PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (517181)

Clipboard (0)
None

Related Articles

1.  The Effectiveness of Community Action in Reducing Risky Alcohol Consumption and Harm: A Cluster Randomised Controlled Trial 
PLoS Medicine  2014;11(3):e1001617.
In a cluster randomized controlled trial, Anthony Shakeshaft and colleagues measure the effectiveness of a multi-component community-based intervention for reducing alcohol-related harm.
Background
The World Health Organization, governments, and communities agree that community action is likely to reduce risky alcohol consumption and harm. Despite this agreement, there is little rigorous evidence that community action is effective: of the six randomised trials of community action published to date, all were US-based and focused on young people (rather than the whole community), and their outcomes were limited to self-report or alcohol purchase attempts. The objective of this study was to conduct the first non-US randomised controlled trial (RCT) of community action to quantify the effectiveness of this approach in reducing risky alcohol consumption and harms measured using both self-report and routinely collected data.
Methods and Findings
We conducted a cluster RCT comprising 20 communities in Australia that had populations of 5,000–20,000, were at least 100 km from an urban centre (population ≥ 100,000), and were not involved in another community alcohol project. Communities were pair-matched, and one member of each pair was randomly allocated to the experimental group. Thirteen interventions were implemented in the experimental communities from 2005 to 2009: community engagement; general practitioner training in alcohol screening and brief intervention (SBI); feedback to key stakeholders; media campaign; workplace policies/practices training; school-based intervention; general practitioner feedback on their prescribing of alcohol medications; community pharmacy-based SBI; web-based SBI; Aboriginal Community Controlled Health Services support for SBI; Good Sports program for sports clubs; identifying and targeting high-risk weekends; and hospital emergency department–based SBI. Primary outcomes based on routinely collected data were alcohol-related crime, traffic crashes, and hospital inpatient admissions. Routinely collected data for the entire study period (2001–2009) were obtained in 2010. Secondary outcomes based on pre- and post-intervention surveys (n = 2,977 and 2,255, respectively) were the following: long-term risky drinking, short-term high-risk drinking, short-term risky drinking, weekly consumption, hazardous/harmful alcohol use, and experience of alcohol harm. At the 5% level of statistical significance, there was insufficient evidence to conclude that the interventions were effective in the experimental, relative to control, communities for alcohol-related crime, traffic crashes, and hospital inpatient admissions, and for rates of risky alcohol consumption and hazardous/harmful alcohol use. Although respondents in the experimental communities reported statistically significantly lower average weekly consumption (1.90 fewer standard drinks per week, 95% CI = −3.37 to −0.43, p = 0.01) and less alcohol-related verbal abuse (odds ratio = 0.58, 95% CI = 0.35 to 0.96, p = 0.04) post-intervention, the low survey response rates (40% and 24% for the pre- and post-intervention surveys, respectively) require conservative interpretation. The main limitations of this study are as follows: (1) that the study may have been under-powered to detect differences in routinely collected data outcomes as statistically significant, and (2) the low survey response rates.
Conclusions
This RCT provides little evidence that community action significantly reduces risky alcohol consumption and alcohol-related harms, other than potential reductions in self-reported average weekly consumption and experience of alcohol-related verbal abuse. Complementary legislative action may be required to more effectively reduce alcohol harms.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12607000123448
Please see later in the article for the Editors' Summary
Editors' Summary
Background
People have consumed alcoholic beverages throughout history, but alcohol use is now an increasing global public health problem. According to the World Health Organization's 2010 Global Burden of Disease Study, alcohol use is the fifth leading risk factor (after high blood pressure and smoking) for disease and is responsible for 3.9% of the global disease burden. Alcohol use contributes to heart disease, liver disease, depression, some cancers, and many other health conditions. Alcohol also affects the well-being and health of people around those who drink, through alcohol-related crimes and road traffic crashes. The impact of alcohol use on disease and injury depends on the amount of alcohol consumed and the pattern of drinking. Most guidelines define long-term risky drinking as more than four drinks per day on average for men or more than two drinks per day for women (a “drink” is, roughly speaking, a can of beer or a small glass of wine), and short-term risky drinking (also called binge drinking) as seven or more drinks on a single occasion for men or five or more drinks on a single occasion for women. However, recent changes to the Australian guidelines acknowledge that a lower level of alcohol consumption is considered risky (with lifetime risky drinking defined as more than two drinks a day and binge drinking defined as more than four drinks on one occasion).
Why Was This Study Done?
In 2010, the World Health Assembly endorsed a global strategy to reduce the harmful use of alcohol. This strategy emphasizes the importance of community action–a process in which a community defines its own needs and determines the actions that are required to meet these needs. Although community action is highly acceptable to community members, few studies have looked at the effectiveness of community action in reducing risky alcohol consumption and alcohol-related harm. Here, the researchers undertake a cluster randomized controlled trial (the Alcohol Action in Rural Communities [AARC] project) to quantify the effectiveness of community action in reducing risky alcohol consumption and harms in rural communities in Australia. A cluster randomized trial compares outcomes in clusters of people (here, communities) who receive alternative interventions assigned through the play of chance.
What Did the Researchers Do and Find?
The researchers pair-matched 20 rural Australian communities according to the proportion of their population that was Aboriginal (rates of alcohol-related harm are disproportionately higher among Aboriginal individuals than among non-Aboriginal individuals in Australia; they are also higher among young people and males, but the proportions of these two groups across communities was comparable). They randomly assigned one member of each pair to the experimental group and implemented 13 interventions in these communities by negotiating with key individuals in each community to define and implement each intervention. Examples of interventions included general practitioner training in screening for alcohol use disorders and in implementing a brief intervention, and a school-based interactive session designed to reduce alcohol harm among young people. The researchers quantified the effectiveness of the interventions using routinely collected data on alcohol-related crime and road traffic crashes, and on hospital inpatient admissions for alcohol dependence or abuse (which were expected to increase in the experimental group if the intervention was effective because of more people seeking or being referred for treatment). They also examined drinking habits and experiences of alcohol-related harm, such as verbal abuse, among community members using pre- and post-intervention surveys. After implementation of the interventions, the rates of alcohol-related crime, road traffic crashes, and hospital admissions, and of risky and hazardous/harmful alcohol consumption (measured using a validated tool called the Alcohol Use Disorders Identification Test) were not statistically significantly different in the experimental and control communities (a difference in outcomes that is not statistically significantly different can occur by chance). However, the reported average weekly consumption of alcohol was 20% lower in the experimental communities after the intervention than in the control communities (equivalent to 1.9 fewer standard drinks per week per respondent) and there was less alcohol-related verbal abuse post-intervention in the experimental communities than in the control communities.
What Do These Findings Mean?
These findings provide little evidence that community action reduced risky alcohol consumption and alcohol-related harms in rural Australian communities. Although there was some evidence of significant reductions in self-reported weekly alcohol consumption and in experiences of alcohol-related verbal abuse, these findings must be interpreted cautiously because they are based on surveys with very low response rates. A larger or differently designed study might provide statistically significant evidence for the effectiveness of community action in reducing risky alcohol consumption. However, given their findings, the researchers suggest that legislative approaches that are beyond the control of individual communities, such as alcohol taxation and restrictions on alcohol availability, may be required to effectively reduce alcohol harms. In other words, community action alone may not be the most effective way to reduce alcohol-related harm.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001617.
The World Health Organization provides detailed information about alcohol; its fact sheet on alcohol includes information about the global strategy to reduce the harmful use of alcohol; the Global Information System on Alcohol and Health provides further information about alcohol, including information on control policies around the world
The US National Institute on Alcohol Abuse and Alcoholism has information about alcohol and its effects on health
The US Centers for Disease Control and Prevention has a website on alcohol and public health that includes information on the health risks of excessive drinking
The UK National Health Service Choices website provides detailed information about drinking and alcohol, including information on the risks of drinking too much, tools for calculating alcohol consumption, and personal stories about alcohol use problems
MedlinePlus provides links to many other resources on alcohol
More information about the Alcohol Action in Rural Communities project is available
doi:10.1371/journal.pmed.1001617
PMCID: PMC3949675  PMID: 24618831
2.  Alcohol Consumption at Midlife and Successful Ageing in Women: A Prospective Cohort Analysis in the Nurses' Health Study 
PLoS Medicine  2011;8(9):e1001090.
Using the Nurses' Health Study, Qi Sun and colleagues examine whether moderate alcohol intake is associated with overall health and well-being among women who survive to older age.
Background
Observational studies have documented inverse associations between moderate alcohol consumption and risk of premature death. It is largely unknown whether moderate alcohol intake is also associated with overall health and well-being among populations who have survived to older age. In this study, we prospectively examined alcohol use assessed at midlife in relation to successful ageing in a cohort of US women.
Methods and Findings
Alcohol consumption at midlife was assessed using a validated food frequency questionnaire. Subsequently, successful ageing was defined in 13,894 Nurses' Health Study participants who survived to age 70 or older, and whose health status was continuously updated. “Successful ageing” was considered as being free of 11 major chronic diseases and having no major cognitive impairment, physical impairment, or mental health limitations. Analyses were restricted to the 98.1% of participants who were not heavier drinkers (>45 g/d) at midlife. Of all eligible study participants, 1,491 (10.7%) achieved successful ageing. After multivariable adjustment of potential confounders, light-to-moderate alcohol consumption at midlife was associated with modestly increased odds of successful ageing. The odds ratios (95% confidence interval) were 1.0 (referent) for nondrinkers, 1.11 (0.96–1.29) for ≤5.0 g/d, 1.19 (1.01–1.40) for 5.1–15.0 g/d, 1.28 (1.03–1.58) for 15.1–30.0 g/d, and 1.24 (0.87–1.76) for 30.1–45.0 g/d. Meanwhile, independent of total alcohol intake, participants who drank alcohol at regular patterns throughout the week, rather than on a single occasion, had somewhat better odds of successful ageing; for example, the odds ratios (95% confidence interval) were 1.29 (1.01–1.64) and 1.47 (1.14–1.90) for those drinking 3–4 days and 5–7 days per week in comparison with nondrinkers, respectively, whereas the odds ratio was 1.10 (0.94–1.30) for those drinking only 1–2 days per week.
