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1.  Does Industry-Driven Alcohol Marketing Influence Adolescent Drinking Behaviour? A Systematic Review 
Aim
To systematically review evidence on the influence of specific marketing components (Price, Promotion, Product attributes and Place of sale/availability) on key drinking outcomes (initiation, continuation, frequency and intensity) in young people aged 9–17.
Methods
MEDLINE, EMBASE, SCOPUS, PsychINFO, CINAHL and ProQuest were searched from inception to July 2015, supplemented with searches of Google Scholar, hand searches of key journals and backward and forward citation searches of reference lists of identified papers.
Results
Forty-eight papers covering 35 unique studies met inclusion criteria. Authors tended to report that greater exposure to alcohol marketing impacted on drinking initiation, continuation, frequency and intensity during adolescence. Nevertheless, 23 (66%) studies reported null results or negative associations, often in combination with positive associations, resulting in mixed findings within and across studies. Heterogeneity in study design, content and outcomes prevented estimation of effect sizes or exploration of variation between countries or age subgroups. The strength of the evidence base differed according to type of marketing exposure and drinking outcome studied, with support for an association between alcohol promotion (mainly advertising) and drinking outcomes in adolescence, whilst only two studies examined the relationship between alcohol price and the drinking behaviour of those under the age of 18.
Conclusion
Despite the volume of work, evidence is inconclusive in all four areas of marketing but strongest for promotional activity. Future research with standardized measures is needed to build on this work and better inform interventions and policy responses.
doi:10.1093/alcalc/agw085
PMCID: PMC5169036  PMID: 27864186
2.  Use of aids for smoking cessation and alcohol reduction: A population survey of adults in England 
BMC Public Health  2016;16:1237.
Background
It is important for policy planning to chart the methods smokers and high-risk drinkers use to help them change their behaviour. This study assessed prevalence of use, and characteristics of users, of support for smoking cessation and alcohol reduction in England.
Methods
Data were used from the Smoking and Alcohol Toolkit Studies, which involve monthly face-to-face computer-assisted interviews of adults aged 16+ in England. We included data collected between June 2014 and July 2015 on 1600 smokers who had made at least one quit attempt and 911 high-risk drinkers (defined as scores >8+ on the full AUDIT or 5+ on questions 1–3 of the AUDIT-C) who had made an attempt to cut down in the past 12 months. Participants provided information on their socio-demographic characteristics and use of aids during their most recent quit attempt including pharmacotherapy, face-to-face counselling, telephone support, self-help materials (digital and printed), and complementary medicine.
Results
A total of 60.3% of smokers used aids in the past year, compared with just 14.9% of high-risk drinkers. Use of pharmacotherapy was high among smokers and very low among drinkers (56.0%versus1.2%). Use of other aids was low for both behaviours: face-to-face counselling (2.6%versus4.8%), self-help materials (1.4%versus4.1%) and complementary medicine (1.0%versus0.5%). Use of aids was more common among smokers aged 25–54 compared with 16–24 year olds (25–34,ORadj1.49,p = 0.012; 35–44,ORadj1.93,p < 0.001; 35–44,ORadj1.93,p < 0.001; 45–54,ORadj1.66,p = 0.008), with cigarette consumption >10 relative to <1 (10–20,ORadj2.47,p = 0.011; >20,ORadj4.23,p = 0.001), and less common among ethnic minorities (ORadj0.69,p = 0.026). For alcohol reduction, use of aids was higher among ethnic minority groups (ORadj2.41;p = 0.015), and those of social-grade D/E relative to AB (ORadj2.29,p = 0.012&ORadj3.13,p < 0.001).
Conclusion
In England, the use of pharmacotherapy is prevalent for smoking cessation but not alcohol reduction. Other aids are used at a low rate, with face-to-face counselling being more common for alcohol reduction than smoking cessation.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-016-3862-7) contains supplementary material, which is available to authorized users.
doi:10.1186/s12889-016-3862-7
PMCID: PMC5146832  PMID: 27931202
Smoking; Alcohol; High-risk drinking; Smoking Toolkit Study; Alcohol Toolkit Study; Treatment; Pharmacotherapy; Behavioural support
3.  Impact of financial incentives on alcohol intervention delivery in primary care: a mixed-methods study 
BMC Family Practice  2016;17:165.
