 [Bristol]; Sutherland et al., 2002 [Cardiff and Swansea]). These data have shown that 75–80% of assaults resulting in hospital treatment do not appear in police records, and also that police record-ing varies by patient age, gender and violence location. Violence resulting in treatment of older women, for example, is more likely to appear in police records than that affecting young men (Sutherland et al., 2002). A principal reason for non-recording of violence by the police is lack of reporting. There are many

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reasons for this, including failure to identify the assailant, fear of reprisals, or hostile attitudes to the police and reluctance to have their own conduct scruti-nized too closely (Cretney et al., 1994). Intoxication – usually with alcohol – also minimizes or delays police reporting. One study found that 7 out of 8 assaults in bars and nightclubs, which resulted in hospital treatment, did not appear in police records (Shepherd et al., 1989). A Danish study suggests that the extent of under-recording is similar across national boundaries (Faergemann, 2006). It is not even safe to assume that even the most serious violence will necessarily be detected by police. Police recording, in a Bristol, UK study, was not related to injury sever-ity (Shepherd, 1997), while a US study found that 13% of fi rearm violence identi-fi ed in Atlanta emergency departments (EDs) did not reach police records (Kellermann et al., 2001).

These fi ndings raise an important justice issue. Unless health professionals judge – which they are not in a position to do – that all assault injuries are the fault of the injured patient, can it be right that week in, week out injured people are admitted to hospital for surgical intervention when the cause of the injury – the assailant – is not even investigated let alone brought to book? This sense of injustice has motivated health professionals – mainly trauma surgeons – to col-laborate with local authorities and police to try to ensure by all ethical means that violent people are prevented from further violence (Shepherd, 2001a; Warburton and Shepherd, 2004, 2006).

In some countries, such as the UK, these fi ndings have prompted legislative change – for example the Crime and Disorder Act 1998, which imposes respon-sibility on health services, local government and the police to work together to audit and prevent crime (Warburton and Shepherd, 2006). A clause of the Police Reform Act 2002 brought primary care trusts (and local health boards in Scotland and Wales) formally into these partnerships. These developments fi t with the realization that primary care data have great potential both to guide national understanding and to lead activity in preventing injury and illness (Wanless, 2004).

Core data for prevention

Since the principal responsibility of health professionals is effective and effi cient care of patients, processes for data collection and sharing need to be compatible with and sustainable in busy everyday practice. Evaluations have found that the best method here is for emergency department reception staff to record data electronically from assault patients and those who accompany them when they fi rst arrive (Goodwin and Shepherd, 2000). This does, however, require strong leadership from senior emergency and trauma service staff. In the UK, a core violence dataset has been agreed with the Home Offi ce. It comprises six basic questions concerning the location of violence (e.g. which street, which licensed



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premises), the weapon (fi st, feet, glass, bottle, knife, fi rearm, other), numbers of assailants, repeat violence and whether the incident was reported to police and, if not, whether the patient would like hospital staff to report on his/her behalf (Goodwin and Shepherd, 2000). Once the data have been collected, it is straight-forward for National Health Service information technology staff to anonymize and share them with local authorities and the police who, increasingly, work together in local crime reduction partnerships. These data can then be combined with police intelligence to identify locations where violence is concentrated and to identify frequency of particular weapon use, to inform and assist prevention initiatives (Warburton and Shepherd, 2006).

Injury data have been used in other practical ways too, for example, to oppose drinks/entertainment license applications by the alcohol industry (Warburton and Shepherd, 2004), to prompt changes to late night transport arrangements and to police patrol routes, to relocate fast food outlets in city centres and pedes-trianize entertainment areas. One evaluation showed that the effectiveness of this violence prevention work was signifi cantly enhanced when emergency physi-cians, in the context of a local crime prevention partnership activity, confronted nightclub managers with injury images and data, and told them that injuries in their premises were not only being audited in the local trauma service but also that results would be published (Warburton and Shepherd, 2004).