Conclusions
These data suggest that regular, moderate consumption of alcohol at midlife may be related to a modest increase in overall health status among women who survive to older ages.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
People have always drunk alcoholic beverages but throughout history there have been arguments about the risks and benefits of beer, wine, and spirits. It is clear that excessive alcohol use—heavy drinking (an average of more than two drinks per day for men or more than one drink per day for women; in the US, a “drink” is defined as 15 g of alcohol or, roughly speaking, a can of beer or a small glass of wine) or binge drinking (five or more drinks on a single occasion for men; 4 or more drinks at one time for women)—is harmful. It causes liver damage and increases the risk of developing some types of cancer. It contributes to depression and violence and interferes with relationships. And it is often implicated in fatal traffic accidents. However, in contrast to these and other harms associated with excessive alcohol use, moderate alcohol consumption seems to reduce the risk of specific diseases such as heart disease, stroke, and cognitive decline (deterioration in learning, reasoning, and perception).
Why Was This Study Done?
Although people who drink moderate amounts of alcohol have a reduced risk of premature death compared to abstainers or heavy drinkers, it is not known whether moderate alcohol consumption is associated with overall health among ageing populations. In many countries, elderly people are an increasingly large part of the population, so it is important to know how moderate alcohol consumption affects their well-being. In this study, the researchers examine the effect of alcohol consumption at midlife on successful ageing among the participants of the Nurses' Health Study. The researchers study the effect of midlife alcohol consumption because the chronic conditions that affect elderly people develop slowly and it is likely that factors in earlier life determine health in later life. Successful ageing is defined as being free of major chronic diseases such as cancer and heart disease, and having no major cognitive impairment, physical impairment, or mental health problems. The Nurses' Health Study enrolled 121,700 female registered nurses in 1976 to investigate the long-term effects of oral contraceptive use but has provided insights into many aspects of health and disease.
What Did the Researchers Do and Find?
The researchers assessed the alcohol consumption of the study participants at midlife (average age 58 years) from food frequency questionnaires completed in 1980 and 1984. Successful ageing for 13,984 participants who survived past 70 years was assessed by analyzing biennial health status questionnaires and cognitive function test results. One tenth of the women achieved successful ageing. After allowing for other factors that might affect their health such as smoking, women who drank light or moderate amounts of alcohol had a modestly increased chance of successful ageing compared to nondrinkers. For example, compared to nondrinkers, women who drank 5–15 g of alcohol per day (between one-third and one drink per day) had about a 20% higher chance of successful ageing. Independent of total alcohol intake, women who drank alcohol regularly had a better chance of successful ageing than occasional drinkers. Thus, compared to nondrinkers, women who drank five to seven days a week had nearly a 50% greater chance of successful ageing whereas women who drank only one or two days a week had a similar likelihood of successful ageing.
What Do These Findings Mean?
These findings suggest that regular, moderate consumption of alcohol at midlife may be related to a modest increase in overall health among women who survive to older ages. Because this is an observational study, it is possible that the women who drank moderately share other unknown characteristics that are actually responsible for their increased chance of successful ageing. Moreover, because all the study participants were women and most had European ancestry, these findings cannot be applied to men or to other ethnic groups. Nevertheless, these findings provide support for the 2010 US Department of Agriculture dietary guidelines, which state that consumption of up to one alcoholic drink per day for women and up to two alcoholic drinks per day for men may provide health benefits. Importantly, they also suggest that drinking alcohol regularly in moderation rather than occasional heavy drinking may be associated with a greater likelihood of successful ageing.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001090.
The US National Institute on Alcohol Abuse and Alcoholism has detailed information about alcohol and its effects on health, including a fact sheet on women and alcohol and a booklet entitled Alcohol, a woman's health issue
The US Centers for Disease Control and Prevention has a website on alcohol and public health
The UK National Health Service Choices website provides detailed information about drinking and alcohol, including how to calculate consumption
The Nutrition Source, a website maintained by the Department of Nutrition at Harvard School of Public Health, has an article entitled Alcohol: balancing risks and benefits
MedlinePlus provides links to many other resources on alcohol and on seniors' health
Details of the Nurses' Health Study are available
The 2010 US Department of Agriculture dietary guidelines are available
doi:10.1371/journal.pmed.1001090
PMCID: PMC3167795  PMID: 21909248
3.  What is the optimal level of population alcohol consumption for chronic disease prevention in England? Modelling the impact of changes in average consumption levels 
BMJ Open  2012;2(3):e000957.
Objective
To estimate the impact of achieving alternative average population alcohol consumption levels on chronic disease mortality in England.
Design
A macro-simulation model was built to simultaneously estimate the number of deaths from coronary heart disease, stroke, hypertensive disease, diabetes, liver cirrhosis, epilepsy and five cancers that would be averted or delayed annually as a result of changes in alcohol consumption among English adults. Counterfactual scenarios assessed the impact on alcohol-related mortalities of changing (1) the median alcohol consumption of drinkers and (2) the percentage of non-drinkers.
Data sources
Risk relationships were drawn from published meta-analyses. Age- and sex-specific distributions of alcohol consumption (grams per day) for the English population in 2006 were drawn from the General Household Survey 2006, and age-, sex- and cause-specific mortality data for 2006 were provided by the Office for National Statistics.
Results
The optimum median consumption level for drinkers in the model was 5 g/day (about half a unit), which would avert or delay 4579 (2544 to 6590) deaths per year. Approximately equal numbers of deaths from cancers and liver disease would be delayed or averted (∼2800 for each), while there was a small increase in cardiovascular mortality. The model showed no benefit in terms of reduced mortality when the proportion of non-drinkers in the population was increased.
Conclusions
Current government recommendations for alcohol consumption are well above the level likely to minimise chronic disease. Public health targets should aim for a reduction in population alcohol consumption in order to reduce chronic disease mortality.
Article summary
Article focus
Alcohol consumption is a risk factor for many chronic diseases, while providing modest protection from others. Assessments of the impact of alcohol on individual chronic diseases can therefore result in contradictory advice about the level of alcohol consumption that is optimal for health.
The UK Government currently recommends that men should consume no more than three to four units per day (24–32 g/day of pure alcohol) and women should drink no more than two to three units per day (16–24 g/day). However the net impact of this level of consumption on chronic disease mortality is unclear.
The aim of this study was to estimate the impact of achieving alternative population alcohol consumption levels on chronic disease mortality in England.
Key messages
Results suggest that the optimum population level of alcohol consumption for minimising chronic disease mortality in England is just 5 g (approximately half a unit) per day.
Current recommendations for alcohol consumption are well above this level and may not be compatible with optimum protection of public health. Substantial reductions in recommendations and in population alcohol consumption levels would be needed to minimise the chronic disease burden associated with alcohol consumption in England.
Community beliefs in the protective role of alcohol in cardiovascular disease are widespread; however, our modelling shows that when multiple conditions are considered simultaneously, the levels of alcohol that would actually be likely to be associated with reduced risk of chronic disease are much lower than is generally accepted or recommended by government.
Strengths and limitations of this study
The study used a detailed modelling approach to synthesise the best available evidence from meta-analysis of prospective cohort studies and provide for the first time an estimate of the level of alcohol associated with theoretical minimum risk of a range of chronic diseases, considering both harmful and protective effects simultaneously.
The model is dependent on the meta-analyses selected to define the parameters. Results may vary significantly in other contexts with varying levels of disease, alcohol consumption and other risk factors. Furthermore, results depend on the quality of the available epidemiological evidence, which remains contested in some areas.
The approach used also relies on chronic (average) consumption of alcohol and is not able to take account of to take account of patterns of drinking (eg, binge drinking). Furthermore, the results are based on the assumption of a steady-state relationship between alcohol consumption patterns and RR of disease and cannot estimate the time required between changes in population alcohol consumption levels occurring and the achievement of changes in mortality rates.
doi:10.1136/bmjopen-2012-000957
PMCID: PMC3367150  PMID: 22649178
4.  A Population-Based Study on Alcohol and High-Risk Sexual Behaviors in Botswana 
PLoS Medicine  2006;3(10):e392.
Background
In Botswana, an estimated 24% of adults ages 15–49 years are infected with HIV. While alcohol use is strongly associated with HIV infection in Africa, few population-based studies have characterized the association of alcohol use with specific high-risk sexual behaviors.
Methods and Findings
We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana using a stratified two-stage probability sample design. Multivariate logistic regression was used to assess correlates of heavy alcohol consumption (>14 drinks/week for women, and >21 drinks/week for men) as a dependent variable. We also assessed gender-specific associations between alcohol use as a primary independent variable (categorized as none, moderate, problem and heavy drinking) and several risky sex outcomes including: (a) having unprotected sex with a nonmonogamous partner; (b) having multiple sexual partners; and (c) paying for or selling sex in exchange for money or other resources. Criteria for heavy drinking were met by 31% of men and 17% of women. Adjusted correlates of heavy alcohol use included male gender, intergenerational relationships (age gap ≥10 y), higher education, and living with a sexual partner. Among men, heavy alcohol use was associated with higher odds of all risky sex outcomes examined, including unprotected sex (AOR = 3.48; 95% confidence interval [CI], 1.65 to 7.32), multiple partners (AOR = 3.08; 95% CI, 1.95 to 4.87), and paying for sex (AOR = 3.65; 95% CI, 2.58 to 12.37). Similarly, among women, heavy alcohol consumption was associated with higher odds of unprotected sex (AOR = 3.28; 95% CI, 1.71 to 6.28), multiple partners (AOR = 3.05; 95% CI, 1.83 to 5.07), and selling sex (AOR = 8.50; 95% CI, 3.41 to 21.18). A dose-response relationship was seen between alcohol use and risky sexual behaviors, with moderate drinkers at lower risk than both problem and heavy drinkers.
Conclusions
Alcohol use is associated with multiple risks for HIV transmission among both men and women. The findings of this study underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.
Alcohol use is associated with multiple risks for HIV transmission in men and women. The findings underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.
Editors' Summary
Background.
