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ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 165-169

Did the supreme court liquor shop ban in 2017 on highways impact the incidence and severity of road traffic accidents


Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission26-Feb-2020
Date of Decision20-Mar-2020
Date of Acceptance04-Apr-2020
Date of Web Publication10-Jul-2020

Correspondence Address:
Dr. Joshua Vijay Joseph
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_20_20

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  Abstract 


Background: Alcohol intoxication plays a major role in the causation of road traffic accidents (RTAs) and assault. On April 1, 2017, the honorable Supreme Court of India banned liquor shops on all national and state highways to a distance of 500 m from them. Out of 231 liquor shops, 178 were closed in Vellore district after the ban. This, we assumed, would have reduced the number of drunken drivers and pedestrians, resulting in the fall in the number and severity of the accidents. Materials and Methods: This is a retrospective observational study done in a tertiary hospital in South India. All RTA patients presented to the emergency department (ED) 1 month before the liquor shop ban (March 2017) were included in the preban group and who presented to the ED 1 month after the liquor shop ban (April 2017) were included in the postban group; their incidence and severity of trauma were assessed and compared. A bivariate analysis was done to identify the relationship between these variables and potential determinants, and their 95% confidence interval (CI) was calculated. For all tests, a two-sided P < 0.05 was considered statistically significant. Results: The study cohort included 438 patients, in which 194 were in preban group and 244 in the postban group. Both groups showed male predominance, with a mean age of 37.57 and 35.12 years, respectively. Majority of the RTAs in both groups involved two-wheelers (75.3% vs. 77.9% [odds ratio (OR): 0.87, 95% CI: 0.55–1.35, P = 0.52]). There was no decrease in the incidence of RTA victims under the influence of alcohol (45.2% vs. 45%, OR: 1.6, 95% CI: 0.89–2.90, P = 0.11). There was no decrease in the incidence of severe head injuries (19.1% vs. 15.6%, OR: 1.28, 95% CI: 0.78–2.10, P = 0.33) or injuries to extremities (42.8% vs. 35.2%, OR: 1.37, 95% CI: 0.93–2.02, P = 0.11). Conclusions: Although three-fourth of the liquor shops in the district were closed, it did not have a significant impact on the incidence and severity of RTAs presenting to the ED.

Keywords: Emergency department, liquor shop ban, road traffic accidents


How to cite this article:
Joseph JV, Roshan R R, Sudhakar G D, Prasanth R, Abhilash KP. Did the supreme court liquor shop ban in 2017 on highways impact the incidence and severity of road traffic accidents. Curr Med Issues 2020;18:165-9

How to cite this URL:
Joseph JV, Roshan R R, Sudhakar G D, Prasanth R, Abhilash KP. Did the supreme court liquor shop ban in 2017 on highways impact the incidence and severity of road traffic accidents. Curr Med Issues [serial online] 2020 [cited 2020 Aug 8];18:165-9. Available from: http://www.cmijournal.org/text.asp?2020/18/3/165/289410




  Introduction Top


Road traffic accidents (RTAs) cause the largest number of injuries and fatalities worldwide by killing around 1.2 million people each year and injuring 50 million.[1] The total number of deaths every year due to road accidents has now passed the 135,000 mark according to the latest report of the National Crime Records Bureau (NCRB).[2] The NCRB report further states that drunken driving is a major factor for road accidents. It is reported in India that 25% of fatalities in RTAs occur due to drunken driving.[2] More than half of all road traffic deaths are among vulnerable road users, namely, pedestrians, cyclists, and motorcyclists. Around 93% of the world's fatalities on road occur in low- and middle-income countries, even though these countries have approximately 60% of the world's vehicles.[3] Road traffic injuries are the leading cause of death for children and young adults aged 5–29 years.[4]

Unsafe consumption of alcohol coupled with driving vehicles puts not only those individuals in harm but also the co-passengers of the vehicle and also the unfortunate ones on the road.[5] Under Section 185 of the Indian Motor Vehicles Act, India, driving with a blood alcohol concentration (BAC) level above 30 mg/dl is a punishable offense.[6]

On December 15, 2016, the Honorable Supreme Court of India ordered the closure of all liquor vendors located within 500 m of state and national highways by April 1, 2017. The court issued its order in recognition of the role of drunken driving in road accidents, injuries, and deaths. In addition, advertising liquor on highways was banned with immediate effect.[7] Around 80% (178 of 231) of liquor shops were closed in Vellore district with immediate effect. We felt that the implementation of liquor shop ban on highways could decrease the incidence of drunken drive and the incidence of severity of RTAs. The primary outcome of the study was to find the reduction in the incidence and severity of RTAs after the implementation of liquor shop ban.