Background
Local and national financial incentives were introduced in England between 2008 and 2015 to encourage screening and brief alcohol intervention delivery in primary care. We used routine Read Code data and interviews with General Practitioners (GPs) to assess their impact.
Methods
A sequential explanatory mixed-methods study was conducted in 16 general practices representing 106,700 patients and 99 GPs across two areas in Northern England. Data were extracted on screening and brief alcohol intervention delivery for 2010-11 and rates were calculated by practice incentive status. Semi-structured interviews with 14 GPs explored which factors influence intervention delivery and recording in routine consultations.
Results
Screening and brief alcohol intervention rates were higher in financially incentivised compared to non-incentivised practices. However absolute rates were low across all practices. Rates of short screening test administration ranged from 0.05% (95% CI: 0.03-0.08) in non-incentivised practices to 3.92% (95% CI: 3.70-4.14) in nationally incentivised practices. For the full AUDIT, rates were also highest in nationally incentivised practices (3.68%, 95% CI: 3.47-3.90) and lowest in non-incentivised practices (0.17%, 95% CI: 0.13-0.22). Delivery of alcohol interventions was highest in practices signed up to the national incentive scheme (9.23%, 95% CI: 8.91-9.57) and lowest in non-incentivised practices (4.73%, 95% CI: 4.50-4.96). GP Interviews highlighted a range of influences on alcohol intervention delivery and subsequent recording including: the hierarchy of different financial incentive schemes; mixed belief in the efficacy of alcohol interventions; the difficulty of codifying complex conditions; and GPs’ beliefs about patient-centred practice.
Conclusions
Financial incentives have had some success in encouraging screening and brief alcohol interventions in England, but levels of recorded activity remain low. To improve performance, future policies must prioritise alcohol prevention work within the quality and outcomes framework, and address the values, attitudes and beliefs that shape how GPs’ provide care.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0561-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0561-5
PMCID: PMC5124277  PMID: 27887577
Alcohol drinking; Screening; Brief intervention; Pay for performance; Primary health care; Mixed methods
4.  Feasibility of alcohol screening among patients receiving opioid treatment in primary care 
BMC Family Practice  2016;17:153.
Background
Identifying and treating problem alcohol use among people who also use illicit drugs is a challenge. Primary care is well placed to address this challenge but there are several barriers which may prevent this occurring. The objective of this study was to determine if a complex intervention designed to support screening and brief intervention for problem alcohol use among people receiving opioid agonist treatment is feasible and acceptable to healthcare providers and their patients in a primary care setting.
Methods
A randomised, controlled, pre-and-post design measured feasibility and acceptability of alcohol screening based on recruitment and retention rates among patients and practices. Efficacy was measured by screening and brief intervention rates and the proportion of patients with problem alcohol use.
Results
Of 149 practices that were invited, 19 (12.8 %) agreed to participate. At follow up, 13 (81.3 %) practices with 81 (62.8 %) patients were retained. Alcohol screening rates in the intervention group were higher at follow up than in the control group (53 % versus 26 %) as were brief intervention rates (47 % versus 19 %). Four (18 %) people reduced their problem drinking (measured by AUDIT-C), compared to two (7 %) in the control group.
Conclusions
Alcohol screening among people receiving opioid agonist treatment in primary care seems feasible. A definitive trial is needed. Such a trial would require over sampling and greater support for participating practices to allow for challenges in recruitment of patients and practices.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0548-2) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0548-2
PMCID: PMC5097838  PMID: 27816057
Alcohol; Primary care; Screening; Agonist treatment; Methadone; General practice; Implementation; Feasibility; Brief intervention; SBIRT
5.  Deconstructing the Alcohol Harm Paradox: A Population Based Survey of Adults in England 
PLoS ONE  2016;11(9):e0160666.
Background
The Alcohol Harm Paradox refers to observations that lower socioeconomic status (SES) groups consume less alcohol but experience more alcohol-related problems. However, SES is a complex concept and its observed relationship to social problems often depends on how it is measured and the demographic groups studied. Thus this study assessed socioeconomic patterning of alcohol consumption and related harm using multiple measures of SES and examined moderation of this patterning by gender and age.