Implementation of these pioneering measures in Cardiff has been followed by an overall decrease of 35% in numbers of assault patients seeking ED treatment (2000–2005) compared with an overall 18% decrease in England and Wales over the same period. There was a 31% decrease in assaults inside licensed premises in Cardiff city centre (1999–2001). Furthermore, according to Home Offi ce data, by 2005, with the exception of Cambridge, Colchester, Southend and York, Cardiff was experiencing lower levels of violence (including robbery) than any other of the 55 towns and cities in England and Wales with a population over 100,000 (Gibbs and Haldenby, 2006). In its Home Offi ce ‘family’ of 15 socioeco-nomically similar cities, Cardiff has been the safest according to these criteria for four years (2003–2007). Thus, clinician cooperation with key local agencies can improve safety in their communities.

This is familiar territory for public health specialists. In his classic epidemio-logical study, which paved the way for the construction of London sewers to prevent cholera outbreaks, John Snow painstakingly mapped cholera hotspots: the watering holes of Victorian London (Centres for Disease Control, 2004). Similar prevention skills are now being deployed to map and eliminate violence hotspots in pubs and clubs – twenty-fi rst-century watering holes (Warburton and Shepherd, 2006).

As with any worthwhile study, measurement methods, in this case of violence, must be objective. Measurement using injury records is possible because all soft-ware systems in UK accident and emergency departments differentiate between accidental and intentional injury. This approach has facilitated study of several

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hundred thousand assaults (Sivarajasingam et al., 2002). An indication of the validity of such measures lies in their established association with low economic activity, low house prices and youth unemployment rates (Matthews et al., 2006). Some previously unrecognized correlations were also identifi ed, for example between the size of the ethnic minority population and violence, suggesting that trauma services are also in a position to provide early warning of racist tension and violence (Matthews et al., 2006). Of particular importance for this review, an inverse relationship has also been found between alcohol prices and hospital treatment for violent injuries (Matthews et al., 2006).

Trends in violence

Offi cial crime statistics published by governments often generate more heat than light since trends derived from different sources commonly confl ict (Shepherd and Sivarajasingam, 2005). Typically, for example, over the period 1999–2005, police data have suggested steady increases in violent crime in England and Wales whereas crime survey data have suggested steady decreases. Injury data derived from trauma services have brought clarity to these trends. Findings from the National Violence Surveillance Project in England and Wales, in which trends are derived from ED data, demonstrate a signifi cant reduction in violence over the same period (see Figure 1) (Sivarajasingam et al., 2002). This is not to say that measuring violence from injury records is without limitations – no method of measurement is perfect – but this evidence does indicate that these ED injury data and, indeed, crime survey data are objective, that police data are not a reliable measure of violence and that rates of violence in England and Wales have fallen since 1999. This is reassuring for a confused public who, in the absence of clear information and often infl uenced by lurid media reporting, are increasingly fearful of violent crime (Shepherd and Sivarajasingam, 2005).

An evaluation of the effectiveness of closed circuit television (CCTV) in city centres has also shed light on violent crime trends (Sivarajasingam et al., 2003). A comparison of fi ve large towns without urban centre CCTV with fi ve with town centre CCTV showed that this surveillance system increased police detection rates for violence and disorder. Trauma services in the towns with CCTV experienced a decrease in the numbers of assault patients seeking treatment in contrast to control towns which experienced an increase. This differential effect was interpreted as follows. CCTV, which is characterized by continuous radio links between those who watch CCTV moni-tors and police patrols on the ground, results in rapid detection of antisocial behaviour and violence and prompts rapid deployment of police patrols to these incidents limiting violence so that less harm is caused (Sivarajasingam et al., 2003).



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Combining patient care with practical prevention

A care pathway for the management of people injured in violence has been developed that combines treatment with prevention at every level of care based on a series of randomized controlled trials and the evaluations summarized in Figure 2 (Shepherd, 2005b). Traditionally, the management of trauma patients has focused on a single issue – the physical injuries – but strategies that take account of the complex mix of factors leading to the violence are of greater long-term benefi t. The care pathway described here was designed to target risk factors such as the locations in which injury was sustained, the weapons and alcohol misuse. It also takes account of the sequelae of violence for mental health (Shepherd, 2005b). In this care pathway, primary prevention is exemplifi ed by the introduction of toughened and plastic beer glasses, secondary prevention is exemplifi ed by trauma clinic and magistrates court brief alcohol misuse inter-ventions (motivational interviews) and tertiary prevention is exemplifi ed by cog-nitive behavioural therapy to treat post-traumatic stress disorder when it occurs.