Human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS), is most commonly spread through unprotected sex with an infected partner. HIV enters the body through the lining of the sex organs, rectum, or mouth, and destroys immune system cells, leaving the infected person susceptible to other viruses and bacteria. Although HIV education and prevention campaigns emphasize the importance of safe sex in reducing HIV transmission, people continue to become infected by having unprotected sex (that is, not using a condom) with either a nonmonogamous partner or multiple sexual partners, or in situations where they are paying for or selling sex. Research in different populations suggested that heavy alcohol use is associated with risky sexual behaviors. This is because alcohol relaxes the brain and body, reduces inhibitions, and diminishes risk perception. Drinking alcohol may further increase the risk of becoming infected with HIV through its suppressive effects on the immune system.
Why Was This Study Done?
Alcohol abuse is widespread in sub-Saharan Africa where most HIV infections occur and has been associated with risky sexual behaviors. It may therefore be one of the most common, potentially modifiable HIV risk factors in this region. However, research to date has concentrated on the association between alcohol consumption and risky sex in people attending HIV-treatment clinics or recruited at beer halls, and these populations may not be representative of the general population of sub-Saharan Africa. In this study, the researchers have investigated the potential role of alcohol in perpetuating the HIV epidemic by undertaking a population-based study on alcohol use and high-risk sexual behaviors in Botswana. Nearly a quarter of adults are infected with HIV here, and alcohol abuse is also common, particularly in the townships.
What Did the Researchers Do and Find?
The researchers recruited a random cross-section of people from the five districts of Botswana with the highest number of HIV-infected individuals and interviewed all 1,268 participants using a questionnaire. This included general questions about the participants (for example, their age and marital status) and questions about alcohol use, sexual behavior, and knowledge of HIV. Overall, 31% of the men in the study and 17% of the women were heavy drinkers—more than 21 drinks/week for men, 14 for women; a drink is half a pint of beer or a glass of wine. Heavy alcohol use was associated with being male, being in an intergenerational relationship (at least 10 years age difference between partners; intergenerational sex facilitates the continued spread of HIV in sub-Saharan Africa), having had more education, and living with a sexual partner. Among men, those who drank heavily were three to four times more likely to have unprotected sex or multiple partners or to pay for sex than nondrinkers. Among women, there was a similar association between heavy drinking and having unprotected sex or multiple partners, and heavy drinkers were eight times as likely to sell sex as nondrinkers. For both men and women, the more they drank, the more likely they were to have risky sex. The study did not address behavior among same-sex partnerships.
What Do These Findings Mean?
This study indicates that heavy alcohol consumption is strongly and consistently associated with sexual risk behaviors in both men and women in Botswana. Because of the study design, it does not prove that heavy alcohol use is the cause of such behaviors but provides strong circumstantial evidence that this is the case. It is possible that these results may not apply to neighboring African countries—Botswana is unique in being relatively wealthy and in its government being strongly committed to tackling HIV. Nevertheless, taken together with the results of other studies, this research strongly argues for the need to deal with alcohol abuse within HIV prevention programs in sub-Saharan Africa. Strategies to do this could include education campaigns that target both alcohol use and HIV in schools and in social venues, including beer halls. But, stress the researchers, any strategy that is used must consider the cultural and social significance of alcohol use (in Botswana, alcohol use is a symbol of masculinity and high socioeconomic status) and must simultaneously tackle not only the overlap between alcohol use and risky sexual behavior but also the overlap between alcohol and other risk behaviors such as intergenerational sex.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030392.
US National Institute of Allergy and Infectious Diseases factsheet on HIV infection and AIDS
US Department of Health and Human Services information on AIDS
US Centers for Disease Control and Prevention information on HIV/AIDS
US National Institute on Alcohol Abuse and Alcoholism patient information on alcohol and HIV/AIDS]
Aidsmap, information on HIV and AIDS provided by the charity NAM,which includes some information on HIV infections and alcohol
AVERT information on HIV and AIDS in Botswana
doi:10.1371/journal.pmed.0030392
PMCID: PMC1592342  PMID: 17032060
5.  Living Alone and Alcohol-Related Mortality: A Population-Based Cohort Study from Finland 
PLoS Medicine  2011;8(9):e1001094.
Kimmo Herttua and colleagues showed that living alone is associated with a substantially increased risk of alcohol-related mortality, irrespective of gender, socioeconomic status, or cause of death, and that this effect was exacerbated after a price reduction in alcohol in 2004.
Background
Social isolation and living alone are increasingly common in industrialised countries. However, few studies have investigated the potential public health implications of this trend. We estimated the relative risk of death from alcohol-related causes among individuals living alone and determined whether this risk changed after a large reduction in alcohol prices.
Methods and Findings
We conducted a population-based natural experimental study of a change in the price of alcohol that occurred because of new laws enacted in Finland in January and March of 2004, utilising national registers. The data are based on an 11% sample of the Finnish population aged 15–79 y supplemented with an oversample of deaths. The oversample covered 80% of all deaths during the periods January 1, 2000–December 31, 2003 (the four years immediately before the price reduction of alcohol), and January 1, 2004–December 31, 2007 (the four years immediately after the price reduction). Alcohol-related mortality was defined using both underlying and contributory causes of death. During the 8-y follow-up about 18,200 persons died due to alcohol-related causes. Among married or cohabiting people the increase in alcohol-related mortality was small or non-existing between the periods 2000–2003 and 2004–2007, whereas for those living alone, this increase was substantial, especially in men and women aged 50–69 y. For liver disease in men, the most common fatal alcohol-related disease, the age-adjusted risk ratio associated with living alone was 3.7 (95% confidence interval 3.3, 4.1) before and 4.9 (95% CI 4.4, 5.4) after the price reduction (p<0.001 for difference in risk ratios). In women, the corresponding risk ratios were 1.7 (95% CI 1.4, 2.1) and 2.4 (95% CI 2.0, 2.9), respectively (p ≤ 0.01). Living alone was also associated with other mortality from alcohol-related diseases (range of risk ratios 2.3 to 8.0) as well as deaths from accidents and violence with alcohol as a contributing cause (risk ratios between 2.1 and 4.7), both before and after the price reduction.
Conclusions
Living alone is associated with a substantially increased risk of alcohol-related mortality, irrespective of gender, socioeconomic status, or the specific cause of death. The greater availability of alcohol in Finland after legislation-instituted price reductions in the first three months of 2004 increased in particular the relative excess in fatal liver disease among individuals living alone.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Throughout most of human history, people have lived in tight-knit communities where there was likely to be someone to turn to for help, advice, or company. But the modern way of life in industrialized countries is greatly reducing the quantity and quality of social relationships. Instead of living in extended families, many people now live miles away from their relatives, often living and working alone. Others commute long distances to work, which leaves little time for socializing with friends or relatives. And many delay or forgo getting married and having children. Consequently, loneliness and social isolation are getting more common. In the UK, according to a recent survey by the Mental Health Foundation, 10% of people often feel lonely, a third have a close friend or relative who they think is very lonely, and half think people are getting lonelier in general. Similarly, over the past two decades, there has been a three-fold increase in the number of Americans who say they have no close confidants.
Why Was This Study Done?
Some experts think that loneliness is bad for human health. They point to studies that show that people with fewer social relationships die earlier on average than people with more social relationships. But does loneliness increase the risk of dying from specific causes? It is important to investigate the relationship between loneliness and cause-specific mortality (death) because, if for example, loneliness increases the risk of dying from alcohol-related causes (heavy drinking causes liver and heart damage, increases the risk of some cancers, contributes to depression, and increases the risk of death by violence or accident), doctors could advise their patients who live alone about safe drinking. But, although loneliness is recognized as both a contributor to and a consequence of alcohol abuse, there have been no large, population-based studies on the association between living alone and alcohol-related mortality. In this population-based study, the researchers estimate the association between living alone (an indicator of a lack of social relationships) and death from alcohol-related causes in Finland for four years before and four years after an alcohol price reduction in 2004 that increased alcohol consumption.
What Did the Researchers Do and Find?
The researchers obtained information on about 80% of all people who died in Finland between 2000 and 2007 from Statistics Finland, which collects official Finnish statistics. During this period, about 18,200 people (two-thirds of whom lived alone) died from underlying alcohol-related causes (for example, liver disease and alcoholic poisoning) or contributory alcohol-related causes (for example, accidents, violence, and cardiovascular disease, with alcohol as a contributing cause). Among married and cohabiting people, the rate of alcohol-related mortality was similar in 2000–2003 and 2004–2007 but for people living alone (particularly those aged 50–69 years) the 2004 alcohol price reduction substantially increased the alcohol-related mortality rate. For liver disease in men, the risk ratio associated with living alone was 3.7 before and 4.9 after the price reduction. That is, between 2000 and 2003, men living alone were 3.7 times more likely to die of liver disease than married or cohabiting men; between 2004 and 2007, they were 4.9 times more likely to die of liver disease. In women, the corresponding risk ratios for liver disease were 1.7 and 2.4, respectively. Living alone was also associated with an increased risk of dying from other alcohol-related diseases and accidents and violence both before and after the price reduction.
What Do These Findings Mean?
These findings indicate that, in Finland, living alone is associated with an increased risk of alcohol-related mortality. Because of the study design, it is impossible to say whether living alone is a cause or a consequence of alcohol abuse, but the greater increase in alcohol-related deaths (particularly fatal liver disease) among people living alone compared to married and cohabiting people after the alcohol price reduction suggests that people living alone are more vulnerable to the adverse effects of increased alcohol availability. Further research in other countries is now needed to identify whether living alone is a cause or effect of alcohol abuse and to extend these findings to cultures where the pattern of alcohol consumption is different. However, the findings of this natural experiment suggest that living alone should be regarded as a potential risk marker for death from alcohol-related causes.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001094.
The Mental Health America Live Your Life Well webpage includes information about how social relationships improve mental and physical health
The Mental Health Foundation (a UK charity) presents the report The Lonely Society?