Method
Data were used from the Alcohol Toolkit Study between March and September 2015 on 31,878 adults (16+) living in England. Participants completed the AUDIT which includes alcohol consumption, harm and dependence modules. SES was measured via qualifications, employment, home and car ownership, income and social-grade, plus a composite of these measures. The composite score was coded such that higher scores reflected greater social-disadvantage.
Results
We observed the Alcohol Harm Paradox for the composite SES measure, with a linear negative relationship between SES and AUDIT-Consumption scores (β = -0.036, p<0.001) and a positive relationship between lower SES and AUDIT-Harm (β = 0.022, p<0.001) and AUDIT-Dependence (β = 0.024, p<0.001) scores. Individual measures of SES displayed different, and non-linear, relationships with AUDIT modules. For example, social-grade and income had a u-shaped relationship with AUDIT-Consumption scores while education had an inverse u-shaped relationship. Almost all measures displayed an exponential relationship with AUDIT-Dependence and AUDIT-Harm scores. We identified moderating effects from age and gender, with AUDIT-Dependence scores increasing more steeply with lower SES in men and both AUDIT-Harm and AUDIT-Dependence scores increasing more steeply with lower SES in younger age groups.
Conclusion
Different SES measures appear to influence whether the Alcohol Harm Paradox is observed as a linear trend across SES groups or a phenomenon associated particularly with the most disadvantaged. The paradox also appears more concentrated in men and younger age groups.
doi:10.1371/journal.pone.0160666
PMCID: PMC5040414  PMID: 27682619
6.  How effective are brief interventions in reducing alcohol consumption: do the setting, practitioner group and content matter? Findings from a systematic review and metaregression analysis 
BMJ Open  2016;6(8):e011473.
Background
While the efficacy and effectiveness of brief interventions for alcohol (ABI) have been demonstrated in primary care, there is weaker evidence in other settings and reviews do not consider differences in content. We conducted a systematic review to measure the effect of ABIs on alcohol consumption and how it differs by the setting, practitioner group and content of intervention.
Methods
We searched MEDLINE, EMBASE, PsycINFO; CINAHL, Social Science Citation Index, Cochrane Library and Global Health up to January 2015 for randomised controlled trials that measured effectiveness of ABIs on alcohol consumption. We grouped outcomes into measures of quantity and frequency indices. We used multilevel meta-analysis to estimate pooled effect sizes and tested for the effect of moderators through a multiparameter Wald test. Stratified analysis of a subset of quantity and frequency outcomes was conducted as a sensitivity check.
Results
52 trials were included contributing data on 29 891 individuals. ABIs reduced the quantity of alcohol consumed by 0.15 SDs. While neither the setting nor content appeared to significantly moderate intervention effectiveness, the provider did in some analyses. Interventions delivered by nurses had the most effect in reducing quantity (d=−0.23, 95% CI (−0.33 to −0.13)) but not frequency of alcohol consumption. All content groups had statistically significant mean effects, brief advice was the most effective in reducing quantity consumed (d=−0.20, 95% CI (−0.30 to −0.09)). Effects were maintained in the stratified sensitivity analysis at the first and last assessment time.
Conclusions
ABIs play a small but significant role in reducing alcohol consumption. Findings show the positive role of nurses in delivering interventions. The lack of evidence on the impact of content of intervention reinforces advice that services should select the ABI tool that best suits their needs.
doi:10.1136/bmjopen-2016-011473
PMCID: PMC4985973  PMID: 27515753
Systematic Review; Meta-analysis; Brief interventions on alcohol
7.  Are recent attempts to quit smoking associated with reduced drinking in England? A cross-sectional population survey 
BMC Public Health  2016;16:535.
Background
Alcohol consumption during attempts at smoking cessation can provoke relapse and so smokers are often advised to restrict their alcohol consumption during this time. This study assessed at a population-level whether smokers having recently initiated an attempt to stop smoking are more likely than other smokers to report i) lower alcohol consumption and ii) trying to reduce their alcohol consumption.
Method
Cross-sectional household surveys of 6287 last-year smokers who also completed the Alcohol Use Disorders Identification Test consumption questionnaire (AUDIT-C). Respondents who reported attempting to quit smoking in the last week were compared with those who did not. Those with AUDIT-C≥5 were also asked if they were currently trying to reduce the amount of alcohol they consume.