  Materials and Methods Top


Methodology

Design

This was a retrospective observational cohort study comparing the incidence and severity of RTA before and after the implementation of liquor shop ban on national highways.

Setting

The study was conducted in the emergency department (ED) of Christian Medical College Hospital, Vellore, which is a tertiary medical care center. The ED is a 49-bed department with about 300 trauma and nontrauma admissions a day.

Duration of study

This study was conducted over a 2-month period. Those who presented in the month of March were considered as the preban group and those in April were considered as the postban group.

Participants

Adults who presented with an alleged history of RTA presenting within 12 h of the incident, between March and April 2017, were included in the study. RTA victims aged below 18 years and those presenting after 12 h of the incident were excluded from the study.

Variables

Data of the patients were obtained from electronic hospital records, and the details of history and physical examination findings of all patients were recorded on a standard data collection sheet. The variables included age, sex, triage priority, time of incident, mechanism of injury, mode of incident, time of admission, and type and severity of injuries. Triage priority level was defined as follows:

  1. Triage priority 1: Patients with airway, breathing, or circulation compromise, or head injury with Glasgow Coma Scale (GCS) score <8
  2. Triage priority 2: Patients with stable airway, breathing, and circulation with long-bone injuries, dislocations, stable abdomino-thoracic injuries, and head injury with GCS score 9 or more
  3. Triage priority 3: Hemodynamically stable patients with minor trauma.


Outcome variable

The incidence and severity of RTAs among the preban group and postban group.

Bias

This was a retrospective study, and therefore, we could not control exposure or outcome assessment, and instead relied on others for accurate recordkeeping.

Study size

To study the incidence among the preban and postban groups, we took the data on RTAs presented in the months of March 2017 (preban) and April 2017 (postban).

Statistical analysis

All categorical variables were expressed as frequencies and percentages. The data were extracted from ED triage software and clinical workstation and entered in the Statistical Package for the Social Science software (SPSS Inc., Released 2018. SPSS for Windows, version 25.0.0.0, Chicago, IL, USA). Data were summarized using mean with standard deviation (SD) for continuous variables and frequencies with percentages. A bivariate analysis was done to identify the relationship between these variables and potential determinants, and their 95% confidence interval (CI) was calculated. For all tests, a two-sided P < 0.05 was considered statistically significant.

Ethical considerations

This study was approved by the institutional review board prior to the commencement of the study, and approval from the institutional review board ethical committee was obtained (IRB Min no. 10912 dated 25.10.2017). Patient confidentiality was maintained using unique identifiers and by password-protected data entry software with restricted users.


  Results Top


The study was conducted over a period of 2 months (March 2017–April 2017), during which we attended to a total of 9393 patients. Of these, 1071 patients presented with trauma. After excluding fall from heights, workplace injuries, and assaults, the number of patients associated with RTAs was found to be 564 patients. Pediatric and adolescent patients were excluded from the study. The final study cohort included a total of 438 patients, out of which 194 were in the preban group (March 2017) and 244 were in the postban group (April 2017) [Figure 1].
Figure 1: STROBE diagram.

