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1.  Drinking Patterns and Alcohol Use Disorders in São Paulo, Brazil: The Role of Neighborhood Social Deprivation and Socioeconomic Status 
PLoS ONE  2014;9(10):e108355.
Research conducted in high-income countries has investigated influences of socioeconomic inequalities on drinking outcomes such as alcohol use disorders (AUD), however, associations between area-level neighborhood social deprivation (NSD) and individual socioeconomic status with these outcomes have not been explored in Brazil. Thus, we investigated the role of these factors on drink-related outcomes in a Brazilian population, attending to male-female variations.
A multi-stage area probability sample of adult household residents in the São Paulo Metropolitan Area was assessed using the WHO Composite International Diagnostic Interview (WMH-CIDI) (n = 5,037). Estimation focused on prevalence and correlates of past-year alcohol disturbances [heavy drinking of lower frequency (HDLF), heavy drinking of higher frequency (HDHF), abuse, dependence, and DMS-5 AUD] among regular users (RU); odds ratio (OR) were obtained.
Higher NSD, measured as an area-level variable with individual level variables held constant, showed an excess odds for most alcohol disturbances analyzed. Prevalence estimates for HDLF and HDHF among RU were 9% and 20%, respectively, with excess odds in higher NSD areas; schooling (inverse association) and low income were associated with male HDLF. The only individual-level association with female HDLF involved employment status. Prevalence estimates for abuse, dependence, and DSM-5 AUD among RU were 8%, 4%, and 8%, respectively, with excess odds of: dependence in higher NSD areas for males; abuse and AUD for females. Among RU, AUD was associated with unemployment, and low education with dependence and AUD.
Regular alcohol users with alcohol-related disturbances are more likely to be found where area-level neighborhood characteristics reflect social disadvantage. Although we cannot draw inferences about causal influence, the associations are strong enough to warrant future longitudinal alcohol studies to explore causal mechanisms related to the heterogeneous patterns of association and male-female variations observed herein. Hopefully, these findings may help guide future directions for public health.
PMCID: PMC4182710  PMID: 25272008
2.  Associations of cohort and socio-demographic correlates with transitions from alcohol use to disorders and remission in metropolitan China 
Addiction (Abingdon, England)  2009;104(8):1313-1323.
To examine sociodemographic associations of transitions from alcohol use to disorders and of remission from disorders in metropolitan China.
Design and Setting
Face-to-face interviewing by trained lay-interviewers on a multi-staged, clustered sample from the general population of Beijing and Shanghai, P.R.C.
5,201 adults aged 18-70 years and with household registration.
World Mental Health version of Composite International Diagnostic Interview.
Lifetime prevalence estimates for alcohol use, regular use (at least 12 drinks in a year), DSM-IV abuse and dependence with abuse were 65.4%, 39.5% (60.4% of ever-drinkers), 4.6% (11.6% of regular users) and 0.9% (20.4% of lifetime alcohol abusers) respectively. These estimates were higher among respondents from the recent cohort. 64.3% and 36.9% respondents with a history of lifetime abuse and dependence had remitted respectively. The number of sociodemographic associations for the onset of each transitional stage decreased from alcohol use to alcohol dependence. Onset of ever-use was more common in respondents who were male, 18-50 years of age, with middle education level, and never married, but less common among the previously married and students. First onset of regular use among those with ever-use was more common in respondents who were male, less than 50 years of age and never married, but less common in students. Being male and less than 50 years of age was associated with more alcohol abusers among regular users.
This study was the first to reveal in a Chinese population that qualitatively different risk factors might operate during the different stages of progression from alcohol use to disorders. Further research is needed to clarify the mechanisms underlying these differences in order to guide prevention programs.
PMCID: PMC3659770  PMID: 19438840
alcohol; abuse; dependence; remission; transitions; China
3.  Sociodemographic Predictors of Transitions across Stages of Alcohol Use, Disorders and Remission in the National Comorbidity Survey-Replication 
Comprehensive psychiatry  2008;50(4):299-306.
Although much is known about risk factors for the initiation of alcohol use, abuse and dependence, few population-based studies have examined the predictors of transitions across these stages.
To examine the sociodemographic predictors of transitions across six stages of alcohol use in the National Comorbidity Survey Replication (NCS-R) a nationally representative household survey of the U.S. population.
A lifetime history of alcohol use, regular use (at least 12 drinks in a year), DSM-IV alcohol abuse and dependence with abuse was collected in 5692 NCS-R respondents using the WHO Composite International Diagnostic Interview (CIDI), Version 3.0.
Lifetime prevalence estimates were 91.7% for lifetime alcohol use, 72.9% for regular use, 13.2% for abuse, and 5.4% for dependence with abuse. Male sex, young age, non-Hispanic White race/ethnicity, low education, student status, and never being married predicted the onset of alcohol use, the transition from use to regular use, and from regular use to abuse. An early age of onset of alcohol use also predicted the latter transition. The transition from abuse to dependence was associated with an early age of onset of regular alcohol use, being previously married, and student status. Remission was predicted by young age, and a later age of onset of alcohol abuse.
The reduced number and magnitude of factors associated with transitions to dependence and remission suggests qualitatively different risk factors at these stages relative to other stages of progression. Further knowledge is needed concerning the mechanisms underlying these differences in order to guide selective and indicated prevention programs.
