The night’s first visitor to the Safe Haven – a Peugeot ambulance with twin sick bays, parked in the shadow of the St Nicholas cathedral – is carried in by friends around 10.30pm. He is unable to walk, although at regular intervals he is able to throw up some of the bottle of rum he has just drunk.

The St John Ambulance team here in Newcastle see dozens of these men and women every night: a head laceration on a rough sleeper, a student who thinks she broke a tooth when a friend accidentally closed a door on her, a German couple concerned about a man tottering precariously close to the edge of the High Level Bridge.

The common denominator? Alcohol, and in due course the patients are walked 20 yards to a second van nearby that has been converted to take eight seats, and has sick bowls and wet wipes. Under the supervision of two police officers the patients are given time to sober up, charge their phones, contact friends or family, and get taxis home.

One of the officers has worked the city centre beat for 16 years. “Babysitting drunk kids didn’t used to be our job,” he says. “But the focus these days is on people’s safety.”

Some surveys suggest a recent trend towards more moderate drinking among younger people, but on tonight’s evidence, there are still plenty who enjoy a drink. The crew will assess and treat more than 50 people by sunrise.

“There are drinkers who know they’ve had enough, those who don’t, and those who do but carry on,” says Daryen Lemmon, clinical operations manager of the North East Ambulance Service, which runs the Safe Haven in partnership with St John and the Northumbria police and crime commissioner.

“They’re the dangerous ones, and the challenge is to make them understand that they are vulnerable.”

The Safe Haven is designed to help tackle that challenge, relieving pressure on Newcastle’s stretched police and hospital resources. Five years ago, before it was introduced, A&E waiting rooms and police station receptions were stuffed on weekend nights. Similar safe havens are in operation in Bristol and Cardiff. In December, NHS England made £300,000 available for other cities to set up similar facilities over the festive period.

But along the so-called Diamond Strip of Newcastle nightclubs, there is still plenty to keep police patrol cars, ambulances and street pastors busy as they rub shoulders with pushy promoters promising three trebles – three triple-shots of spirits, such as vodka or rum, with a mixer like Red Bull or orange – for little more than a fiver.

Recent data shows the number of reported alcohol-related ambulance callouts in the city centre is rising, not falling. A University Hospital Galway study found that in some cities the percentage of A&E patients with alcohol-related injuries can rise to 30% at weekends. Newcastle’s council, health and police chiefs are doing more than most to minimise the damage. Yet while Big Tobacco is on the retreat, alcohol still runs freely through Britain’s cities.

Post-industrial cities such as Newcastle, Leeds, Liverpool, Manchester and Nottingham dominate the latest Which? University rankings of best cities for nightlife. They have some of the highest densities of pubs and bars per sq km, and the most recent Public Health England figures suggest those densities are increasing every year – and much faster than the national average.

Those same cities tend also to be the ones with the highest rates of alcohol-related injuries. Those rates are increasing, too – again, at a rate faster than the national average. A University of Sheffield study published in August found that places with the most pubs, bars and nightclubs had a 13% higher hospital admission rate for acute conditions caused by alcohol than places with the lowest density of such establishments.

Serving a regional population of around 2 million, Newcastle’s compact city centre offers a rowdy but representative sample on a Saturday night: all ages, men and women, but skewed heavily in favour of the 50,000 students who study here. These younger revellers seek entry between the red velvet ropes erected by pre-bars and clubs with exotic names like Tup Tup Palace, Florita’s and Bijoux. A more affluent set of locals head for the gin bars and microbreweries of Grey Street and High Bridge. Older drinkers settle in for the night in the traditional pubs of the Bigg Market.

Facebook Twitter Pinterest People talk to a friend being treated in an ambulance parked outside a night spot in Cardiff city centre. Photograph: Matt Cardy/Getty Images

These pubs, bars and nightclubs are the engine of the night-time economy, on which Britain’s struggling post-industrial cities and towns are becoming ever more dependent. In many ways it is itself a hangover from the past: the great industrial cities of 19th-century Britain were saturated with beer houses, gin palaces and pubs, and in Newcastle drinking patterns formed around the working lives of shipbuilders and coal miners who finished their last shifts at 1pm on a Saturday, then went to the pub and drank away their wages until closing time.