Results
After adjustment for socio-demographic characteristics and current smoking status, smokers who reported a quit attempt within the last week had lower AUDIT-C scores compared with those who did not report an attempt in the last week (βadj = −0.56, 95 % CI = −1.08 to −0.04) and were less likely to be classified as higher risk (AUDIT-C≥5: ORadj = 0.57, 95 % CI = 0.38 to 0.85). The lower AUDIT-C scores appeared to be a result of lower scores on the frequency of ‘binge’ drinking item (βadj = −0.25, 95 % CI = −0.43 to −0.07), with those who reported a quit attempt within the last week compared with those who did not being less likely to binge drink at least weekly (ORadj = 0.54, 95 % CI = 0.29 to 0.999) and more likely to not binge drink at all (ORadj = 1.70, 95 % CI = 1.16 to 2.49). Among smokers with higher risk consumption (AUDIT-C≥5), those who reported an attempt to stop smoking within the last week compared with those who did not were more likely to report trying to reduce their alcohol consumption (ORadj = 2.98, 95 % CI = 1.48 to 6.01).
Conclusion
Smokers who report starting a quit attempt in the last week also report lower alcohol consumption, including less frequent binge drinking, and appear more likely to report currently attempting to reduce their alcohol consumption compared with smokers who do not report a quit attempt in the last week.
doi:10.1186/s12889-016-3223-6
PMCID: PMC4957412  PMID: 27443348
Alcohol drinking; Attempts; Cutting down; Smoking; Smoking cessation
8.  Unravelling the alcohol harm paradox: a population-based study of social gradients across very heavy drinking thresholds 
BMC Public Health  2016;16:599.
Background
There is consistent evidence that individuals in higher socioeconomic status groups are more likely to report exceeding recommended drinking limits, but those in lower socioeconomic status groups experience more alcohol-related harm. This has been called the ‘alcohol harm paradox’. Such studies typically use standard cut-offs to define heavy drinking, which are exceeded by a large proportion of adults. Our study pools data from six years (2008–2013) of the population-based Health Survey for England to test whether the socioeconomic distribution of more extreme levels of drinking could help explain the paradox.
Methods
The study included 51,498 adults from a representative sample of the adult population of England for a cross-sectional analysis of associations between socioeconomic status and self-reported drinking. Heavy weekly drinking was measured at four thresholds, ranging from 112 g+/168 g + (alcohol for women/men, or 14/21 UK standard units) to 680 g+/880 g + (or 85/110 UK standard units) per week. Heavy episodic drinking was also measured at four thresholds, from 48 g+/64 g + (or 6/8 UK standard units) to 192 g+/256 g + (or 24/32 UK standard units) in one day. Socioeconomic status indicators were equivalised household income, education, occupation and neighbourhood deprivation.
Results
Lower socioeconomic status was associated with lower likelihoods of exceeding recommended limits for weekly and episodic drinking, and higher likelihoods of exceeding more extreme thresholds. For example, participants in routine or manual occupations had 0.65 (95 % CI 0.57–0.74) times the odds of exceeding the recommended weekly limit compared to those in ‘higher managerial’ occupations, and 2.15 (95 % CI 1.06–4.36) times the odds of exceeding the highest threshold. Similarly, participants in the lowest income quintile had 0.60 (95 % CI 0.52–0.69) times the odds of exceeding the recommended weekly limit when compared to the highest quintile, and 2.30 (95 % CI 1.28–4.13) times the odds of exceeding the highest threshold.
Conclusions
Low socioeconomic status groups are more likely to drink at extreme levels, which may partially explain the alcohol harm paradox. Policies that address alcohol-related health inequalities need to consider extreme drinking levels in some sub-groups that may be associated with multiple markers of deprivation. This will require a more disaggregated understanding of drinking practices.
doi:10.1186/s12889-016-3265-9
PMCID: PMC4950253  PMID: 27430342
9.  Impact of primary healthcare providers’ initial role security and therapeutic commitment on implementing brief interventions in managing risky alcohol consumption: a cluster randomised factorial trial 
Background
Brief interventions in primary healthcare are cost-effective in reducing drinking problems but poorly implemented in routine practice. Although evidence about implementing brief interventions is growing, knowledge is limited with regard to impact of initial role security and therapeutic commitment on brief intervention implementation.