PMCID: PMC2933383  PMID: 19486727
alcohol; abuse; dependence; remission; transitions
4.  Correlates of alcohol abuse/dependence in early-onset alcohol-using women 
Early-onset alcohol use is associated with increased vulnerability to subsequent alcohol abuse and dependence. However, not all early-onset alcohol users develop alcohol use disorders (AUDs). Using a sample of young women from the U.S., we identify correlates that contribute to a greater likelihood of AUDs in early-onset alcohol users.
Using interview and questionnaire data on participants of the Missouri Adolescent Female Twin Study (MOAFTS), we examine whether measures from domains including socio-demographic, pubertal development, religiosity, educational achievement, adverse life events, internalizing disorders, externalizing disorders and family history and discipline were associated with development of AUDs in 1,158 women who had their first drink of alcohol prior to age 16.
Early-onset drinkers were 3.6 times more likely to meet criteria for AUDs than later onset drinkers. While univariate analyses revealed that a host of correlates were associated with likelihood of AUDs in early-onset drinkers, multivariate analyses suggested that, even after accounting for a particularly early age of onset of drinking, those with a history of physical abuse, co-twin alcohol problems, conduct disorder, regular smoking, older peers and peer substance use were considerably more likely to meet criteria for AUDs than early onset drinkers without a lifetime history of these correlates.
The progression from first drink to AUDs is complex, and while early age at first drink is a potent risk factor, other aspects of psychopathology, family history, conduct problems and peer affiliations can exacerbate or alleviate the risk of AUDs in these young female drinkers.
PMCID: PMC3571676  PMID: 21838841
alcohol; early-onset; alcohol abuse/dependence; female
5.  Social networks and alcohol use disorders: findings from a nationally representative sample 
While some argue that social network ties of individuals with alcohol use disorders (AUD) are robust, there is evidence to suggest that individuals with AUDs have few social network ties, which are a known risk factor for health and wellness.
Social network ties to friends, family, co-workers and communities of individuals are compared among individuals with a past-year diagnosis of alcohol dependence or alcohol abuse to individuals with no lifetime diagnosis of AUD.
Respondents from Wave 2 of the National Epidemiologic Survey on Alcohol Related Conditions (NESARC) were assessed for the presence of past-year alcohol dependence or past-year alcohol abuse, social network ties, sociodemographics and clinical characteristics.
Bivariate analyses showed that both social network size and social network diversity was significantly smaller among individuals with alcohol dependence, compared to individuals with alcohol abuse or no AUD. When social and clinical factors related to AUD status were controlled, multinomial logistic models showed that social network diversity remained a significant predictor of AUD status, while social network size did not differ among AUD groups.
Social networks of individuals with AUD may be different than individuals with no AUD, but this claim is dependent on specific AUD diagnosis and how social networks are measured.
PMCID: PMC4004646  PMID: 24405256
Alcohol use disorders; National Epidemiologic Survey on Alcohol Related Conditions (NESARC); social networks
6.  Predictors of Initial and Sustained Remission from Alcohol Use Disorders: Findings from the 30-Year Follow-Up of the San Diego Prospective Study 
Individuals who report problematic drinking early in life often recover from alcohol-related disorders, with or without formal treatment. While risk factors associated with developing alcohol use disorders (AUDs), such as a family history (FH) of alcoholism and the genetically-influenced low level of response (LR) to alcohol, have been identified, less is known about characteristics that relate to remission from AUDs.
The male subjects (98% Caucasian) for this study were 129 probands from the San Diego Prospective Study who were first evaluated at age 20 as drinking but not alcohol dependent young men, most of whom were college graduates by followup. The individuals evaluated here met criteria for an AUD at their first follow-up at age 28 to 33 and were followed every 5 years for the next two decades. Discrete-time survival analysis was used to examine rates of initial and sustained AUD remission and to evaluate the relationships of premorbid characteristics and other risk factors to these outcomes.
60% of the sample met criteria for an initial AUD remission of five or more years, including 45% with sustained remission (i.e. no subsequent AUD diagnosis). Higher education, lower drinking frequency, and having a diagnosis of alcohol abuse (rather than dependence) were associated with higher rates of initial AUD remission. A lower LR to alcohol at age 20, as well as lower drinking frequency, having received formal alcohol treatment, and older age at the first follow-up all predicted a greater likelihood of sustained AUD remission.
This study identified key factors associated with initial and sustained AUD remission in subjects diagnosed with AUD in young adulthood. Characteristics associated with better outcomes early in the lifespan, such as lower drinking frequency and early treatment appear to have a lasting impact on remission from AUD across adulthood.
PMCID: PMC3675188  PMID: 23458300
Level of Response; Alcoholism; Survival Analysis; Longitudinal; Remission
7.  Diffusion Tensor Measures of the Corpus Callosum in Adolescents With Adolescent Onset Alcohol Use Disorders 
In adults, myelination injury is associated with alcoholism. Maturation of the corpus callosum is prominent during adolescence. We hypothesized that subjects with adolescent-onset alcohol use disorders (AUD; defined as Diagnostic and Statistical Manual of Mental Disorders-IV alcohol dependence or abuse) would have myelination mircostructural differences compared to controls.
Adolescent subjects (25 males, 7 females) with an AUD (16.9 ± 1.2 years), who were recruited from substance abuse treatment programs and had co-morbid mental disorders, and 28 sociodemographically similar healthy controls (17 males, 11 females; 15.9 ± 1.1 years) underwent a 3.0 T MRI diffusion tensor imaging scan.