The US National Institute on Alcohol Abuse and Alcoholism has information about alcohol and its effects on health
The US Centers for Disease Control and Prevention has a website on alcohol and public health that includes information on the health risks of excessive drinking
The UK National Health Service Choices website provides detailed information about drinking and alcohol, including information on the risks of drinking too much, and personal stories about alcohol problems, including stories from people living alone (My drinks diary shock and I used to drink all day)
MedlinePlus provides links to many other resources on alcohol
doi:10.1371/journal.pmed.1001094
PMCID: PMC3176753  PMID: 21949642
6.  Midwives’ knowledge, attitudes and practice about alcohol exposure and the risk of fetal alcohol spectrum disorder 
Background
Midwives are an influential profession and a key group in informing women about alcohol consumption in pregnancy and its consequences. There are no current quantitative Australian data on midwives’ knowledge, attitudes and practice in relation to alcohol consumption during pregnancy and Fetal Alcohol Spectrum Disorder. We aimed to reduce this knowledge gap by understanding midwives’ perceptions of their practice in addressing alcohol consumption during pregnancy.
Methods
This cross-sectional study was conducted at 19 maternity sites across the seven health regions of country Western Australia. A questionnaire was designed following review of the literature and other relevant surveys. Midwifery managers of the maternity sites distributed questionnaires to all midwives working in their line of management. A total of 334 midwives were invited to participate in the research and (n = 245, 73.4%) of these were eligible.
Results
The response fraction was (n = 166, 67.8%). Nearly all (n = 151, 93.2%) midwives asked pregnant women about their alcohol consumption during pregnancy and (n = 164, 99.4%) offered advice about alcohol consumption in accordance with the Australian Alcohol Guideline, which states “For women who are pregnant or planning a pregnancy, not drinking is the safest option”. Nearly two thirds (n = 104, 64.2%) of the midwives informed pregnant women about the effects of alcohol consumption in pregnancy, they did not always use the recommended AUDIT screening tool (n = 66, 47.5%) to assess alcohol consumption during pregnancy, nor conduct brief intervention when indicated (n = 107, 70.4%). Most midwives endorsed professional development about screening tools (n = 145, 93.5%), brief intervention (n = 144, 92.9%), and alcohol consumption during pregnancy and FASD (n = 144, 92.9%).
Conclusion
Nearly all midwives in this study asked and advised about alcohol consumption in pregnancy and around two thirds provided information about the effects of alcohol in pregnancy. Our findings support the need for further professional development for midwives on screening and brief intervention. Policy should support midwives’ practice to screen for alcohol consumption in pregnancy and offer brief intervention when indicated.
doi:10.1186/s12884-014-0377-z
PMCID: PMC4228156  PMID: 25366388
Midwives; Knowledge; Attitude; Practice; Alcohol; Pregnancy; Fetal alcohol spectrum disorder
7.  Alcohol Intake and Blood Pressure: A Systematic Review Implementing a Mendelian Randomization Approach 
PLoS Medicine  2008;5(3):e52.
Background
Alcohol has been reported to be a common and modifiable risk factor for hypertension. However, observational studies are subject to confounding by other behavioural and sociodemographic factors, while clinical trials are difficult to implement and have limited follow-up time. Mendelian randomization can provide robust evidence on the nature of this association by use of a common polymorphism in aldehyde dehydrogenase 2 (ALDH2) as a surrogate for measuring alcohol consumption. ALDH2 encodes a major enzyme involved in alcohol metabolism. Individuals homozygous for the null variant (*2*2) experience adverse symptoms when drinking alcohol and consequently drink considerably less alcohol than wild-type homozygotes (*1*1) or heterozygotes. We hypothesise that this polymorphism may influence the risk of hypertension by affecting alcohol drinking behaviour.
Methods and Findings
We carried out fixed effect meta-analyses of the ALDH2 genotype with blood pressure (five studies, n = 7,658) and hypertension (three studies, n = 4,219) using studies identified via systematic review. In males, we obtained an overall odds ratio of 2.42 (95% confidence interval [CI] 1.66–3.55, p = 4.8 × 10−6) for hypertension comparing *1*1 with *2*2 homozygotes and an odds ratio of 1.72 (95% CI 1.17–2.52, p = 0.006) comparing heterozygotes (surrogate for moderate drinkers) with *2*2 homozygotes. Systolic blood pressure was 7.44 mmHg (95% CI 5.39–9.49, p = 1.1 × 10−12) greater among *1*1 than among *2*2 homozygotes, and 4.24 mmHg (95% CI 2.18–6.31, p = 0.00005) greater among heterozygotes than among *2*2 homozygotes.
Conclusions
These findings support the hypothesis that alcohol intake has a marked effect on blood pressure and the risk of hypertension.
Using a mendelian randomization approach Sarah Lewis and colleagues find strong support for the hypothesis that alcohol intake has a marked effect on blood pressure and the risk of hypertension.
Editors' Summary
Background.
High blood pressure (hypertension) is a common medical condition that affects nearly a third of US and UK adults. Hypertension has no symptoms but can lead to heart attacks or strokes. It is diagnosed by measuring blood pressure—the force that blood moving around the body exerts on the inside of large blood vessels. Blood pressure is highest when the heart is pumping out blood (systolic pressure) and lowest when it is filling up with blood (diastolic pressure). Normal blood pressure is defined as a systolic pressure of less than 130 millimeters of mercury (mmHg) and a diastolic pressure of less than 85 mmHg (a blood pressure of 130/85). A reading of more than 140/90 indicates hypertension. Many factors affect blood pressure, but overweight people and individuals who eat too much salty or fatty foods are at high risk of developing hypertension. Mild hypertension can often be corrected by lifestyle changes, but many people also take antihypertensive drugs to reduce their blood pressure.
Why Was This Study Done?
Another modifiable lifestyle factor thought to affect blood pressure is alcohol intake. Observational studies that ask people about their drinking habits and measure their blood pressure suggest that alcohol intake correlates with blood pressure, but they cannot prove a causal link because of “confounding”—other risk factors associated with alcohol drinking, such as diet, might also affect the study participant's blood pressures. A trial that randomly assigns people to different alcohol intakes could provide this proof of causality, but such a trial is impractical. In this study, therefore, the researchers have used “Mendelian randomization” to investigate whether alcohol intake affects blood pressure. An inactive variant of aldehyde dehydrogenase 2 (ALDH2; the enzyme that removes alcohol from the body) has been identified. People who inherit the variant form of this gene from both parents have an ALDH2 *2*2 genotype (genetic makeup) and become flushed and nauseated after drinking. Consequently, they drink less than people with a *1*2 genotype and much less than those with a *1*1 genotype. Because inheritance of these genetic variants does not affect lifestyle factors other than alcohol intake, an association between ALDH2 genotypes and blood pressure would indicate that alcohol intake has an effect on blood pressure without any confounding.
What Did the Researchers Do and Find?
The researchers identified ten published studies (mainly done in Japan where the ALDH2 gene variant is common) on associations between ALDH2 genotype and blood pressure or hypertension using a detailed search protocol (a “systematic review”). A meta-analysis (a statistical method for combining the results of independent studies) of the studies that had investigated the association between ALDH2 genotype and hypertension showed that men with the *1*1 genotype (highest alcohol intake) and those with the *1*2 genotype (intermediate alcohol intake) were 2.42 and 1.72 times more likely, respectively, to have hypertension than those with the *2*2 genotype (lowest alcohol intake). There was no association between ALDH2 genotype and hypertension among the women in these studies because they drank very little. Systolic and diastolic blood pressures showed a similar relationship to ALDH2 genotype in a second meta-analysis of relevant studies. Finally, the researchers estimated that for men the lifetime effect of drinking 1 g of alcohol a day (one unit of alcohol contains 8 g of alcohol in the UK and 14 g in the US; recommended daily limits in these countries are 3–4 and 1–2 units, respectively) would be an increase in systolic blood pressure of 0.24 mmHg.
What Do These Findings Mean?
These findings support the suggestion that alcohol has a marked effect on blood pressure and hypertension. Consequently, some cases of hypertension could be prevented by encouraging people to reduce their daily alcohol intake. Although the Mendelian randomization approach avoids most of the confounding intrinsic to observational studies, it is possible that a gene near ALDH2 that has no effect on alcohol intake affects blood pressure, since genes are often inherited in blocks. Alternatively, ALDH2 could affect blood pressure independent of alcohol intake. The possibility that ALDH2 could effect blood pressure independently of alcohol is intake made unlikely by the fact that no effect of genotype on blood pressure is seen among women who drink very little. Additional large-scale studies are needed to address these possibilities, to confirm the current finding in more people, and to improve the estimates of the effect that alcohol intake has on blood pressure.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050052.
The MedlinePlus encyclopedia has a page on hypertension (in English and Spanish)
The American Heart Association provides information for patients and health professionals about hypertension
The UK Blood Pressure Association provides information for patients and health professionals on all aspects of hypertension, including information about alcohol affects blood pressure
The Explore@Bristol science center (a UK charity) provides an alcohol unit calculator and information on the effects of alcohol
The International Center for Alcohol Policies provides drinking guidelines for countries around the world
doi:10.1371/journal.pmed.0050052
PMCID: PMC2265305  PMID: 18318597
8.  Comparative Analysis of Alcohol Control Policies in 30 Countries 
PLoS Medicine  2007;4(4):e151.
Background
Alcohol consumption causes an estimated 4% of the global disease burden, prompting goverments to impose regulations to mitigate the adverse effects of alcohol. To assist public health leaders and policymakers, the authors developed a composite indicator—the Alcohol Policy Index—to gauge the strength of a country's alcohol control policies.
Methods and Findings
The Index generates a score based on policies from five regulatory domains—physical availability of alcohol, drinking context, alcohol prices, alcohol advertising, and operation of motor vehicles. The Index was applied to the 30 countries that compose the Organization for Economic Cooperation and Development and regression analysis was used to examine the relationship between policy score and per capita alcohol consumption. Countries attained a median score of 42.4 of a possible 100 points, ranging from 14.5 (Luxembourg) to 67.3 (Norway). The analysis revealed a strong negative correlation between score and consumption (r = −0.57; p = 0.001): a 10-point increase in the score was associated with a one-liter decrease in absolute alcohol consumption per person per year (95% confidence interval, 0.4–1.5 l). A sensitivity analysis demonstrated the robustness of the Index by showing that countries' scores and ranks remained relatively stable in response to variations in methodological assumptions.