Methods
In a cluster randomised factorial trial, 120 primary healthcare units (PHCUs) were randomised to eight groups: care as usual, training and support, financial reimbursement, and the opportunity to refer patients to an internet-based brief intervention (e-BI); paired combinations of these three strategies, and all three strategies combined. To explore the impact of initial role security and therapeutic commitment on implementing brief interventions, we performed multilevel linear regression analyses adapted to the factorial design.
Results
Data from 746 providers from 120 PHCUs were included in the analyses. Baseline role security and therapeutic commitment were found not to influence implementation of brief interventions. Furthermore, there were no significant interactions between these characteristics and allocated implementation groups.
Conclusions
The extent to which providers changed their brief intervention delivery following experience of different implementation strategies was not determined by their initial attitudes towards alcohol problems. In future research, more attention is needed to unravel the causal relation between practitioners’ attitudes, their actual behaviour and care improvement strategies to enhance implementation science.
Trial registration
ClinicalTrials.gov: NCT01501552
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-016-0468-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s13012-016-0468-5
PMCID: PMC4947288  PMID: 27422283
Brief interventions; Risky drinking; Primary healthcare; Provider influences; Implementation research
10.  Prevalence of alcohol related attendance at an inner city emergency department and its impact: a dual prospective and retrospective cohort study 
Emergency Medicine Journal : EMJ  2015;33(3):187-193.
Background
Alcohol related hospital attendances are a potentially avoidable burden on emergency departments (EDs). Understanding the number and type of patients attending EDs with alcohol intoxication is important in estimating the workload and cost implications. We used best practice from previous studies to establish the prevalence of adult alcohol related ED attendances and estimate the costs of clinical management and subsequent health service use.
Methods
The setting was a large inner city ED in northeast England, UK. Data were collected via (i) retrospective review of hospital records for all ED attendances for four pre-specified weeks in 2010/2011 to identify alcohol related cases along with 12 months of follow-up of the care episode and (ii) prospective 24/7 assessment via breath alcohol concentration testing of patients presenting to the ED in the corresponding weeks in 2012/2013.
Results
The prevalence rates of alcohol related attendances were 12% and 15% for the retrospective and prospective cohorts, respectively. Prospectively, the rates ranged widely from 4% to 60% across week days, rising to over 70% at weekends. Younger males attending in the early morning hours at weekends made up the largest proportion of alcohol related attendances. The mean cost per attendance was £249 (SD £1064); the mean total cost for those admitted was £851 (SD £2549). The most common reasons for attending were trauma related injuries followed by psychiatric problems.
Conclusions
Alcohol related attendances are a major and avoidable burden on emergency care. However, targeted interventions at weekends and early morning hours could capture the majority of cases and help prevent future re-attendance.
doi:10.1136/emermed-2014-204581
PMCID: PMC4789717  PMID: 26698364
alcohol abuse; emergency departments
11.  A Qualitative Study of Service Provision for Alcohol Related Health Issues in Mid to Later Life 
PLoS ONE  2016;11(2):e0148601.
Aims
Epidemiological surveys over the last 20 years show a steady increase in the amount of alcohol consumed by older age groups. Physiological changes and an increased likelihood of health problems and medication use make older people more likely than younger age groups to suffer negative consequences of alcohol consumption, often at lower levels. However, health services targeting excessive drinking tend to be aimed at younger age groups. The aim of this study was to gain an in-depth understanding of experiences of, and attitudes towards, support for alcohol related health issues in people aged 50 and over.
Methods
Qualitative interviews (n = 24, 12 male/12 female, ages 51–90 years) and focus groups (n = 27, 6 male/21 female, ages 50–95 years) were carried out with a purposive sample of participants who consumed alcohol or had been dependent.
Findings
Participants’ alcohol misuse was often covert, isolated and carefully regulated. Participants tended to look first to their General Practitioner for help with alcohol. Detoxification courses had been found effective for dependent participants but only in the short term; rehabilitation facilities were appreciated but seen as difficult to access. Activities, informal groups and drop-in centres were endorsed. It was seen as difficult to secure treatment for alcohol and mental health problems together. Barriers to seeking help included functioning at a high level, concern about losing positive aspects of drinking, perceived stigma, service orientation to younger people, and fatalistic attitudes to help-seeking. Facilitators included concern about risk of fatal illness or pressure from significant people.