Measures of rostral body fractional anisotropy (FA) were higher in the AUD group than in the control group. Compared to controls, mean diffusivity (MD) was lower, while FA was higher, in the AUD group in the isthmus region. Anterior corpus callosum mircostructural development differed in adolescents with AUD, as age was positively (not negatively) associated with rostrum MD and age was negatively (not positively) associated with rostrum FA. There were sex by group interactions in that control females had higher posterior midbody FA when com pared to female adolescents with AUD.
Lower MD and higher FA values in the AUD group suggest pre-morbid vulnerability for accelerated prefrontal and temporo-parietal myelin maturation that may enhance the risk for adolescent AUD. Significant (and opposite to developmentally expected) correlations were seen between anterior corpus callosum MD and FA measures and age in the AUD group, suggesting neurotoxic effects of alcohol on adolescent corpus callosum microstructure. As seen in adults, female adolescents with AUD may be especially vulnerable to corpus callosum mircostructural injury. Further diffusion tensor imaging studies of corpus callosum maturation in children at familial risk for alcoholism, and in those with AUD, need to be done to elucidate these mechanisms.
PMCID: PMC3566638  PMID: 18241319
Alcohol Use Disorders; Alcohol Abuse or Dependence; Diffusion Tensor Imaging; Adolescence; Corpus Callosum
8.  Environmental influences predominate in remission from alcohol use disorder in young adult twins 
Psychological medicine  2012;42(11):2421-2431.
Familial influences on remission from alcohol use disorder (AUD) have been studied using family history of AUD rather than family history of remission. The current study used a remission phenotype in a twin sample to examine the relative contributions of genetic and environmental influences to remission
The sample comprised 6183 twins with an average age of 30 years from the Australian Twin Registry. Lifetime history of alcohol abuse and dependence symptoms and symptom recency were assessed with a structured telephone interview. AUD was defined broadly and narrowly as history of two or more or three or more abuse or dependence symptoms. Remission was defined as absence of symptoms at time of interview among individuals with lifetime AUD. Standard bivariate genetic analyses were conducted to derive estimates of genetic and environmental influences on AUD and remission
Environmental influences alone accounted for remission in males and for 89% of influences on remission in females, with 11% due to genetic influences shared with AUD, which decreased the likelihood of remission. For women, more than 80% of influences on remission were distinct from influences on AUD, and environmental influences were from individual experiences only. For men, just over 50% of influences on remission were distinct from those on AUD, and the influence of environments shared with the co-twin were substantial. The results for the broad and narrow phenotypes were similar
The current study establishes young adult remission as a phenotype distinct from AUD and highlights the importance of environmental influences on remission
PMCID: PMC3752317  PMID: 22423619
Alcohol dependence; alcohol use disorder; remission; twins
9.  Transitions In and Out of Alcohol Use Disorders: Their Associations with Conditional Changes in Quality of Life Over a 3-Year Follow-Up Interval† 
Aims: The aim of this study was to investigate longitudinal changes in quality of life (QOL) as a function of transitions in alcohol use disorders (AUD) over a 3-year follow-up of a general US population sample. Methods: The analysis is based on individuals who drank alcohol in the year preceding the Wave 1 National Epidemiologic Survey on Alcohol and Related Conditions and were reinterviewed at Wave 2 (n = 22,245). Using multiple linear regression models, changes in SF-12 QOL were estimated as a function of DSM-IV AUD transitions, controlling for baseline QOL and multiple potential confounders. Results: Onset and offset of AUD were strongly associated with changes in mental/psychological functioning, with significant decreases in mental component summary (NBMCS) scores among individuals who developed dependence and significant increases among those who achieved full and partial remission from dependence. The increases in overall NBMCS and its social functioning, role emotional and mental health components were equally great for abstinent and nonabstinent remission from dependence, but improvements in bodily pain and general health were associated with nonabstinent remission only. Onset of abuse was unrelated to changes in QOL, and the increase in NBMCS associated with nonabstinent remission from abuse only was slight. Individuals with abuse only or no AUD who stopped drinking had significant declines in QOL. Conclusions: These results suggest the possible importance of preventing and treating AUD for maintaining and/or improving QOL. They are also consistent with the sick quitter hypothesis and suggest that abuse is less a mental disorder than a maladaptive pattern of behavior.
PMCID: PMC2605522  PMID: 19042925
10.  Transitions In and Out of Alcohol Use Disorders: Their Associations with Conditional Changes in Quality of Life Over a 3-Year Follow-Up Interval 
To investigate longitudinal changes in quality of life (QOL) as a function of transitions in alcohol use disorders (AUD) over a 3-year follow-up of a general U.S. population sample.
The analysis is based on individuals who drank alcohol in the year preceding the Wave 1 National Epidemiologic Survey on Alcohol and Related Conditions and were reinterviewed at Wave 2 (n=22,245). Using multiple linear regression models, changes in SF-12 QOL were estimated as a function of DSM-IV AUD transitions, controlling for baseline QOL and multiple potential confounders.