Conclusions
The strength of alcohol control policies, as estimated by the Alcohol Policy Index, varied widely among 30 countries located in Europe, Asia, North America, and Australia. The study revealed a clear inverse relationship between policy strength and alcohol consumption. The Index provides a straightforward tool for facilitating international comparisons. In addition, it can help policymakers review and strengthen existing regulations aimed at minimizing alcohol-related harm and estimate the likely impact of policy changes.
Using an index that gauges the strength of national alcohol policies, a clear inverse relationship was found between policy strength and alcohol consumption.
Editors' Summary
Background.
Alcohol drinking is now recognized as one of the most important risks to human health. Previous research studies (see the research article by Rodgers et al., linked below) have predicted that around 4% of the burden of disease worldwide comes about as a result of drinking alcohol, which can be a factor in a wide range of health problems. These include chronic diseases such as cirrhosis of the liver and certain cancers, as well as poor health resulting from trauma, violence, and accidental injuries. For these reasons, most governments try to control the consumption of alcohol through laws, although very few countries ban alcohol entirely.
Why Was This Study Done?
Although bodies such as the World Health Assembly have recommended that its member countries develop national control policies to prevent excessive alcohol use, there is a huge variation between national policies. It is also very unclear whether there is any link between the strictness of legislation regarding alcohol control in any given country and how much people in that country actually drink.
What Did the Researchers Do and Find?
The researchers carrying out this study had two broad goals. First, they wanted to develop an index (or scoring system) that would allow them and others to rate the strength of any given country's alcohol control policy. Second, they wanted to see whether there is any link between the strength of control policies on this index and the amount of alcohol that is drunk by people on average in each country. In order to develop the alcohol control index, the researchers chose five main areas relating to alcohol control. These five areas related to the availability of alcohol, the “drinking context,” pricing, advertising, and vehicles. Within each policy area, specific policy topics relating to prevention of alcohol consumption and harm were identified. Then, each of 30 countries within the OECD (Organization for Economic Cooperation and Development) were rated on this index using recent data from public reports and databases. The researchers also collected data on alcohol consumption within each country from the World Health Organization and used this to estimate the average amount drunk per person in a year. When the researchers plotted scores on their index against the average amount drunk per person per year, they saw a negative correlation. That is, the stronger the alcohol control policy in any given country, the less people seemed to drink. This worked out at around roughly a 10-point increase on the index equating to a one-liter drop in alcohol consumption per person per year. However, some countries did not seem to fit these predictions very well.
What Do These Findings Mean?
The finding that there is a link between the strength of alcohol control policies and amount of alcohol drinking does not necessarily mean that greater government control causes lower drinking rates. The relationship might just mean that some other variable (e.g., some cultural factor) plays a role in determining the amount that people drink as well as affecting national policies for alcohol control. However, the index developed here is a useful method for researchers and policy makers to measure changes in alcohol controls and therefore understand more clearly the factors that affect drinking rates. This study looked only at the connection between control measures and extent of alcohol consumption, and did not examine alcohol-related harm. Future research might focus on the links between controls and the harms caused by alcohol.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040151.
A Perspective in PLoS Medicine by Alison Ritter accompanies this article: “Comparing alcohol policies between countries: Science or silliness?”
Facts and figures on alcohol are available from the World Health Organization, including information about the burden of disease worldwide as a result of alcohol
Information from the US Centers for Disease Control and Prevention is available about alcohol and public health
A 2004 PLoS Medicine research article includes discussion of the health burdens of alcohol: Rodgers A, Ezzati M, Vander Hoorn S, Lopez AD, Lin RB, et al. (2004) Distribution of major health risks: Findings from the global burden of disease study. PLoS Medicine 1(1): e27. doi:10.1371/journal.pmed.0010027
Current information about research on alcohol and alcoholism is available from the National Institute on Alcohol Abuse and Alcoholism
doi:10.1371/journal.pmed.0040151
PMCID: PMC1876414  PMID: 17455992
9.  Drinking Patterns of Older Adults with Chronic Medical Conditions 
Journal of General Internal Medicine  2013;28(10):1326-1332.
ABSTRACT
BACKGROUND
Understanding alcohol consumption patterns of older adults with chronic illness is important given the aging baby boomer generation, the increase in prevalence of chronic conditions and associated medication use, and the potential consequences of excessive drinking in this population.
OBJECTIVES
To estimate the prevalence of alcohol consumption patterns, including at-risk drinking, in older adults with at least one of seven common chronic conditions.
DESIGN/METHODS
This descriptive study used the nationally representative 2005 Medicare Current Beneficiary Survey linked with Medicare claims. The sample included community-dwelling, fee-for-service beneficiaries 65 years and older with one or more of seven chronic conditions (Alzheimer’s disease and other senile dementia, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hypertension, and stroke; n = 7,422). Based on self-reported alcohol consumption, individuals were categorized as nondrinkers, within-guidelines drinkers, or at-risk drinkers (exceeds guidelines).
RESULTS
Overall, 30.9 % (CI 28.0–34.1 %) of older adults with at least one of seven chronic conditions reported alcohol consumption in a typical month in the past year, and 6.9 % (CI 6.0–7.8 %) reported at-risk drinking. Older adults with higher chronic disease burdens were less likely to report alcohol consumption and at-risk drinking.
CONCLUSIONS
Nearly one-third of older adults with selected chronic illnesses report drinking alcohol and almost 7 % drink in excess of National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines. It is important for physicians and patients to discuss alcohol consumption as a component of chronic illness management. In cases of at-risk drinking, providers have an opportunity to provide brief intervention or to offer referrals if needed.
doi:10.1007/s11606-013-2409-1
PMCID: PMC3785666  PMID: 23609178
at-risk drinking; alcohol consumption; Medicare beneficiaries; chronic conditions; older adults
10.  Effectiveness of Guided and Unguided Low-Intensity Internet Interventions for Adult Alcohol Misuse: A Meta-Analysis 
PLoS ONE  2014;9(6):e99912.
Background
Alcohol misuse ranks within the top ten health conditions with the highest global burden of disease. Low-intensity, Internet interventions for curbing adult alcohol misuse have been shown effective. Few meta-analyses have been carried out, however, and they have involved small numbers of studies, lacked indicators of drinking within low risk guidelines, and examined the effectiveness of unguided self-help only. We therefore conducted a more thorough meta-analysis that included both guided and unguided interventions.
Methods
Systematic literature searches were performed up to September 2013. Primary outcome was the mean level of alcohol consumption and drinking within low risk guidelines for alcohol consumption at post-treatment.
Findings
We selected 16 randomised controlled trials (with 23 comparisons and 5,612 participants) for inclusion. Results, showed a small but significant overall effect size in favour of Internet interventions (g = 0.20, 95% CI: 0.13–0.27, p<.001). Participants in Internet interventions drunk on average 22 grams of ethanol less than controls and were significantly more likely to be adhering to low-risk drinking guidelines at post-treatment (RD 0.13, 95% CI: 0.09–0.17, p<.001). Subgroup analyses revealed no significant differences in potential moderators for the outcome of alcohol consumption, although there was a near-significant difference between comparisons with waitlist control and those with assessment-only or alcohol information control conditions (p = .056).
Conclusions
Internet interventions are effective in reducing adult alcohol consumption and inducing alcohol users to adhere to guidelines for low-risk drinking. This effect is small but from a public health point of view this may warrant large scale implementation at low cost of Internet interventions for adult alcohol misuse. Moderator analyses with sufficient power are, however, needed in order to assess the robustness of these overall results and to assess whether these interventions may impact on subgroups with different levels of success.
doi:10.1371/journal.pone.0099912
PMCID: PMC4061051  PMID: 24937483
11.  Women’s perceptions of information about alcohol use during pregnancy: a qualitative study 
BMC Public Health  2014;14(1):1048.
Background
A number of alcohol guidelines worldwide suggest that pregnant women should abstain from alcohol. However, high prevalence rates of alcohol consumption during pregnancy still exist. It is unknown whether there are problems with the dissemination of guideline information that is potentially contributing to such consumption. This qualitative study aimed to explore women’s perceptions of information they received about alcohol use during pregnancy after the introduction of abstinence guidelines.
Methods
Nineteen women from the Australian Longitudinal Study on Women’s Health (ALSWH) 1973–78 cohort that reported a pregnancy in 2009 were recruited for semi-structured telephone interviews. The interviews were conducted until data saturation was reached. Interviews were transcribed, then thematically analysed. ALSWH survey data was used to augment the findings. The main outcome measure was women’s perceptions of information received about alcohol use during pregnancy after the introduction of the 2009 Australian guidelines promoting abstinence during pregnancy.
Results
Women reported a number of problems with the information about alcohol use during pregnancy and with its dissemination. There were inconsistencies in the information about alcohol use during pregnancy and in the advice provided. Mixed messages and confusion about identifying a safe level of consumption had implications on women’s decisions to drink or abstain during pregnancy. Women expressed a need for a clear, consistent message to be provided to women as early as possible. They preferred that the message come from healthcare professionals or another reputable source.
Conclusions
To make an informed decision about alcohol use during pregnancy, women must first be provided with the latest evidence-based information. As this study found a number of limitations with information provision, it is suggested that a systematic approach be adopted by healthcare professionals, in line with best-practice guidelines, to ensure all women are made aware of the alcohol recommendations for pregnancy.
doi:10.1186/1471-2458-14-1048
PMCID: PMC4195901  PMID: 25297463
Alcohol drinking; Pregnancy; Information dissemination; Qualitative research
12.  Diet and Physical Activity for the Prevention of Noncommunicable Diseases in Low- and Middle-Income Countries: A Systematic Policy Review 
PLoS Medicine  2013;10(6):e1001465.
Carl Lachat and colleagues evaluate policies in low- and middle-income countries addressing salt and fat consumption, fruit and vegetable intake, and physical activity, key risk factors for non-communicable diseases.