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Demographics

The mean age of the population in the preban arm was 37.6 (SD: 17.4) years and 35.2 (SD: 16.1) years in the postban arm. There was a male predominance in both the arms accounting to 77%. The baseline characteristics and events related to the incident are summarized in [Table 1]. The time of incidence or triage priority at the time of presentation to ED also did not have a significant difference among the preban and postban groups [Table 2]. There was no significant difference between the incidence of two-wheeler accidents in the preban and postban groups (77.9% vs. 75.3%, respectively) (odds ratio [OR]: 0.86, 95% CI: 0.55–1.35, P = 0.52) [Table 3].
Table 1: Baseline characteristics

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Table 2: Association of time and triage priorities of road traffic accidents in pre- and postban

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Table 3: Mode of injury

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The pattern of injuries was compared in both groups. From this, we found a predominance in musculoskeletal injuries to extremities in both the groups (43% vs. 39%), followed by head injury (19% vs. 15%) [Figure 2].
Figure 2: Association of pattern of injuries between preban and postban.

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The incidence of RTAs in weekdays and weekends was compared, and no significant correlation could be made between the preban and postban groups (67.5% vs. 62.7%) in weekdays and (32.5% vs. 37.3%) in weekends.

The BAC positivity was equal in both the pre- and postban groups, thirty patients in each arm (15.5% vs. 12.4%), and injury patterns were compared [Table 4]. Of all the patients recruited, 14% (60) were positive for plasma alcohol (>0.3 g/L), and they were found to be at a higher risk of sustaining head injuries (OR: 3.23, 95% CI: 1.77–5.9, P =0.0001) and thoracic injuries (OR: 2.49, 95% CI: 1.01–6.22, P =0.049), compared to the population who were not under the influence.
Table 4: Association of injuries among patients with positive blood alcohol concentrations in pre- and postban

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The Revised Trauma Score (RTS) was used to characterize the severity of the trauma. Thirteen patients had an RTS <4: 8 (4.1%) in the preban group and 5 (1.7%) in the postban group.


  Discussion Top


Our study which assessed the association between liquor shop ban in highways and the incidence of RTAs before and after ban, found that there was no significant difference in the incidence or severity of RTAs before and after the ban.

Alcohol is a major risk factor in all RTAs. As driving under the influence of alcohol causes imprecise and irrational behavior, there is an increased chance of being involved in an accident. The WHO reports that the risk of being in an accident increases significantly with BAC above 40 mg/dl. A systematic review conducted by Das et al. estimated that alcohol was responsible for 2%–33% of injuries and 6%–48% of deaths in RTAs.[8] Our study shows that 14% of the study population were under the influence of alcohol and had had severe injuries.

Motorization has enhanced the lives of many individuals and societies, but the benefits have come with a price. RTAs injure or disable between 20 and 50 million people a year, with the most vulnerable road users being pedestrians, cyclists, two-wheeler riders, and passengers on public transport.[4] Our study showed three-fourth of RTA victims being two-wheeler riders.

A study done in Brazil in the year 2012 analyzed the impact of short-term alcohol bans on RTAs, traffic injuries, and hospital admissions. Eleven out of 27 states imposed on its 2733 municipalities the decision to adopt alcohol bans. Using day-level data from municipalities, they found that alcohol ban caused substantial reductions in RTAs (19%), traffic injuries (43%), and traffic-related hospitalizations (17%). An analysis of traffic-related hospitalization costs allows us to estimate the lower bound of the negative externality associated with excessive alcohol consumption in this context, and it reveals that electoral dry laws saved Brazil's public health-care system $100,000 per day.[9] This study showed a significant reduction in RTA during the liquor ban as it was a complete ban compared to our partial liquor shop ban only on highways.

Studies done in Bogota, Columbia, showed that the average cost per accident was estimated at 1349 USD. On an average, the total cost for health care for patients with positive blood alcohol level was 1.8 times higher than those who did not consume alcohol. The indirect costs were on average 115.3 USD per injured person.[10]

A study done in the United States by Hadjizacharia et al. on alcohol exposure and outcomes in trauma patients and alcohol influence was associated with an increased incidence of admission, hypotension, and depressed GCS score, and alcohol exposure appeared to increase mortality after injury.[11] Our study shows that a person under the influence of alcohol has significantly increased risk of sustaining head injury and chest injuries compared to those not under the influence of alcohol.

This study clearly demonstrates that alcohol consumption has increased the risk of sustaining major injuries. Partial liquor shop ban in highways did not have any significant decrease in the incidence or severity of RTAs. More studies need to be done including a complete liquor ban and its relevance in RTAs.