Onset and offset of AUD were strongly associated with changes in mental/psychological functioning, with significant decreases in mental component summary (NBMCS) scores among individuals who developed dependence and significant increases among those who achieved full and partial remission from dependence. The increases in overall NBMCS and its social functioning, role emotional and mental health components were equally great for abstinent and nonabstinent remission from dependence, but improvements in bodily pain and general health were associated with nonabstinent remission only. Onset of abuse was unrelated to changes in QOL, and the increase in NBMCS associated with nonabstinent remission from abuse only was slight. Individuals with abuse only or no AUD who stopped drinking had significant declines in QOL.
These results suggest the possible importance of preventing and treating AUD for maintaining and/or improving QOL. They are also consistent with the sick quitter hypothesis and suggest that abuse is less a mental disorder than a maladaptive pattern of behavior.
PMCID: PMC2605522  PMID: 19042925
quality of life; QOL; HRQOL; alcohol use disorders; remission; transitions
11.  Perturbation of the Glutamate–Glutamine System in Alcohol Dependence and Remission 
Neuropsychopharmacology  2011;36(7):1359-1365.
As acute ethanol exposure inhibits N-methyl--aspartate glutamate (Glu) receptors, sudden withdrawal from chronic alcohol use may lead to an increased activation of these receptors with excitotoxic effects. In the longer term, brain levels of Glu and its metabolites, such as glutamine (Gln), are likely to be chronically altered by alcohol, possibly providing a measure of overall abnormal Glu–Gln cycling. However, few studies have assessed concentrations of these metabolites in clinical populations of individuals with alcohol use disorders. Glu and Gln levels were compared in groups of 17 healthy controls and in 13 participants with alcohol dependence. Within the alcohol-dependent group, seven participants had current alcohol use disorder (AUD), and six had AUD in remission for at least 1 year (AUD-R). Neurometabolite concentrations were measured with proton magnetic resonance spectroscopy (1H-MRS) in a predominantly gray matter voxel that included the bilateral anterior cingulate gyri. Tissue segmentation provided an assessment of the proportion of gray matter in the 1H-MRS voxel. The Drinker Inventory of Consequences (DrInC) and Form-90 were administered to all participants to quantify alcohol consequences and use. Glu level was lower and Gln level was higher in the AUD and AUD-R groups relative to the control group; creatine, choline, myo-inositol, and total N-acetyl groups, primarily N-acetylaspartate did not differ across groups. These results were not confounded by age, sex, or proportion of gray matter in the 1H-MRS voxel. Neurometabolite concentrations did not differ between AUD and AUD-R groups. Subsequent regressions in the combined clinical group, treating voxel gray matter proportion as a covariate, revealed that total score on the DrInC was positively correlated with Gln but negatively correlated with both Glu and gray matter proportion. Regression analyses, including DrInC scores and smoking variables, identified a marginal independent effect of smoking on Gln. The current findings of higher Gln and lower Glu in the combined AUD and AUD-R groups might indicate a perturbation of the Glu–Gln cycle in alcohol use disorders. The absence of differences in mean Glu and Gln between the AUD and AUD-R groups suggests that altered Glu–Gln metabolism may either predate the onset of abuse or persist during prolonged abstinence.
PMCID: PMC3096805  PMID: 21389979
magnetic resonance spectroscopy; alcohol use disorders; alcoholism; glutamate; glutamine; addiction & substance abuse; alcohol & alcoholism; glutamate; biological psychiatry; magnetic resonance spectroscopy
12.  Alcohol use disorder-related sick leave and mortality: a cohort study 
Alcohol use disorders (AUDs) are associated with the highest all-cause mortality rates of all mental disorders. The majority of patients with AUDs never receive inpatient treatment for their AUD, and there is lack of data about their mortality risks despite their constituting the majority of those affected. Absenteeism from work (sick leave) due to an AUD likely signals worsening. In this study, we assessed whether AUD-related sick leave was associated with mortality in a cohort of workers in Germany.
128,001 workers with health insurance were followed for a mean of 6.4 years. We examined the associations between 1) AUD-related sick leave managed on an outpatient basis and 2) AUD-related psychiatric inpatient treatment, and mortality using survival analysis, and Cox proportional hazard regression models (separately by sex) adjusted for age, education, and job code classification. We also stratified analyses by sick leave related to three groups of alcohol-related conditions (all determined by International Classification of Diseases 9th ed. (ICD-9) codes): alcohol abuse and dependence; alcohol-induced mental disorder; and alcohol-induced medical conditions.
Outpatient-managed AUD-related sick leave was significantly associated with higher mortality (hazard ratio (HR) 2.90 (95% Confidence interval (CI) 2.24-3.75) for men, HR 5.83 (CI 2.90-11.75) for women). The magnitude of the association was similar for receipt of AUD-related psychiatric inpatient treatment (HR 3.2 (CI 2.76-3.78) for men, HR 6.5 (CI 4.41-9.47) for women). Compared to those without the conditions, higher mortality was observed consistently for outpatients and inpatients across the three groups of alcohol-related conditions. Those with alcohol-related medical conditions who had AUD-related psychiatric inpatient treatment appeared to have the highest mortality.
Alcohol use disorder-related sick leave as documented in health insurance records is associated with higher mortality. Such sick leave does not necessarily lead to any specific AUD treatment. Therefore, AUD-related sick leave might be used as a trigger for insurers to intervene by offering AUD treatment to patients to try to reduce their risk of death.