Conclusion
Primary care professionals need training on improving the detection and treatment of alcohol problems among older people. There is also a compelling need to ensure that aftercare is in place to prevent relapse. Strong preferences were expressed for support to be provided by those who had experienced alcohol problems themselves.
doi:10.1371/journal.pone.0148601
PMCID: PMC4744048  PMID: 26848583
12.  Comparison of brief interventions in primary care on smoking and excessive alcohol consumption: a population survey in England 
Background
Brief interventions have a modest but meaningful effect on promoting smoking cessation and reducing excessive alcohol consumption. Guidelines recommend offering such advice opportunistically and regularly but incentives vary between the two behaviours.
Aim
To use representative data from the perspective of patients to compare the prevalence and characteristics of people who smoke or drink excessively and who receive a brief intervention.
Design and setting
Data was from a representative sample of 15 252 adults from household surveys in England.
Method
Recall of brief interventions on smoking and alcohol use, sociodemographic information, and smoking and alcohol consumption patterns were assessed among smokers and those who drink excessively (AUDIT score of ≥8), who visited their GP surgery in the previous year.
Results
Of 1775 smokers, 50.4% recalled receiving brief advice on smoking in the previous year. Smokers receiving advice compared with those who did not were more likely to be older (odds ratio [OR] 17-year increments 1.19, 95% confidence interval [CI] =1.06 to 1.34), female (OR 1.35, 95% CI =1.10 to 1.65), have a disability (OR 1.44, 95% CI = 1.11 to 1.88), have made more quit attempts in the previous year (compared with no attempts: one attempt, OR 1.65, 95% CI = 1.32 to 2.08; ≥2 attempts, OR 2.02, 95% CI =1.49 to 2.74), and have greater nicotine dependence (OR 1.17, 95% CI =1.05 to 1.31) but were less likely to have no post-16 qualifications (OR 0.81, 95% CI = 0.66 to 1.00). Of 1110 people drinking excessively, 6.5% recalled receiving advice in their GP surgery on their alcohol consumption in the previous year. Those receiving advice compared with those who did not had higher AUDIT scores (OR 1.17, 95% CI =1.12 to 1.23) and were less likely to be female (OR 0.44, 95% CI = 0.23 to 0.87).
Conclusion
Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, <10% of those who drink excessively report having received advice on their alcohol consumption.
doi:10.3399/bjgp16X683149
PMCID: PMC4684029  PMID: 26719481
alcohol drinking; brief advice; brief intervention; counselling; smoking
13.  Linked randomised controlled trials of face-to-face and electronic brief intervention methods to prevent alcohol related harm in young people aged 14–17 years presenting to Emergency Departments (SIPS junior) 
BMC Public Health  2015;15:345.
Background
Alcohol is a major global threat to public health. Although the main burden of chronic alcohol-related disease is in adults, its foundations often lie in adolescence. Alcohol consumption and related harm increase steeply from the age of 12 until 20 years. Several trials focusing upon young people have reported significant positive effects of brief interventions on a range of alcohol consumption outcomes. A recent review of reviews also suggests that electronic brief interventions (eBIs) using internet and smartphone technologies may markedly reduce alcohol consumption compared with minimal or no intervention controls.
Interventions that target non-drinking youth are known to delay the onset of drinking behaviours. Web based alcohol interventions for adolescents also demonstrate significantly greater reductions in consumption and harm among ‘high-risk’ drinkers; however changes in risk status at follow-up for non-drinkers or low-risk drinkers have not been assessed in controlled trials of brief alcohol interventions.
Design and methods
The study design comprises two linked randomised controlled trials to evaluate the effectiveness and cost-effectiveness of two intervention strategies compared with screening alone. One trial will focus on high-risk adolescent drinkers attending Emergency Departments (Eds) and the other will focus on those identified as low-risk drinkers or abstinent from alcohol but attending the same ED.
Our primary (null) hypothesis is similar for both trials: Personalised Feedback and Brief Advice (PFBA) and Personalised Feedback plus electronic Brief Intervention (eBI) are no more effective than screening alone in alcohol consumed at 12 months after randomisation as measured by the Time-Line Follow-Back 28-day version. Our secondary (null) hypothesis relating to economics states that PFBA and eBI are no more cost-effective than screening alone.