Now, with heavy industry gone, these cities are left with their reputation as party towns. Newcastle city council estimates its night-time economy accounts for 7,000 jobs, £500m of revenue and 17 million visitors a year – more than a few of them on stag or hen parties. “As proud Geordies, we sure know how to party in style,” boasts the local bar crawl organiser Last Night of Freedom. “If you’re visiting the city and you’re looking for a canny night out – slap on your false tan, prepare to tash on and get propa mortal.”

Protecting this reputation comes at a high price. You hardly need a Lancet subscription to know the links between alcohol and a slew of health and social problems: heart disease, liver disease, brain damage, cancer, mental health problems, accidents, injuries, assaults, domestic violence and sexual offences, to name a few.

The alcohol-related mortality rate in Newcastle has risen in the last five years from 48 to 61 per 100,000 people. The English average is 46. Rachael Hope, the city’s community safety specialist for drugs and alcohol, says she knows of 4,066 dependent drinkers in Newcastle, including 180 she describes as having multiple issues of substance abuse or mental health. “They’re the ‘frequent flyers’ who come in and out of various different services,” she says, “but you don’t necessarily see alcohol problems present themselves in the same way as you would see a drug issue – until possibly it’s too late.”

Newcastle has done more than most to constrain what economists would call these “externalities”: side effects of a product that have a negative impact on society as a whole but aren’t reflected in its price.

Now keen to shed the image it gained as a stag and hen party destination of alcoholic excess – amplified to the world through the MTV reality show Geordie Shore – the city introduced a new licensing strategy last year that seeks to prove its night-time economy is about more than just alcohol.

By having the right planning and licensing policies, we can help business fit in with our vision of the future of the city Ed Foster, Newcastle City Council

In neighbourhoods with the most licensed premises, the council is encouraging operators to move towards a more mixed offer: more restaurants, more bars with seating, more family-oriented attractions.

Bars along the city’s Georgian Grey Street have accepted a voluntary minimum unit pricing of 50p. Newcastle is one of just eight cities and local authorities to introduce a late-night levy: 243 licensed premises pay into a fund that pays for the extra policing, taxi marshals and after-hours cleaning incurred by the night-time economy.

On the top floor of the Newcastle Civic Centre, a half-hour walk from the Diamond Strip, Ed Foster heads up the city’s public safety and regulation team. “We want to support business and growth in the city, but we want to shape what goes where,” he says. “By having the right planning and licensing policies, we can help business fit in with what our vision is of the future of the city.”

Police, meanwhile, have been working with bar and club staff, training them to take better care of drunk and vulnerable people following a series of tragic incidents: in 2012, a drunk 17-year-old schoolgirl was raped by at least two men after being thrown out of Digital nightclub; in 2016, the death of an 18-year-old student at Hoults Yard revealed a shortage of qualified first-aiders on the premises.

That same year, a 20-year-old Newcastle University student died from excessive alcohol during an Agric Society initiation ceremony. The school and other universities in the city have since intervened, encouraging freshers’ week organisers to plan as many “grub crawls” as pub crawls. Meanwhile, a drugs bust and forced closure of three adjoining late-night bars on the Diamond Strip in 2017 has led to clampdowns on club-night promoters, who could soon become licensed and regulated in the same way as bouncers and door staff.

Facebook Twitter Pinterest People walk between pubs and clubs in Cardiff city centre. Photograph: Matt Cardy/Getty Images

“Police budgets have shrunk, so I’ve got to work differently,” says Ch Insp Dave Pickett, who is responsible for Newcastle city centre. “One of my sons is 13 now, so in the not-too-distant future he’ll be wanting to go out with his friends and I want to know he’ll be looked after, not left abandoned on a night out.”

He says his methods are working. Over the 12 months to September 2018, he points to a 10% decrease in alcohol-related violent crime in the city centre in the “peak hours” – midnight to 5am at weekends. Nevertheless, 60% of violent crime at those times remains alcohol-related, and that period saw 713 incidents of alcohol-related violence result in injury.

The city of Liverpool reckons its economic cost from misuse of alcohol at around £750m a year. In January this year it opened a Centre for Alcohol Research, but it faces the same dilemma as Newcastle and others seeking to reduce harm from alcohol: how to regenerate city centres without it? Central government funding to Newcastle will have fallen by £282m in the 10 years to 2020. Licensed premises are some of the city’s most successful remaining businesses.

The rules are skewed towards the interests of Big Alcohol, says Colin Shevills, director of the north-east campaign group Balance.

“At the centre of the [2003] Licensing Act is a presumption to approve an alcohol licence, unless you can prove that damage is going to emanate from that particular location – and that’s very difficult to prove,” he says.