PMCID: PMC3565982  PMID: 23363536
Workers; Alcohol; Mortality; Gender; Addiction; Outpatients; Inpatients
13.  Social Anxiety Disorder and Alcohol Use Disorder Comorbidity in the National Epidemiologic Survey on Alcohol and Related Conditions 
Psychological medicine  2010;40(6):977-988.
To assess the prevalence and clinical impact of comorbid Social Anxiety Disorder (SAD) and Alcohol Use Disorders (AUD, i.e., alcohol abuse and alcohol dependence) in a nationally representative sample of adults in the United States.
Data came from a large representative sample of the United States population. Face-to-face interviews of 43,093 adults residing in households were conducted during 2001–2002. Diagnoses of mood, anxiety, alcohol and drug use disorders, and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule—DSM-IV Version.
Lifetime prevalence of comorbid AUD and SAD in the general population was 2.4%. SAD was associated with significantly increased rates of alcohol dependence (OR=2.8) and alcohol abuse (OR=1.2). Among respondents with alcohol dependence, SAD was associated with significantly more mood, anxiety, psychotic, and personality disorders. Among respondents with SAD, alcohol dependence and abuse were most strongly associated with more substance use disorders, pathological gambling, and antisocial personality disorders. SAD occurred before alcohol dependence in 79.7% of comorbid cases, but comorbidity status did not influence age of onset for either disorder. Comorbid SAD was associated with increased severity of alcohol dependence and abuse. Respondents with comorbid SAD and alcohol dependence or abuse reported low rates of treatment-seeking.
Comorbid lifetime AUD and SAD is a prevalent dual diagnosis, associated with substantial rates of additional comorbidity, but remaining largely untreated. Future research should clarify the etiology of this comorbid presentation to better identify effective means of intervention.
PMCID: PMC2917264  PMID: 20441690
14.  Consequences of an Adolescent Onset and Persistent Course of Alcohol Dependence in Men: Adolescent Risk Factors and Adult Outcomes 
While there is an extensive literature on the correlates of alcohol use disorders (AUD; alcohol abuse and dependence), there are relatively few prospective studies of representative birth cohorts that have examined the unique effects of an adolescent onset and persistent course of AUD on a wide range of psychosocial variables.
A longitudinal, community-based sample of 530 men was used to examine the impact of an adolescent onset (AUD+ at age 17) and persistent course (AUD+ at age 29) of AUD on adolescent and adult functioning including substance use, antisocial behavior, mental health problems, overall psychosocial functioning, environmental risk and protective factors, and social outcomes such as peer and romantic relationships, marriage, educational and occupational attainment, and parenthood.
An adolescent onset of AUD (n = 57) was associated with severe deficits across multiple domains of psychosocial functioning in adolescence. Measures of behavioral disinhibition in adolescence were strong predictors of a persistent course of AUD (n = 93). Nearly 40% of men with an adolescent onset were able to desist by age 29, and were similar, but not identical to men who never experienced an AUD in terms of adult functioning. Men with an adolescent onset and persistent course of AUD exhibited the most severe deficits in functioning.
Results emphasize the importance of examining developmental course to understand the etiology of AUD. Our findings are optimistic in that individuals who desist from AUD are able to achieve high levels of psychosocial functioning. Our findings suggest that future research on the persistence of AUD into adulthood should focus on the contributions of behavioral disinhibition and social environment variables including peer and romantic relationships.
PMCID: PMC2884045  PMID: 20184563
15.  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.
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.
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
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
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
PMCID: PMC3949675  PMID: 24618831
16.  Increased Risk for Suicidal Behavior in comorbid Bipolar Disorder and Alcohol Use Disorders 
Bipolar Disorder (BD) has a high rate of suicide attempt, and Alcohol Use Disorders (AUD) have also been associated with elevated risk for suicidal behavior. Whether risk for suicidal behavior is elevated when these conditions are comorbid has not been addressed in epidemiologic studies.
1643 individuals with a lifetime diagnosis of Bipolar Disorder were identified from 43,093 general population respondents who were interviewed in the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions. Lifetime prevalence of reported history of suicide attempt and suicidal thoughts among Bipolar Disorder respondents with and without DSM IV lifetime alcohol use disorders (abuse or dependence) was assessed using X2 and adjusted odds ratios and confidence intervals calculated. Logistic regression was used to test relevance of other comorbid clinical conditions to suicide risk in BD respondents with and without comorbid AUD
More than half (54%) of respondents who met criteria for BD also reported AUD. BD individuals with comorbid AUD were at greater risk for suicide attempt than those without AUD (Adjusted Odds Ratio =2.25) and were more likely to have comorbid nicotine dependence and drug use disorders. Nicotine dependence and drug use disorders did not increase risk for suicidal behavior among those with BD, nor did they confer additional risk among BD respondents who also reported AUD. Despite greater psychopathological burden, individuals with comorbid BD and AUD did not receive more or more intensive treatment.
Suicidal behavior is more likely in bipolar respondents who also suffer from AUD. Interventions to reduce suicide risk in BD need to address the common and high-risk comorbidity with AUD.
PMCID: PMC2914308  PMID: 20667292
Bipolar Disorder; Alcohol Use Disorders; comorbidity; suicide attempt
Existing information on consequences of the DSM-5 revision for diagnosis of alcohol use disorders (AUD) has gaps, including missing information critical to understanding implications of the revision for clinical practice.