In total 1,500 participants will be recruited into the trials, 750 high-risk drinkers and 750 low-risk drinkers or abstainers. Participants will be randomised with equal probability, stratified by centre, to either a screening only control group or one of the two interventions: single session of PFBA or eBI. All participants will be eligible to receive treatment as usual in addition to any trial intervention. Individual participants will be followed up at 6 and 12 months after randomisation.
Discussion
The protocol represents an ambitious innovative programme of work addressing alcohol use in the adolescent population.
Trial registration
ISRCTN45300218. Registered 5th July 2014.
doi:10.1186/s12889-015-1679-4
PMCID: PMC4394590  PMID: 25886178
Adolescents; SBI; eBI; Emergency Department
14.  Online Health Check for Reducing Alcohol Intake among Employees: A Feasibility Study in Six Workplaces across England 
PLoS ONE  2015;10(3):e0121174.
Background
Most hazardous and harmful drinkers are of working age and do not seek help with their drinking. Occupational health services are uniquely placed to universally screen employees across the range of socioeconomic and ethnic groups. The aim was to explore the feasibility and acceptability of offering electronic screening and brief intervention for alcohol misuse in the context of a health check in six different workplace settings.
Methods and Findings
Employees were recruited from six workplaces across England, including three local authorities, one university, one hospital and one petro-chemical company. A total of 1,254 (8%) employees completed the health check and received personalised feedback on their alcohol intake, alongside feedback on smoking, fruit and vegetable consumption and physical activity. Most participants were female (65%) and of ‘White British’ ethnicity (94%), with a mean age of 43 years (SD 11). Participants were mostly in Intermediate occupations (58%), followed by Higher managerial / professional (39%) and Routine and manual occupations (2%). A quarter of participants (25%) were drinking at hazardous levels (33% male, 21% female), which decreased with age. Sixty-four percent (n=797) of participants completed online follow-up at three months. Most participants were supportive of workplaces offering employees an online health check (95%), their preferred format was online (91%) and many were confident of the confidentiality of their responses (60%). Whilst the feedback reminded most participants of things they already knew (75%), some were reportedly motivated to change their behaviour (13%).
Conclusions
Online health screening and personalised feedback appears feasible and acceptable, but challenges include low participation rates, potentially attracting ‘worried well’ employees rather than those at greatest health risk, and less acceptance of the approach among older employees and those from ethnic minority backgrounds and routine or manual occupations.
doi:10.1371/journal.pone.0121174
PMCID: PMC4370494  PMID: 25798596
15.  Protocol for a national monthly survey of alcohol use in England with 6-month follow-up: ‘The Alcohol Toolkit Study’ 
BMC Public Health  2015;15:230.
Background
Timely tracking of national patterns of alcohol consumption is needed to inform and evaluate strategies and policies aimed at reducing alcohol-related harm. Between 2014 until at least 2017, the Alcohol Toolkit Study (ATS) will provide such tracking data and link these with policy changes and campaigns. By virtue of its connection with the ‘Smoking Toolkit Study’ (STS), links will also be examined between alcohol and smoking-related behaviour.
Methods/Design
The ATS consists of cross-sectional household, computer-assisted interviews of representative samples of adults in England aged 16+. Each month a new sample of approximately 1800 adults complete the survey (~n = 21,600 per year). All respondents who consent to be followed-up are asked to complete a telephone survey 6 months later. The ATS has been funded to collect at least 36 waves of baseline and 6-month follow-up data across a period of 3 years. Questions cover alcohol consumption and related harm (AUDIT), socio-demographic characteristics, attempts to reduce or cease consumption and factors associated with this, and exposure to health professional advice on alcohol. The ATS complements the STS, which has been tracking key performance indicators relating to smoking since 2006. As both the ATS and STS involve the same respondents, it is possible to assess interactions between changes in alcohol and tobacco use. Data analysis will involve: 1) Descriptive and exploratory analyses undertaken according to a pre-defined set of principles while allowing scope for pursuing lines of enquiry that arise from prior analyses; 2) Hypothesis testing according to pre-specified, published analysis plans. Descriptive data on important trends will be published monthly on a dedicated website: www.alcoholinengland.info.