Trends in Violence in England and Wales

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Figure 1: Trends in violence in England and Wales according to police, crime survey and injury data

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Preventing glass injury

Trauma surgery research in the 1980s, for the fi rst time, identifi ed bar glasses and bottles as commonly used weapons (Hocking 1989; Shepherd et al., 1990a). The principal glass types and their associated morbidity were identifi ed (Shepherd et al., 1990b). In total, 75% of injuries were of the face, most likely to leave noticeable scarring a year later; eye injuries were infrequent but often serious (Shepherd et al., 1990b). Laboratory research then concluded that glasses typi-cally used as weapons in violence which were tempered (toughened) in the manufacturing process had two qualities with potential for injury prevention – fi rst, they were more resistant to breakage and, second, when they did break they disintegrated into relatively harmless, cuboid pieces with comparatively blunt edges compared with non-toughened glass (Shepherd et al., 1993). A community randomized controlled trial was then carried out in which 57 public houses in the West Midlands and South Wales were restocked on a random and blinded basis either with toughened or non-toughened one-pint-capacity glasses. Injury

PREVENTING COMMUNITY VIOLENCE:

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Figure 2: Care pathway for assault patients attending trauma services



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data were provided by 1229 bar workers over the course of the trial (Warburton and Shepherd, 2000). This informed refi nement of the properties of the drinking vessels when surprise fi ndings – that the injury rates were higher with the “tough-ened” glass (the toughening process actually weakened the trial glasses) – sug-gested that impact resistance per se was the most important quality. These fi ndings prompted the UK glass and alcohol retail industries to switch to impact-resistant glassware (Anon., 1997) and recommendations for a manufacturing standard.

Successive British Crime Surveys have estimated that in the year before the switch 13% of violence between strangers involved glasses or bottles as weapons but in the year after this had fallen to 4% (an estimated annual reduction of 81,000 violent incidents involving such weapons; 95% CI 47,000–115,000) (Mirrlees-Black et al., 2001; sub-analysis Janson, 2006). With the knowledge that increasing impact resistance of drinking vessels decreases injury risk, use of alter-native materials – particularly plastics – can reduce risks even further (Coomaraswamy and Shepherd, 2003). This remains a priority area for prevention since reductions in glass injury have not been maintained consequent upon increased use of bottles in bars and the lack of any manufacturing standards concerning toughened glass.

Reducing alcohol misuse

Substantial reductions in road traffi c injury as the result of drink-drive legislation and law enforcement prompts optimism that changing behaviour with regard to alcohol consumption is achievable in other contexts (Shepherd, 2001b). A practi-cal way to achieve this has emerged from research into use of motivational interviews designed to link alcohol misuse with risky behaviour in the minds of drinkers during ‘teachable moments’, and so reduce drinking (Gentilello et al., 1999). Effectiveness has been established through several meta-analyses of such brief interventions (Effective Health Care Research Team, 1993; Mattick and Jarvis, 1994).

Trauma clinics provide excellent ‘teachable moments’ for delivery of these brief motivational interventions (Smith et al., 2003). They are cost-effective there, since trauma-clinic nurses can be trained to deliver them during standard wound care (e.g. removing sutures). A randomized trial of this approach in maxil-lofacial clinics, which patients usually attend 5–7 days after their injury when they are sober, has demonstrated effectiveness. One year later, for males aged 18–35 who had consumed seven units of alcohol or more in the six hours prior to their face injury, the marginal benefi t of this intervention was 22%. This means that in addition to the alcohol consumption reduction prompted by the injury itself, the brief intervention converted a further one in fi ve at-risk patients to safe drinking (Smith et al., 2003). The results of a randomized trial of a similar

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intervention delivered immediately following sentencing in magistrates’ courts to offenders who had caused injury has demonstrated a signifi cant reduction in injury sustained in the fi rst year, although no signifi cant effect on violent or other offending, or on alcohol consumption (Watt and Shepherd, 2005). In sum, this evidence suggests that reducing alcohol misuse reduces the risk of injury more than the propensity to be violent. The roles of perpetrator and victim are not distinct (Rivara et al., 1995).