Data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were used to compare AUD severity, alcohol consumption and treatment, sociodemographic and health characteristics and psychiatric comorbidity among individuals with DSM-IV abuse versus DSM-5 moderate AUD and DSM-IV dependence versus DSM-5 severe AUD. For each pair of disorders, we additionally compared three mutually exclusive groups: individuals positive solely for the DSM-IV disorder, those positive solely for the DSM-5 disorder and those positive for both.
Whereas 80.5% of individuals positive for DSM-IV dependence were positive for DSM-5 severe AUD, only 58.0% of those positive for abuse were positive for moderate AUD. The profiles of individuals with DSM-IV dependence and DSM-5 severe AUD were almost identical. The only significant (p<.005) difference, more AUD criteria among the former, reflected the higher criterion threshold (≥4 vs. ≥3) for severe AUD relative to dependence. In contrast, the profiles of individuals with DSM-5 moderate AUD and DSM-IV abuse differed substantially. The former endorsed more AUD criteria, had higher rates of physiological dependence, were less likely to be White and male, had lower incomes, were less likely to have private and more likely to have public health insurance, and had higher levels of comorbid anxiety disorders than the latter.
Similarities between the profiles of DSM-IV and DSM-5 AUD far outweigh differences; however, clinicians may face some changes with respect to appropriate screening and referral for cases at the milder end of the AUD severity spectrum, and the mechanisms through which these will be reimbursed may shift slightly from the private to public sector.
PMCID: PMC3800556  PMID: 22974144
DSM-5; AUD; treatment; severity; clinical profile
18.  Probability and predictors of remission from lifetime nicotine, alcohol, cannabis, or cocaine dependence: Results from the National Epidemiologic Survey on Alcohol and Related Conditions 
Addiction (Abingdon, England)  2010;106(3):657-669.
To estimate the general and racial-ethnic specific cumulative probability of remission from nicotine alcohol cannabis or cocaine dependence, and to identify predictors of remission across substances.
Data were collected from structured diagnostic interviews using the Alcohol Use Disorder and Associated Disabilities Interview Schedule – DSM-IV version.
The 2001–2002 NESARC surveyed a nationally representative sample from USA adults (n=43,093) selected in a three-stage sampling design.
The subsamples of individuals with lifetime DSM-IV diagnosis of dependence on nicotine (n=6,937), alcohol (n=4,781), cannabis (n=530) and cocaine (n=408).
Cumulative probability estimates of dependence remission for the general population and across racial-ethnic groups. Hazard ratios for remission from dependence.
Lifetime cumulative probability estimates of dependence remission were 83.7% for nicotine, 90.6% for alcohol, 97.2% for cannabis, and 99.2% for cocaine. Half of the cases of nicotine, alcohol, cannabis and cocaine dependence remitted approximately 26, 14, 6 and 5 years after dependence onset, respectively. Males, Blacks and individuals with diagnosis of personality disorders and history of substance use comorbidity exhibited lower hazards of remission for at least two substances.
A significant proportion of individuals with dependence on nicotine, alcohol, cannabis or cocaine achieve remission at some point in their lifetime, although the probability and time to remission varies by substance and racial-ethnic group. Several predictors of remission are shared by at least two substances, suggesting that the processes of remission overlap. The lower rates of remission of individuals with comorbid personality or substance use disorders highlight the need of providing coordinated psychiatric and substance abuse interventions.
PMCID: PMC3227547  PMID: 21077975
19.  Item Response Theory Analysis of Binge Drinking and its Relationship to Lifetime Alcohol Use Disorder Symptom Severity in an American Indian Community Sample 
Item Response Theory (IRT) has been used to examine alcohol use disorder (AUD) symptoms and their psychometric properties but has not been previously applied to AUD symptoms from an American Indian sample.
Lifetime DSM-IV AUD symptoms and binge drinking (5+ drinks men/4+ drinks women) at ≥1, ≥4, ≥8, ≥15 days per month during the period of heaviest lifetime drinking criteria were assessed in 530 American Indian participants. Exploratory (EFA) factor analysis was used to examine the factor structure of the ten AUD symptoms and each alcohol consumption criterion. Two-parameter IRT models generated marginal maximum likelihood estimates for discrimination (a) and threshold (b) parameters for ten DSM-IV AUD symptoms and each consumption criterion. Differential Item Functioning (DIF) analysis was used to assess AUD symptom severity in groups defined by gender and age at interview.
The AUD symptoms of “Withdrawal” and “Activities Given Up” were the most severe symptoms. “Tolerance” and “Social/Interpersonal Problems” were the least severe. All AUD symptoms fell on the moderate portion of the severity continuum, except “Withdrawal”, which fell at the lower end of the severe portion. The consumption criterion of 5+/4+ (male/female) at ≥8 times per month demarcated the portion of the severity continuum where AUD symptoms began to occur at a probability of 50%. DIF analysis showed significant gender and age at interview differences for “Hazardous Use,” “Tolerance,” and “Activities Given Up,” but not for the other AUD symptoms.
In this American Indian community sample, alcohol abuse and dependence did not represent distinct disorders. Only one AUD symptom was found outside the moderate portion of the underlying AUD severity continuum. Drinking 5+/4+ (male/female) drinks at a frequency of ≥8 times per month during the period of heaviest lifetime drinking was found to function well as both a risk and a diagnostic criterion for lifetime DSM-IV AUD. DSM-IV AUD symptom criteria, as currently assessed, may be limited in their ability to capture the full range of symptom severity of AUDs, at least in this high risk population.