Please see later in the article for the Editors' Summary
Background
Diet-related noncommunicable diseases (NCDs) are increasing rapidly in low- and middle-income countries (LMICs) and constitute a leading cause of mortality. Although a call for global action has been resonating for years, the progress in national policy development in LMICs has not been assessed. This review of strategies to prevent NCDs in LMICs provides a benchmark against which policy response can be tracked over time.
Methods and Findings
We reviewed how government policies in LMICs outline actions that address salt consumption, fat consumption, fruit and vegetable intake, or physical activity. A structured content analysis of national nutrition, NCDs, and health policies published between 1 January 2004 and 1 January 2013 by 140 LMIC members of the World Health Organization (WHO) was carried out. We assessed availability of policies in 83% (116/140) of the countries. NCD strategies were found in 47% (54/116) of LMICs reviewed, but only a minority proposed actions to promote healthier diets and physical activity. The coverage of policies that specifically targeted at least one of the risk factors reviewed was lower in Africa, Europe, the Americas, and the Eastern Mediterranean compared to the other two World Health Organization regions, South-East Asia and Western Pacific. Of the countries reviewed, only 12% (14/116) proposed a policy that addressed all four risk factors, and 25% (29/116) addressed only one of the risk factors reviewed. Strategies targeting the private sector were less frequently encountered than strategies targeting the general public or policy makers.
Conclusions
This review indicates the disconnection between the burden of NCDs and national policy responses in LMICs. Policy makers urgently need to develop comprehensive and multi-stakeholder policies to improve dietary quality and physical activity.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Noncommunicable diseases (NCDs)—chronic medical conditions including cardiovascular diseases (heart disease and stroke), diabetes, cancer, and chronic respiratory diseases (chronic obstructive pulmonary disease and asthma)—are responsible for two-thirds of the world's deaths. Nearly 80% of NCD deaths, close to 30 million per year, occur in low- and middle-income countries (LMICs), where they are also rising most rapidly. Diet and lifestyle (including smoking, lack of exercise, and harmful alcohol consumption) influence a person's risk of developing an NCD and of dying from it. Because they can be modified, these risk factors have been at the center of strategies to combat NCDs. In 2004, the World Health Organization (WHO) adopted the Global Strategy on Diet, Physical Activity and Health. For diet, it recommended that individuals achieve energy balance and a healthy weight; limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids; increase consumption of fruits, vegetables, legumes, whole grains, and nuts; limit the intake of free sugars; and limit salt consumption from all sources and ensure that salt is iodized. For physical activity, it recommended at least 30 minutes of regular, moderate-intensity physical activity on most days throughout a person's life.
Why Was This Study Done?
By signing onto the Global Strategy in 2004, WHO member countries agreed to implement it with high priority. A first step of implementation is usually the development of local policies. Consequently, one of the four objectives of the WHO Global Strategy is “to encourage the development, strengthening and implementation of global, regional, national and community policies and action plans to improve diets and increase physical activity.” Along the same lines, in 2011 the United Nations held a high-level meeting in which the need to accelerate the policy response to the NCD epidemic was emphasized. This study was done to assess the existing national policies on NCD prevention in LMICs. Specifically, the researchers examined how well those policies matched the WHO recommendations for intake of salt, fat, and fruits and vegetables, as well as the recommendations for physical activity.
What Did the Researchers Do and Find?
The researchers searched the Internet (including websites of relevant ministries and departments) for all publicly available national policies related to diet, nutrition, NCDs, and health from all 140 WHO member countries classified as LMICs by the World Bank in 2011. For countries for which the search did not turn up policies, the researchers sent e-mail requests to the relevant national authorities, to the regional WHO offices, and to personal contacts. All documents dated from 1 January 2004 to 1 January 2013 that included national objectives and guidelines for action regarding diet, physical exercise, NCD prevention, or a combination of the three, were analyzed in detail.
Most of the policies obtained were not easy to find and access. For 24 countries, particularly in the Eastern Mediterranean, the researchers eventually gave up, unable to establish whether relevant national policies existed. Of the remaining 116 countries, 29 countries had no relevant policies, and another 30 had policies that failed to mention specifically any of the diet-related risk factors included in the analysis. Fifty-four of the 116 countries had NCD policies that addressed at least one of the risk factors. Thirty-six national policy documents contained strategies to increase fruit and vegetable intake, 20 addressed dietary fat consumption, 23 aimed to limit salt intake, and 35 had specific actions to promote physical activity. Only 14 countries, including Jamaica, the Philippines, Iran, and Mongolia, had policies that addressed all four risk factors. The policies of 27 countries mentioned only one of the four risk factors.
Policies primarily targeted consumers and government agencies and failed to address the roles of the business community or civil society. Consistent with this, most were missing plans, mechanisms, and incentives to drive collaborations between the different stakeholders.
What Do These Findings Mean?
More than eight years after the WHO Global Strategy was agreed upon, only a minority of the LMICs included in this analysis have comprehensive policies in place. Developing policies and making them widely accessible is a likely early step toward specific implementation and actions to prevent NCDs. These results therefore suggest that not enough emphasis is placed on NCD prevention in these countries through actions that have been proven to reduce known risk factors. That said, the more important question is what countries are actually doing to combat NCDs, something not directly addressed by this analysis.
In richer countries, NCDs have for decades been the leading cause of sickness and death, and the fact that public health strategies need to emphasize NCD prevention is now widely recognized. LMICs not only have more limited resources, they also continue to carry a large burden from infectious diseases. It is therefore not surprising that shifting resources towards NCD prevention is a difficult process, even if the human cost of these diseases is massive and increasing. That only about 3% of global health aid is aimed at NCD prevention does not help the situation.
The authors argue that one step toward improving the situation is better sharing of best practices and what works and what doesn't in policy development. They suggest that an open-access repository like one that exists for Europe could improve the situation. They offer to organize, host, and curate such a resource under the auspices of WHO, starting with the policies retrieved for this study, and they invite submission of additional policies and updates.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001465.
This study is further discussed in a PLOS Medicine Perspective by Stuckler and Basu
The WHO website on diet and physical activity contains links to various documents, including a diet and physical activity implementation toolbox that contains links to the 2004 Global Strategy document and a Framework to Monitor and Evaluate Implementation
There is a 2011 WHO primer on NCDs entitled Prioritizing a Preventable Epidemic
A recent PLOS Medicine editorial and call for papers addressing the global disparities in the burden from NCDs
A PLOS Blogs post entitled Politics and Global HealthAre We Missing the Obvious? and associated comments discuss the state of the fight against NCDs in early 2013
The NCD Alliance was founded by the Union for International Cancer Control, the International Diabetes Federation, the World Heart Federation, and the International Union Against Tuberculosis and Lung Disease; its mission is to combat the NCD epidemic by putting health at the center of all policies
The WHO European Database on Nutrition, Obesity and Physical Activity (NOPA) contains national and subnational surveillance data, policy documents, actions to implement policy, and examples of good practice in programs and interventions for the WHO European member states
doi:10.1371/journal.pmed.1001465
PMCID: PMC3679005  PMID: 23776415
13.  Estimating Chronic Disease Deaths and Hospitalizations Due to Alcohol Use in Canada in 2002: Implications for Policy and Prevention Strategies 
Preventing Chronic Disease  2006;3(4):A121.
Introduction
Alcohol consumption is a factor that increases risk of chronic disease. This study estimates various indicators of alcohol-attributable premature chronic-disease morbidity and mortality for Canada in 2002.
Methods
Information on mortality and morbidity was obtained from Statistics Canada and from the Canadian Institute for Health Information database. Data on alcohol use were obtained from the Canadian Addiction Survey and weighted for per capita consumption. Risk information was taken from published literature and combined with alcohol consumption information to calculate age- and sex-specific alcohol-attributable chronic disease morbidity and mortality.
Results
In Canada in 2002, there were 1631 chronic disease deaths among adults aged 69 years and younger attributed to alcohol consumption, and these deaths were 2.4% of the deaths in Canada for this age group. The net number of deaths comprised 2577 deaths caused and 947 deaths prevented by alcohol consumption. Moderate drinking was involved in 25% of deaths caused and 85% of deaths prevented by alcohol. There were 42,996 years of life lost prematurely in Canada due to alcohol consumption in 2002, 28,890 for men and 14,106 for women. In Canada in 2002, there were 91,970 net chronic disease hospitalizations attributed to alcohol consumption among individuals aged 69 years and younger. The net numbers were 124,621 hospitalizations caused and 32,651 hospitalizations prevented by alcohol consumption.
Conclusion
With rising rates of alcohol consumption and extensive high-risk drinking, both chronic and acute damage from alcohol are expected to increase. Attention is needed to 1) create effective policies and interventions; 2) control access to alcohol; 3) reduce high-risk drinking; and 4) provide brief interventions for high-risk drinkers.
PMCID: PMC1779285  PMID: 16978496
14.  Alcohol consumption in tertiary education students 
BMC Public Health  2011;11:545.
Background
Heavy alcohol consumption among adolescents and young adults is an issue of significant public concern. With approximately 50% of young people aged 18-24 attending tertiary education, there is an opportunity within these settings to implement programs that target risky drinking. The aim of the current study was to survey students and staff within a tertiary education institution to investigate patterns of alcohol use, alcohol-related problems, knowledge of current National Health and Medical Research Council (NHMRC) guidelines for alcohol consumption and intentions to seek help for alcohol problems.
Methods
Students of an Australian metropolitan university (with staff as a comparison group) participated in a telephone interview. Questions related to knowledge of NHMRC guidelines, drinking behaviour, alcohol-related problems and help-seeking intentions for alcohol problems. Level of psychological distress was also assessed.
Results
Of the completed interviews, 774 (65%) were students and 422 (35%) were staff. While staff were more likely to drink regularly, students were more likely to drink heavily. Alcohol consumption was significantly higher in students, in males and in those with a history of earlier onset drinking. In most cases, alcohol-related problems were more likely to occur in students. The majority of students and staff had accurate knowledge of the current NHMRC guidelines, but this was not associated with lower levels of risky drinking. Psychological distress was associated with patterns of risky drinking in students.