Limitations

The study could not be continued beyond the month of April as there were several petitions made demanding to revoke the ban, which eventually led to reopening of those liquor shops that were closed after the implementation of the ban. The alcohol levels of the patient presenting to the ED alone could not be used to assess the outcome as there was a possibility that the patient presenting to the ED alone might not have consumed alcohol, but the perpetrator of the RTA might have, at the time of the incident.


  Conclusions Top


RTAs are associated with significant morbidity and mortality, especially in developing countries like India. Alcohol on its own is injurious to health, and driving under the influence of alcohol puts drivers and civilians at the risk of RTA. With this study, we were able to conclude that the partial liquor shop ban on highways by the Supreme Court of India did not have any significant reduction in the incidence and severity of RTAs. Furthermore, patients presenting to the ED under the influence of alcohol were found to have significant head-and-facial injuries, whereas patients who were not under the influence of alcohol during the accident had significant injuries localized to the extremities which were not life threatening. A prospective multicentric community-level study will help us to determine the incidence and severity of RTAs. Proper health education, awareness, precautions, and safer roads could help in reducing the incidence and severity of RTAs. Reinforcement and implementation of laws can reduce RTAs associated with the consumption of alcohol.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require institutional review board/ethics committee review, and the corresponding protocol/approval number is IRB Min no. 10912 dated 25.10.2017. We also certify that we have not plagiarized the contents in this submission and have done a plagiarism check.



 
  References Top

1.
World Health Organization. The World Health Report 2002 - Reducing Risks, Promoting Healthy Life. World Health Organization. Available from: https://www.who.int/whr/2002/en/. [Last accessed on 2019 Dec 03].  Back to cited text no. 1
    
2.
Crime in India; 2016 Available from: http://ncrb.gov.in/StatPublications/CII/CII2016/cii2016.html. [Last accessed on 2020 Feb 16].  Back to cited text no. 2
    
3.
Toroyan T, Peden MM, Iaych K. WHO launches second global status report on road safety. Inj Prev 2013;19:150.  Back to cited text no. 3
    
4.
Road Traffic Injuries. Available from: https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries. [Last accessed on 2019 Dec 03].  Back to cited text no. 4
    
5.
Heydari ST, Vossoughi M, Akbarzadeh A, Lankarani KB, Sarikhani Y, Javanmardi K, et al. Prevalence and risk factors of alcohol and substance abuse among motorcycle drivers in Fars province, Iran. Chin J Traumatol 2016;19:79-84.  Back to cited text no. 5
    
6.
Section 185 in the Motor Vehicles Act; 1988. Available from: https://indiankanoon.org/doc/139481594/[Last accessed on 2020 Feb 16].  Back to cited text no. 6
    
7.
A Timeline of the Supreme Court's Ban On The Sale Of Liquor Along Highways Features. NDTV-Diageo Road to Safety; 2017. Available from: https://sites.ndtv.com/roadsafety/a-timeline-of-the-supreme-courts-ban-on-the-sale-of-liquor-along-highways-3187/. [Last accessed on 2019 Dec o3].  Back to cited text no. 7
    
8.
Das A, Gjerde H, Gopalan SS, Normann PT. Alcohol, drugs, and road traffic crashes in India: A systematic review. Traffic Inj Prev 2012;13:544-53.  Back to cited text no. 8
    
9.
Nakaguma MY, Restrepo BJ. Restricting access to alcohol and public health: Evidence from electoral dry laws in Brazil. Health Econ 2018;27:141-56.  Back to cited text no. 9
    
10.
Gómez-Restrepo C, Naranjo-Lujan S, Rondón M, Acosta A, Maldonado P, Arango Villegas C, et al. Latin American Clinical Epidemiology Network Series - Paper 6: The influence of alcohol in traffic accidents and health care costs of it in Bogotá-Colombia. J Clin Epidemiol 2017;86:106-10.  Back to cited text no. 10
    
11.
Hadjizacharia P, O'Keeffe T, Plurad DS, Green DJ, Brown CV, Chan LS, et al. Alcohol exposure and outcomes in trauma patients. Eur J Trauma Emerg Surg 2011;37:169-75.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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