PMCID: PMC3083452  PMID: 21314696
IRT; Binge Drinking; Alcohol Symptoms; Native American
20.  Cigarette Smoking and the Risk for Alcohol Use Disorders Among Adolescent Drinkers 
Cigarette smoking and alcohol use disorders are closely linked, but it is not clear whether higher rates of alcohol use disorder (AUD) among smokers are solely attributable to heavier drinking, or alternatively, whether smokers are more vulnerable to alcohol abuse and dependence than non-smokers who drink comparable quantities. We sought to address this issue using data from a nationally representative U.S. sample of adolescents and young adults. Specifically, we analyzed the relationship between cigarette smoking, drinking, and alcohol use disorders.
Data were from the aggregated 2002 through 2004 U.S. National Survey on Drug Use and Health. Participants were randomly selected, household-dwelling adolescents and young adults (ages 12-20) from the non-institutionalized, civilian population of the United States (N=74,836). Measurements included current DSM-IV alcohol abuse or dependence, number of drinks in the past 30-days, and past-year cigarette smoking, defined as having smoked more than 100 cigarettes across the lifetime and having smoked during the past year.
Past-year smokers, (prevalence=16.0%) drank in higher quantities than never-smokers, but were also at elevated risk for AUD when compared to never-smokers who drank equivalent quantities. The effect was observed across age groups, but was more prominent among younger adolescents. After adjusting for drinking quantity and sociodemographic variables, smokers had 4.5-fold higher odds of AUD than never-smokers (95% CI: 3.1-6.6). Youths who reported smoking but did not cross the 100-cigarette threshold were at intermediate risk (OR=2.3, 95% CI: 1.7-3.3). Differences in AUD between smokers and never-smokers were most pronounced at lower levels of drinking.
The results are consistent with a higher vulnerability to alcohol use disorders among smokers, compared to non-smokers who drink equivalent quantities.
PMCID: PMC2431150  PMID: 17117970
Cigarettes; epidemiology; alcohol; abuse; dependence; tobacco; adolescence
21.  Probability and Predictors of Transition from Abuse to Dependence on Alcohol, Cannabis, and Cocaine: Results from the National Epidemiologic Survey on Alcohol and Related Conditions 
Little is known about the transition from substance abuse to substance dependence. Objectives: This study aims to estimate the cumulative probability of developing dependence and to identify predictors of transition to dependence among individuals with lifetime alcohol, cannabis, or cocaine abuse.
Analyses were done for the subsample of individuals with lifetime alcohol abuse (n = 7802), cannabis abuse (n = 2832), or cocaine abuse (n = 815) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Estimated projections of the cumulative probability of transitioning from abuse to dependence were obtained by the standard actuarial method. Discrete-time survival analyses with time-varying covariates were implemented to identify predictors of transition to dependence.
Lifetime cumulative probability estimates indicated that 26.6% of individuals with alcohol abuse, 9.4% of individuals with cannabis abuse, and 15.6% of individuals with cocaine abuse transition from abuse to dependence at some point in their lives. Half of the transitions of alcohol, cannabis, and cocaine dependence occurred approximately 3.16, 1.83, and 1.42 years after abuse onset, respectively. Several sociodemographic, psychopathological, and substance use-related variables predicted transition from abuse to dependence for all of the substances assessed.
The majority of individuals with abuse do not transition to dependence. Lifetime cumulative probability of transition from abuse to dependence was highest for alcohol, followed by cocaine and lastly cannabis. Time from onset of abuse to dependence was shorter for cocaine, followed by cannabis and alcohol. Although some predictors of transition were common across substances, other predictors were specific for certain substances.
PMCID: PMC3755735  PMID: 23721532
transition; abuse; dependence; cannabis; alcohol; cocaine
22.  Clinical Indices of Familial Alcohol Use Disorder 
Alcohol use disorders (AUDs) are clinically heterogeneous and strongly influenced by familial/genetic factors. Can we identify specific clinical features of AUDs that index familial liability to illness?
In twins from the Virginia Adult Twin Study of Psychiatric and Substance Use Disorders meeting DSM-IV criteria for lifetime AUDs, we examined whether clinical features of AUDs, including individual DSM-IV criteria for alcohol dependence (AD) and alcohol abuse (AA), predicted risk for AUDs in cotwins and/or parents. Analyses of individual criterion were repeated controlling for the total number of endorsed criteria.
Across these analyses, examining narrowly and broadly defined AUDs, risk of AUDs in relatives was more consistently predicted by abuse criteria than by dependence criteria, and by criteria reflecting negative psychosocial consequences rather than pharmacologic/biological criteria. Age at onset (AAO) poorly predicted risk in relatives. AUD associated legal problems, the one criterion slated for removal in DSM-5, was the most consistent single predictor of familial risk. Associations observed between individual criteria and risks of illness in relatives were generally stronger in monozygotic than dizygotic twin pairs, suggesting that these symptoms reflect a genetic risk for AUDs.
Individual DSM-IV criteria for AA and AD differ meaningfully in the degree to which they reflect the familial/genetic liability to AUDs. Contrary to expectation, the familial/genetic risk to AUDs was better reflected by symptoms of abuse and negative psychosocial consequences of AUD than by early AAO, or symptoms of tolerance and withdrawal.