Conclusions
Our findings are consistent with previous studies of tertiary student populations, and highlight the disconnect between knowledge of relevant guidelines and actual behaviour. There is a clear need for interventions within tertiary education institutions that promote more effective means of coping with psychological distress and improve help-seeking for alcohol problems, particularly among young men.
doi:10.1186/1471-2458-11-545
PMCID: PMC3223920  PMID: 21740593
15.  Alcohol consumption and sport: a cross-sectional study of alcohol management practices associated with at-risk alcohol consumption at community football clubs 
BMC Public Health  2013;13:762.
Background
Excessive alcohol consumption is responsible for considerable harm from chronic disease and injury. Within most developed countries, members of sporting clubs participate in at-risk alcohol consumption at levels above that of communities generally. There has been limited research investigating the predictors of at-risk alcohol consumption in sporting settings, particularly at the non-elite level. The purpose of this study was to examine the association between the alcohol management practices and characteristics of community football clubs and at-risk alcohol consumption by club members.
Methods
A cross sectional survey of community football club management representatives and members was conducted. Logistic regression analysis (adjusting for clustering by club) was used to determine the association between the alcohol management practices (including alcohol management policy, alcohol-related sponsorship, availability of low- and non-alcoholic drinks, and alcohol-related promotions, awards and prizes) and characteristics (football code, size and location) of sporting clubs and at-risk alcohol consumption by club members.
Results
Members of clubs that served alcohol to intoxicated people [OR: 2.23 (95% CI: 1.26-3.93)], conducted ‘happy hour’ promotions [OR: 2.84 (95% CI: 1.84-4.38)] or provided alcohol-only awards and prizes [OR: 1.80 (95% CI: 1.16-2.80)] were at significantly greater odds of consuming alcohol at risky levels than members of clubs that did not have such alcohol management practices. At-risk alcohol consumption was also more likely among members of clubs with less than 150 players compared with larger clubs [OR:1.45 (95% CI: 1.02-2.05)] and amongst members of particular football codes.
Conclusions
The findings of this study suggest a need and opportunity for the implementation of alcohol harm reduction strategies targeting specific alcohol management practices at community football clubs.
doi:10.1186/1471-2458-13-762
PMCID: PMC3751764  PMID: 23947601
Alcohol drinking; Sports; Public health
16.  Alcohol consumption screening of newly-registered patients in primary care: a cross-sectional analysis 
The British Journal of General Practice  2013;63(615):e706-e712.
Background
Although screening and brief intervention is effective at reducing alcohol consumption in primary care and is recommended by guidelines, there are numerous barriers to its delivery. Screening newly-registered patients for alcohol-use disorders provides an opportunity for systematic collection of alcohol consumption data.
Aim
To examine how alcohol screening data are recorded in primary care, the extent to which they are recorded, and whether reported levels of consumption differ from general population data.
Design and setting
Cross-sectional analysis, with data collected from patients in the year after registration.
Method
Data on alcohol consumption were collected from The Health Improvement Network (THIN) primary care database from patients aged ≥18 years, newly registered with a general practice in 2007 to 2009, and compared with the Office for National Statistics Opinions (ONS Omnibus) survey.
Results
A total of 292 376 (76%) of the 382 609 newly-registered patients had entries for alcohol consumption (units a week, Read Codes for level of consumption, and/or screening test). Only 25 975 (9%) were recorded as completing a validated screening test, most commonly AUDIT/AUDIT-C (16 004, 5%) or FAST (9419, 3%). Alcohol-use disorders are underreported in primary care (for example, higher risk drinking 1% males, 0.5% females) in comparison with the Opinions survey (8% males, 7% females).
Conclusion
Alcohol screening data are collected from most patients within 1 year of registration with a GP practice; however, use of a validated screening test is rarely documented and alcohol-use disorders are underreported. Further efforts are needed to encourage or incentivise the use of validated tests to improve the quality of data collected.
doi:10.3399/bjgp13X673720
PMCID: PMC3782804  PMID: 24152486
alcohol drinking; cross-sectional studies; ONS Opinions (Omnibus) survey; primary health care; The Health Improvement Network (THIN)
17.  GPs’ role security and therapeutic commitment in managing alcohol problems: a randomised controlled trial of a tailored improvement programme 
BMC Family Practice  2014;15:70.
Background
General practitioners with more positive role security and therapeutic commitment towards patients with hazardous or harmful alcohol consumption are more involved and manage more alcohol-related problems than others. In this study we evaluated the effects of our tailored multi-faceted improvement implementation programme on GPs’ role security and therapeutic commitment and, in addition, which professional related factors influenced the impact of the implementation programme.
Methods
In a cluster randomised controlled trial, 124 GPs from 82 Dutch general practices were randomised to either the intervention or control group. The tailored, multi-faceted programme included combined physician, organisation, and patient directed alcohol-specific implementation strategies to increase role security and therapeutic commitment in GPs. The control group was mailed the national guideline and patients received feedback letters. Questionnaires were completed before and 12 months after start of the programme. We performed linear multilevel regression analysis to evaluate effects of the implementation programme.
Results
Participating GPs were predominantly male (63%) and had received very low levels of alcohol related education before start of the study (0.4 h). The programme increased therapeutic commitment (p = 0.005; 95%-CI 0.13 – 0.73) but not role security (p = 0.58; 95%-CI −0.31 – 0.54). How important GPs thought it was to improve their care for problematic alcohol consumption, and the GPs’ reported proportion of patients asked about alcohol consumption at baseline, contributed to the effect of the programme on therapeutic commitment.
Conclusions
A tailored, multi-faceted programme aimed at improving GP management of patients with hazardous and harmful alcohol consumption improved GPs’ therapeutic commitment towards patients with alcohol-related problems, but failed to improve GPs’ role security. How important GPs thought it was to improve their care for problematic alcohol consumption, and the GPs’ reported proportion of patients asked about alcohol consumption at baseline, both increased the impact of the programme on therapeutic commitment. It might be worthwhile to monitor proceeding of role security and therapeutic commitment throughout the year after the implementation programme, to see whether the programme is effective on short term but faded out on the longer term.
Trial registration
ClinicalTrials.gov Identifier: NCT00298220
doi:10.1186/1471-2296-15-70
PMCID: PMC4021502  PMID: 24742032
Alcohol; Role security; Therapeutic commitment; Prevention; Primary healthcare; Implementation
18.  Under the radar: a cross-sectional study of the challenge of identifying at-risk alcohol consumption in the general practice setting 
BMC Family Practice  2014;15:74.
Background
Primary care providers are an important source of information regarding appropriate alcohol consumption. As early presentation to a provider for alcohol-related concerns is unlikely, it is important that providers are able to identify at-risk patients in order to provide appropriate advice. This study aimed to report the sensitivity, specificity, positive predictive value and negative predictive value of General Practitioner (GP) assessment of alcohol consumption compared to patient self-report, and explore characteristics associated with GP non-detection of at-risk status.
Method
GP practices were selected from metropolitan and regional locations in Australia. Eligible patients were adults presenting for general practice care who were able to understand English and provide informed consent. Patients completed a modified AUDIT-C by touchscreen computer as part of an omnibus health survey while waiting for their appointment. GPs completed a checklist for each patient, including whether the patient met current Australian guidelines for at-risk alcohol consumption. Patient self-report and GP assessments were compared for each patient.
Results
GPs completed the checklist for 1720 patients, yielding 1565 comparisons regarding alcohol consumption. The sensitivity of GPs’ detection of at-risk alcohol consumption was 26.5%, with specificity of 96.1%. Higher patient education was associated with GP non-detection of at-risk status.
Conclusions
GP awareness of which patients might benefit from advice regarding at-risk alcohol consumption appears low. Given the complexities associated with establishing whether alcohol consumption is ‘at-risk’, computer-based approaches to routine screening of patients are worthy of exploration as a method for prompting the provision of advice in primary care.
doi:10.1186/1471-2296-15-74
PMCID: PMC4004529  PMID: 24766913
General practice; Alcohol; Detection; Accuracy; Sensitivity
19.  The Nature and Extent of Flavored Alcoholic Beverage Consumption among Underage Youth: Results of a National Brand-specific Survey 
Background
Flavored alcoholic beverages are popular among underage drinkers. Existing studies that assessed flavored alcoholic beverage use among youth relied upon respondents to correctly classify the beverages they consume, without defining what alcohol brands belong to this category.
Objectives
To demonstrate a new method for analyzing the consumption of flavored alcoholic beverages among youth on a brand-specific basis, without relying upon youth to correctly classify brands they consume.
Methods
Using a pre-recruited internet panel developed by Knowledge Networks, we measured the brands of alcohol consumed by a national sample of youth drinkers, ages 16-20 years, in the United States. The sample consisted of 108 youths who had consumed at least one drink of an alcoholic beverage in the past 30 days. We measured the brand-specific consumption of alcoholic beverages within the past 30 days, ascertaining the consumption of 380 alcohol brands, including 14 brands of flavored alcoholic beverages.
Results
Measuring the brand-specific consumption of flavored alcoholic beverages was feasible. Based on a brand-specific identification of flavored alcoholic beverages, nearly half of youth drinkers in the sample reported having consumed such beverages in the past 30 days. Flavored alcoholic beverage preference was concentrated among the top four brands, which accounted for nearly all of the consumption volume reported in our study.
Conclusions and Scientific Significance
These findings underscore the need to assess youth alcohol consumption at the brand level and the potential value of such data in better understanding underage youth drinking behavior and the factors that influence it.
doi:10.3109/00952990.2011.568558
PMCID: PMC3153436  PMID: 21517708
alcohol; brand; flavored alcoholic beverages; surveillance; youth
20.  Changes in undergraduate student alcohol consumption as they progress through university 
BMC Public Health  2008;8:163.
Background
Unhealthy alcohol use amongst university students is a major public health concern. Although previous studies suggest a raised level of consumption amongst the UK student population there is little consistent information available about the pattern of alcohol consumption as they progress through university. The aim of the current research was to describe drinking patterns of UK full-time undergraduate students as they progress through their degree course.