Preventing post traumatic stress

Any traumatic event may precipitate an acute psychological response. Characteristic features of this are fear, anger, recurrent distressing thoughts, guilt, depression, anxiety, bad dreams, irritability and generalized hyper-arousal, and at certain times and levels should be considered normal (Bisson and Shepherd, 1995). Most research on the mental health outcomes of violent crime has focused on the psychological effects on women of sexual assaults (e.g. Rothbaum et al., 1992). The prevalence of PTSD after physical injury of other kinds is lower but, according to most studies, still around 30% (Bisson and Shepherd, 1995), and long-term psychological responses are more pronounced after violence than after accidents. In a study of patients with jaw fractures, for example, although levels of anxiety and depression were similar after one week, by three months levels had reduced only in the accident group (Shepherd et al., 1990c).

Attempts have been made to prevent PTSD or similar disorders by providing psychological interventions soon after the trauma, but a Cochrane systematic review of randomized controlled trials of early single-session psychological inter-ventions that involved some reliving of the traumatic experience, often known as debriefi ng, compared with no intervention found that debriefi ng had a negative effect on subsequent psychological distress, despite being well received by a major-ity of participants (Rose et al., 2001). Complex early psychological interventions using cognitive behavioural methods are more effective (Andre et al., 1997; Bryant et al., 1998). These fi ndings, and the effectiveness of exposure therapy for established PTSD, led to the development of a four-session targeted intervention that included elements of exposure therapy and cognitive restructuring (Bisson et al., 2004), which incorporated explanations of the stress experienced, encour-agement to describe the assault in detail (including thoughts, feelings, sights, smells, emotions and physical reactions at the time) and challenge, where appro-priate, to erroneous beliefs that the violence had been the patient’s fault. ‘Image habituation’ training, in which the traumatic image is kept repeatedly in mind, was also done. Psychological symptoms were reduced in treated patients (Bisson et al., 2004) one year later.



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Conclusions

What does all this mean for mental health and criminal justice practitioners? First, it means that many violent injuries can be prevented. Second, emergency care professionals can contribute to safety by working beyond their traditional boundaries. Third, mental health professionals can contribute distinctively and effectively to prevention by ensuring that data regarding the circumstances of injury are collected and shared.

Prevention in medicine is often considered to fall under the purview of public health but this attitude needs to change. All specialists with long-term appoint-ments are authoritative senior citizens in the towns and cities in which they live. Legislation and guidance such as the European Directive on Human Rights, the 1998 Human Rights Act, data protection legislation and crime prevention legisla-tion all encourage and make provision for collaboration to detect, investigate and prevent community violence. Regulatory bodies already encourage and expect prompt collaboration with the police and other agencies responsible for domestic violence prevention and child protection and this expectation is now justifi ed with regard to all categories of serious violence.

The development of effective mental health interventions, whether brief motivational interventions for decreasing alcohol use or interventions to prevent post traumatic anxiety, depression and other stress disorders mean that mental health professionals should develop strong links with all trauma services so that care pathways such as the one described here can be instituted. This is a chal-lenge for all those who manage trauma patients. Communities, towns and cities can be made safer and the burdens of trauma on health services and, most impor-tantly, patients can be reduced if mental health and criminal justice professionals are committed to prevention as well as cure.

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Rothbaum BO, Foa EB, Murdock T, et al. (1992) A perspective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress 5: 455–475.