PMCID: PMC3606908  PMID: 22978547
Alcohol Abuse; Alcohol Dependence; Twin Studies; Heritability; Symptoms
23.  Toward National Estimates of Alcohol Use Disorders among Drivers: Results from the National Roadside Survey Pilot Program 
Traffic injury prevention  2009;10(5):403-409.
To determine whether drivers contacted at the roadside can be screened for alcohol use disorders (AUDs). Secondarily, to produce preliminary estimates of AUDs among drivers and estimate the relationship between AUD status and BAC measured at the roadside.
A two-phase survey program was undertaken. In phase 1, 206 motorists were interviewed at the roadside using a 15-item AUD Survey derived from a condensed version of the AUDADIS and the AUDIT-C. One hundred sixty-seven of these motorists were invited, for a $25 incentive, to call the research team within 48 hours of the roadside assessment to repeat the questionnaire and complete a more detailed AUD assessment. Phase 2 involved a six-state pilot test of the AUD Survey as an add-on to the 2005 National Roadside Survey Pilot Program. The setting for both phases of the survey program was U.S. roadways on weekends between 10 p.m. and 3 a.m.
Ninety-seven percent of all eligible drivers completed the AUD questionnaire. The correlation between roadside and telephone interview results was 0.3 for alcohol abuse, 0.6 for alcohol dependence and heavy drinking, and 0.7 for binge drinking. Alcohol abuse and dependence diagnoses had 0.6 and 0.7 correlation with diagnoses derived from the full AUDADIS and the AUDIT-C had a 0.8 correlation with the full AUDIT. There was also a statistically significant and positive relationship between having a positive BAC at the roadside and meeting criteria for heavy drinking.
AUD status can be effectively measured at the roadside. The poor reliability for alcohol abuse is related to underreporting of drinking and driving during roadside assessments, compared to telephone follow up. Other measures of hazardous alcohol use should be used in the roadside context to measure alcohol abuse.
PMCID: PMC2837509  PMID: 19746302
Alcohol Dependence; Alcohol Abuse; Impaired Driving; Roadside Surveys; Drinking and Driving; Binge Drinking
24.  Negative Symptoms are Associated with Less Alcohol Use, Craving, and “High” in Alcohol Dependent Patients with Schizophrenia 
Schizophrenia research  2008;105(1-3):201-207.
Alcohol use disorders (AUDs) frequently co-occur with and exacerbate schizophrenia, yet the specific relationships between schizophrenia symptoms and alcohol use remain unclear.
PANSS scores were correlated with measures of alcohol and other substance use in patients with schizophrenia-spectrum disorders and AUDs entering a trial of monitored naltrexone treatment. Data were analyzed from the first 80 participants; 55% had schizophrenia and 45% had schizoaffective disorder. All had AUDs; 95% had alcohol dependence and 5% alcohol abuse; 34% also had cannabis abuse/dependence and 31% cocaine abuse/dependence.
PANSS Negative scores were inversely correlated with Addiction Severity Index alcohol composite score, alcohol craving, quality of alcohol “high” (euphoria), and with frequency of cannabis use. An exploratory analysis indicated that the negative symptoms that may most strongly correlate with less alcohol use, craving or euphoria were passive/apathetic social withdrawal, blunted affect, difficulty in abstract thinking, and stereotyped thinking. Higher PANSS Composite scores, indicating the predominance of positive over negative PANSS symptoms, correlated with more alcohol craving and cannabis use. Higher PANSS General scores were associated with more alcohol craving.
These findings extend previous reports of the association of negative schizophrenia symptoms with less alcohol and substance use to patients with AUDs and indicate that this relationship also includes less alcohol craving and less alcohol euphoria. The findings may also provide some initial evidence that specific negative symptoms may be key to these relationships.
PMCID: PMC2582942  PMID: 18701256
schizophrenia; alcohol; PANSS; negative symptom; positive symptom; naltrexone; craving
25.  The Factor Structure and Severity of DSM-IV Alcohol Abuse and Dependence Symptoms in Psychiatric Outpatients 
The goal of the present study was to examine the factor structure and estimated severity of alcohol use disorder (AUD) symptoms in a sample of treatment-seeking psychiatric outpatients. Participants (n = 1027, 51.2% women) met the screening criteria for the lifetime assessment of alcohol use disorders according to the Structured Clinical Interview for DSM-IV Disorders (SCID-I/P; First et al., 1995) and as a result completed an assessment of alcohol abuse and dependence symptoms. The average age of the sample was 36.6 (SD = 11.4) and 71% of participants met lifetime DSM-IV criteria for an alcohol use disorder. Exploratory factor analysis of the tetrachoric correlation matrix of alcohol abuse and dependence criteria revealed that a single factor best accounted for the data in this sample. Results of Rasch model analyses indicated that the severity ordering of the DSM-IV abuse and dependence symptoms was not consistent with the hierarchical structure suggested by the DSM-IV. Instead, abuse items were found to be spread across a full range of the AUD continuum and were not consistently in the lower ranges of severity. This study extends the literature by examining a treatment-seeking psychiatric outpatient sample and using a semi-structured diagnostic interview administered by mental health professionals. Methodological considerations and implications for the conceptualization of AUD are discussed.
PMCID: PMC3741100  PMID: 18612564
DSM-IV; alcohol abuse; alcohol dependence; factor structure; SCID; Rasch model

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