Method
Data were collected over three years from 5895 undergraduate students who began their studies in either 2000 or 2001. Longitudinal data (i.e. Years 1–3) were available from 225 students. The remaining 5670 students all responded to at least one of the three surveys (Year 1 n = 2843; Year 2 n = 2219; Year 3 n = 1805).
Results
Students reported consuming significantly more units of alcohol per week at Year 1 than at Years 2 or 3 of their degree. Male students reported a higher consumption of units of alcohol than their female peers. When alcohol intake was classified using the Royal College of Physicians guidelines [1] there was no difference between male and females students in terms of the percentage exceeding recommended limits. Compared to those who were low level consumers students who reported drinking above low levels at Year 1 had at least 10 times the odds of continuing to consume above low levels at year 3. Students who reported higher levels of drinking were more likely to report that alcohol had a negative impact on their studies, finances and physical health. Consistent with the reduction in units over time students reported lower levels of negative impact during Year 3 when compared to Year 1.
Conclusion
The current findings suggest that student alcohol consumption declines over their undergraduate studies; however weekly levels of consumption at Year 3 remain high for a substantial number of students. The persistence of high levels of consumption in a large population of students suggests the need for effective preventative and treatment interventions for all year groups.
doi:10.1186/1471-2458-8-163
PMCID: PMC2405793  PMID: 18489734
21.  Communicating about Alcohol Consumption to Nonharmful Drinkers with Hepatitis C: Patient and Provider Perspectives 
Background
Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C (HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not be a problem in the absence of their HCV diagnosis.
Objective
This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear.
Design
We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N = 50) and healthcare providers (N = 14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program.
Results
We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients. Patient respondents who reported hearing “stop completely” were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in “medical language” than were GI providers.
Conclusions
To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV.
doi:10.1007/s11606-007-0483-y
PMCID: PMC2359467  PMID: 18172739
Hepatitis C; alcohol consumption; patient-provider communication
22.  Communicating About Alcohol Consumption to Nonharmful Drinkers with Hepatitis C: Patient and Provider Perspectives 
Journal of General Internal Medicine  2008;23(8):1290-1295.
Background
Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C (HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not be a problem in the absence of their HCV diagnosis.
Objective
This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear.
Design
We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N = 50) and healthcare providers (N = 14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program.
Results
We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients. Patient respondents who reported hearing “stop completely” were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in “medical language” than were GI providers.
Conclusions
To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV.
doi:10.1007/s11606-008-0649-2
PMCID: PMC2517959  PMID: 22135843
Hepatitis C; alcohol consumption; patient–provider communication
23.  Brief FASD prevention intervention: physicians’ skills demonstrated in a clinical trial in Russia 
Background
Alcohol consumption during pregnancy can result in a range of adverse pregnancy outcomes including Fetal Alcohol Spectrum Disorders (FASD). Risky drinking among Russian women constitutes a significant risk for alcohol-exposed pregnancies (AEP). Russian women report that obstetrics and gynecology (OB/GYN) physicians are the most important source of information about alcohol consumption during pregnancy and developing effective prevention interventions by OB/GYNs is indicated. This is the first study focused on implementation of an AEP prevention intervention at women’s clinics in Russia.
Method
The paper describes the intervention protocol and addresses questions about the feasibility of a brief FASD prevention intervention delivered by OB/GYNs at women’s clinics in Russia. Brief physician intervention guidelines and two evidence-based FASD prevention interventions were utilized to design a brief dual-focused physician intervention (DFBPI) appropriate to Russian OB/GYN care. The questions answered were whether trained OB/GYN physicians could deliver DFBPI during women’s routine clinic visits, whether they maintained skills over time in clinical settings, and which specific intervention components were better maintained. Data were collected as part of a larger study aimed at evaluating effectiveness of DFBPI in reducing AEP risk in non-pregnant women. Methods of monitoring the intervention delivery included fidelity check lists (FCL) with the key components of the intervention completed by physicians and patients and live and audio taped observations of intervention sessions. Physicians (N = 23) and women (N = 372) independently completed FCL, and 78 audiotapes were coded.
Results
The differences between women’s and physicians’ reports on individual items were not significant. Although the majority of physician and patient reports were consistent (N = 305), a discrepancy existed between the reports in 57 cases. Women reported more intervention components missing compared to physicians (p < 0.001). Discussing barriers was the most difficult component for physicians to implement, and OB/GYN demonstrated difficulties in discussing contraception methods.
Conclusions
The results supported the feasibility of the DFBPI in Russia. OB/GYN physicians trained in the DFBPI, monitored, and supported were able to implement and maintain skills during the study. In addition to the alcohol focus, DFBPI training needs to have a sufficient component to improve physicians’ skills in discussing contraception use.
doi:10.1186/1940-0640-8-1
PMCID: PMC3685594  PMID: 23294846
24.  Invited commentary on Australian fetal alcohol spectrum disorder diagnostic guidelines 
BMC Pediatrics  2014;14:85.
The publication of Australian fetal alcohol spectrum disorder (FASD) diagnostic guidelines marks an important step forward in Australia’s efforts to prevent FASD. But do we need yet another set of FASD guidelines? At the 5th International FASD Conference, the ever growing number of FASD diagnostic guidelines was identified as a core area of concern by leaders in FASD worldwide. All agreed we need to strive to adopt a single set of guidelines. It is essential that FASD diagnosis advance to incorporate new knowledge and technology. But to date, the field of FASD has seen multiple sets of guidelines published that do not address the important question-How is the performance of these new guidelines superior to the performance of existing guidelines to warrant/justify their introduction into the medical literature?
The Australian guidelines include FAS, PFAS and Neurodevelopmental Disorder-Alcohol Exposed (ND-AE). This latter group includes individuals with severe CNS abnormalities without the physical features of FAS. This is the group the 4-Digit-Code calls Static-Encephalopathy-Alcohol-Exposed (SE-AE). The criteria for FAS, PFAS, and ND-AE (or what the 4-Digit-Code calls SE-AE) are identical between the Australian and 4-Digit-Code guidelines with the exception of one very small, but very consequential difference in facial criteria for PFAS. The 4-Digit-Code requires a Rank 3 FAS facial phenotype for PFAS (J Popul Ther Clin Pharmacol20(3):e416–e467, 2013); the Australian guidelines relax the criteria to include the Rank 2 FAS facial phenotype. This relaxation of the criteria renders the facial phenotype NOT specific to prenatal alcohol exposure as confirmed in published empirical studies. If the facial phenotype is not specific to (caused only by) prenatal alcohol exposure one can no longer validly call the outcome PFAS. When one makes a diagnosis of FAS (full or partial), one is stating explicitly that the individual has a syndrome caused by prenatal alcohol exposure. One is also stating explicitly that the biological mother drank alcohol during pregnancy and, as a result, harmed her child. These are bold conclusions to draw and are not without medical, ethical, and even legal consequences. So the question remains-Why go against the published empirical evidence and relax the PFAS facial criteria into the normal range?
doi:10.1186/1471-2431-14-85
PMCID: PMC3994222  PMID: 24685275
Fetal alcohol spectrum disorders; FASD 4-digit diagnostic code
25.  Lifestyle modifications to prevent and control hypertension. 3. Recommendations on alcohol consumption. Canadian Hypertension Society, Canadian Coalition for High Blood Pressure Prevention and Control, Laboratory Centre for Disease Control at Health Canada, Heart and Stroke Foundation of Canada 
OBJECTIVE: To provide updated, evidence-based recommendations concerning the effects of alcohol consumption on the prevention and control of hypertension in otherwise healthy adults (except pregnant women). OPTIONS: There are 2 main options for those at risk for hypertension: avert the condition by limiting alcohol consumption or by using other nonpharmacologic methods, or maintain or increase the risk of hypertension by making no change in alcohol consumption. The options for those who already have hypertension include decreasing alcohol consumption or using another nonpharmacologic method to reduce hypertension; commencing, continuing or intensifying antihypertensive medication; or taking no action and remaining at increased risk of cardiovascular disease. OUTCOMES: The health outcomes considered were changes in blood pressure and in morbidity and mortality rates. Because of insufficient evidence, no economic outcomes were considered. EVIDENCE: A MEDLINE search was conducted for the period 1966-1996 with the terms ethyl alcohol and hypertension. Other relevant evidence was obtained from the reference lists of articles identified, from the personal files of the authors and through contacts with experts. The articles were reviewed, classified according to study design, and graded according to the level of evidence. VALUES: A high value was placed on the avoidance of cardiovascular morbidity and premature death caused by untreated hypertension. BENEFITS, HARMS AND COSTS: A reduction in alcohol consumption from more than 2 standard drinks per day reduces the blood pressure of both hypertensive and normotensive people. The lowest overall mortality rates in observational studies were associated with drinking habits that were within these guidelines. Side effects and costs were not measured in any of the studies. RECOMMENDATIONS: (1) It is recommended that health care professionals determine how much alcohol their patients consume. (2) To reduce blood pressure in the population at large, it is recommended that alcohol consumption be in accordance with Canadian low-risk drinking guidelines (i.e., healthy adults who choose to drink should limit alcohol consumption to 2 or fewer standard drinks per day, with consumption not exceeding 14 standard drinks per week for men and 9 standard drinks per week for women). (3) Hypertensive patients should also be advised to limit alcohol consumption to the levels set out in the Canadian low-risk drinking guidelines. VALIDATION: These recommendations are similar to those of the World Hypertension League, the National High Blood Pressure Education Program Working Group on Primary Prevention of Hypertension and the previous recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control and the Canadian Hypertension Society. They have not been clinically tested. The low-risk drinking guidelines are those of the Addiction Research Foundation of Ontario and the Canadian Centre on Substance Abuse. SPONSORS: The Canadian Hypertension Society, the Canadian Coalition for High Blood Pressure Prevention and Control, the Laboratory Centre for Disease Control at Health Canada, and the Heart and Stroke Foundation of Canada. The low-risk drinking guidelines have been endorsed by the College of Family Physicians of Canada and several provincial organizations.
PMCID: PMC1230335  PMID: 10333849

Results 1-25 (517181)