Shepherd JP (1990) Alcohol and violence. Lancet 336: 1223–1224.Shepherd JP (1997) Violence: the relation between seriousness of injury and outcome in the

criminal justice system. Journal of Accident & Emergency Medicine 14: 204–208.Shepherd JP (1998) Emergency room research on links between alcohol and violent injury.

Addiction 93: 1261–1263.Shepherd JP (2001a) Emergency medicine and police collaboration to prevent community vio-

lence. Annals of Emergency Medicine 38: 420–427.Shepherd JP (2001b) Criminal deterrence as a public health strategy. Lancet 358: 1717–1722.Shepherd JP (2004) NHS Reporting of Firearms Injuries. Firearms Consultative Committee 12th

Annual Report. HC1082: 17–21. London: Stationery Offi ce.Shepherd JP (2005a) The contributions of accident and emergency departments to community

violence prevention. Cardiff University, Cardiff. www.cardiff.ac.uk/vrgShepherd JP (2005b) Victims in the National Health Service: combining treatment with violence

prevention. Criminal Behaviour and Mental Health 15: 75–82.Shepherd JP, Scully C, Shapland M (1989) Recording of violent offences by the police:

an accident and emergency department perspective. Medicine, Science and the Law 29: 251–257.

Shepherd JP, Shapland M, Pearce NX, Scully C (1990a) Pattern, severity and aetiology of injuries in victims of assault. Journal of the Royal Society of Medicine 83: 75–79.

Shepherd JP, Price M, Shenfi ne P (1990b) Glass abuse and urban licensed premises. Journal of the Royal Society of Medicine 83: 276–277.

Shepherd JP, Qureshi R, Preston MS (1990c) Psychological distress after assaults and accidents. British Medical Journal 301: 849–850.

Shepherd JP, Huggett RH, Kidner G (1993) Impact resistance of bar glasses. Journal of Trauma 35: 935–938.

Shepherd J, Sivarajasingam V (2005) Injury research explains confl icting violence trends. Injury Prevention 11: 324–325.

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Sivarajasingam V, Shepherd JP, Matthews K (2002) Trends in violence in England and Wales 1995–2000: an accident and emergency perspective. Journal of Public Health Medicnie 24: 219–226.

Sivarajasingam V, Shepherd JP, Matthews K (2003) Effect of urban closed circuit television on assault injury and violence detection. Injury Prevention 9: 312–316.

Smith AJ, Hodgson RJ, Bridgeman K, Shepherd JP (2003) A randomised controlled trial of a brief intervention after alcohol-related facial injury. Addiction 98: 43–52.

Sutherland I, Sivarajasingam V, Shepherd JP (2002) Recording of community violence by medical and police services. Injury Prevention 8: 246–247.

Wanless D (2004) Securing Good Health for the Whole Population. London: HMSO.Warburton AL, Shepherd JP (2000) Effectiveness of toughened glassware in terms of reducing

injury in bars: a randomised controlled trial. Injury Prevention 6: 36–40.Warburton AL, Shepherd JP (2004) Development, utilisation and importance of accident and

emergency-derived assault data in violence management. Emergency Medicine Journal 21: 473–477.

Warburton AL, Shepherd JP (2006) Tackling alcohol related violence in city centres: effect of emergency medicine and police intervention. Emergency Medicine Journal 23: 12–17.

Watt K, Shepherd JP (2005) A Randomised Controlled Trial of Alcohol Brief Intervention for Violent Offenders in a Magistrates’ Court. Cardiff: Wales Offi ce for Research in Health and Social Care.

White DR, Chen PH (2002) Problem drinking and intimate partner violence, Journal of Studies on Alcohol 63: 205–214.

White HR, Tice PC, Loeber R, Stouthamer-Loeber M (2002) Illegal acts committed by adolescents under the infl uence of alcohol and drugs. Journal of Research in Crime and Delinquency 39: 131–152.

Address correspondence to: Jonathan Shepherd FMedSci, Professor of Oral and Maxillofacial Surgery, Cardiff University School of Dentistry, Heath Park, Cardiff CF14 4XY, UK. Email: [email protected]

preventing alcohol-related violence: a public health approach

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