Indeed, more than nine out of 10 applications for licences – many of them for high-volume “vertical-drinking” bars – are being approved, even in “cumulative impact zones”, areas that cities have already identified as saturated. In Newcastle the number of licensed premises continues to rise, not fall, from 1,165 in 2013 to 1,197 now. Each pays as much as £1,000 for a licence. To a cash-strapped city, alcohol is a much-needed source of revenue.

The extended drinking hours introduced by the Licensing Act were aimed at bringing “continental”-style café culture to England: according to a slogan of the time, “Bologna in Birmingham, Madrid in Manchester, why not?”

A decade later, the government devolved responsibility for drugs and alcohol treatment services to local authorities, leaving cities to pick up the bill. Subsequent austerity cuts meant places like Newcastle could no longer afford to pay for dedicated alcohol services, which are now merged with drugs treatment services. At least 41 English hospitals do not currently have an alcohol care team.

The government’s toothless approach to alcohol contrasts with its aggressive targeting of Big Tobacco, which has seen it restrict the sales of cigarettes and all but banish advertising.

That would be tricky to do with booze. Much of the night-time economy is run by the alcohol industry. Night-time mayors typically have backgrounds in nightclubs or licensed premises: in London, for example, the current chair of the Night Time Commission, Kate Nicholls, is also the CEO of UK Hospitality; her vice chair is a director of the Drinkaware Trust, which is funded largely by donations from UK alcohol producers, retailers and supermarkets.

The UK government receives more than £10.7bn a year from alcohol in excise duty. Shevills believes cities could benefit if the government raised that duty, and quotes figures published by his organisation that nearly half (49%) of people in the north-east support higher alcohol taxes if the money goes into public services affected by alcohol use, such as the NHS and police. A cross-party parliamentary group recently published an “alcohol charter”, calling for alcohol duties to rise enough to provide £100m of new money for treatment services.

And yet with alcohol cheaper than ever – it is 60% more affordable than it was in 1980 – some cities might also benefit from minimum unit pricing, which might also tackle the “pre-loading” habit of tanking up at home on supermarket-bought booze before catching a cab into town at 11pm. The number of convenience stores selling alcohol in cities has more than doubled over the last decade.

Facebook Twitter Pinterest People enjoy themselves in Newcastle on the night the drinking laws are relaxed, Wednesday 23 November 2005. Photograph: Owen Humphreys/PA

Restricting advertising is another option. In the US, several cities already ban alcohol ads on public transport, including New York, Los Angeles and San Francisco. “History has shown us is that when restrictions and bans were placed on tobacco sponsorship, other companies come in and fill the advertising void,” says Shevills.

But the alcohol industry, like Big Tobacco before it, is resilient and resourceful, and unlikely to give up control of cities without a fight. Lobbying in Chicago, Charlotte and Washington DC, for example, has recently overturned bans on alcohol advertising on public transit.

Likewise, in another Newcastle – the one in New South Wales, Australia – “lockout” laws that have halved alcohol-related assaults are under constant attack. Local activist Tony Brown says the city centre used to be a no-go zone at night, held hostage by the “three Vs: violence, vandalism and vomit”.

The solution he and fellow campaigners spearheaded scaled back trading hours in the central business district to 3am, and licensed premises were barred from admitting anyone after 1am. He says those changes have led to a 72% reduction in reported alcohol non-domestic assaults in the central business district, and have also boosted the night-time economy, with the number of smaller licensed premises – restaurants and smaller bars – more than doubling.

How British ‘cafe culture’ drinks revolution ended in failure Read more

And yet New South Wales’s Independent Liquor and Gaming Authority is under sustained lobbying to roll back the changes, in spite of evidence of what can happen when licensing hours are relaxed.

“We had this whole narrative going on, which is common internationally, that the blame was all about the young people themselves. It really pissed me off from a social equity view,” says Brown. “No one was ever talking about political responsibility or the industry’s responsibility. This is a dominant mono-narrative about blaming young people.

“Our cities must disentangle themselves from the industry and escape from the notion that the unfettered availability and supply of alcohol is a prerequisite for the development and sustainability of the night-time economy. Our city has proven otherwise.”

For the rest, as any addict knows, the first step to recovery is admitting they have a problem.

Follow Guardian Cities on Twitter, Facebook and Instagram to join the discussion, catch up on our best stories or sign up for our weekly newsletter