Discussion
The Alcohol Toolkit Study will improve understanding of population level factors influencing alcohol consumption and be an important resource for policy evaluation and planning.
doi:10.1186/s12889-015-1542-7
PMCID: PMC4363185  PMID: 25884652
Alcohol toolkit study; Epidemiology; Smoking toolkit study; Alcohol consumption; AUDIT
16.  A pilot feasibility trial of alcohol screening and brief intervention in the police custody setting (ACCEPT): study protocol for a cluster randomised controlled trial 
Background
There is evidence of an association between alcohol use and offending behaviour and around a quarter of police time is spent on alcohol-related incidents. Police custody, therefore, provides an important opportunity to intervene. This pilot trial aims to investigate whether a definitive evaluation of screening and brief interventions aimed at reducing risky drinking in arrestees is acceptable and feasible in the custody suite setting.
Methods
Screening will be carried out by trained detention officers or drug and alcohol workers in four police forces across two geographical areas (North East and South West England). Detention officers (or drug and alcohol workers) will be cluster randomised to one of three conditions: screening only (control group), screening followed immediately by 10 min of manualised brief structured advice delivered by the individual responsible for screening (intervention 1) or screening followed by 10 min of manualised brief structured advice delivered by the individual responsible for screening plus the offer of a subsequent 20-min session of behaviour change counselling delivered by a trained alcohol health worker (intervention 2). Participants will be arrestees aged 18+ who screen positive on the Alcohol Use Disorders Identification Test. Participants will be followed up at 6 and 12 months post-intervention. An embedded qualitative process evaluation will explore acceptability of alcohol screening and brief intervention to staff and arrestees as well as facilitators and barriers to the delivery of such approaches in this setting.
Results
Recruitment is currently underway and due to end May 2015.
Conclusion
Results from this pilot trial will determine if a definitive evaluation is possible in the future and will provide stakeholder input to its design.
Trial registration
Reference number: ISRCTN89291046.
doi:10.1186/s40814-015-0001-7
PMCID: PMC5066519  PMID: 27965786
Alcohol; Screening and brief intervention; Feasibility pilot trial; Behaviour change; Police custody
17.  From Efficacy to Effectiveness and Beyond: What Next for Brief Interventions in Primary Care? 
Background: Robust evidence supports the effectiveness of screening and brief alcohol interventions in primary healthcare. However, lack of understanding about their “active ingredients” and concerns over the extent to which current approaches remain faithful to their original theoretical roots has led some to demand a cautious approach to future roll-out pending further research. Against this background, this paper provides a timely overview of the development of the brief alcohol intervention evidence base to assess the extent to which it has achieved the four key levels of intervention research: efficacy, effectiveness, implementation, and demonstration.
Methods: Narrative overview based on (1) the results of a review of systematic reviews and meta-analyses of the effectiveness of brief alcohol intervention in primary healthcare and (2) synthesis of the findings of key additional primary studies on the improvement and evaluation of brief alcohol intervention implementation in routine primary healthcare.
Results: The brief intervention field seems to constitute an almost perfect example of the evaluation of a complex intervention. Early evaluations of screening and brief intervention approaches included more tightly controlled efficacy trials and have been followed by more pragmatic trials of effectiveness in routine clinical practice. Most recently, attention has shifted to dissemination, implementation, and wider-scale roll-out. However, delivery in routine primary health remains inconsistent, with an identified knowledge gap around how to successfully embed brief alcohol intervention approaches in mainstream care, and as yet unanswered questions concerning what specific intervention component prompt the positive changes in alcohol consumption.
Conclusion: Both the efficacy and effectiveness of brief alcohol interventions have been comprehensively demonstrated, and intervention effects seem replicable and stable over time, and across different study contexts. Thus, while unanswered questions remain, given the positive evidence amassed to date, research efforts should maintain a continued focus on promoting sustained implementation of screening and brief alcohol intervention approaches in primary care to ensure that those who might benefit from screening and brief alcohol interventions actually receive such support.
doi:10.3389/fpsyt.2014.00113
PMCID: PMC4147417  PMID: 25221524
brief alcohol intervention; efficacy; effectiveness; implementation; research needs; secondary prevention; primary care
18.  The Effectiveness of Alcohol Screening and Brief Intervention in Emergency Departments: A Multicentre Pragmatic Cluster Randomized Controlled Trial 
PLoS ONE  2014;9(6):e99463.
Background
Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial.
Methods and Findings
Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings.
Conclusions
SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions.
Trial Registration
Current Controlled Trials ISRCTN 93681536
doi:10.1371/journal.pone.0099463
PMCID: PMC4070907  PMID: 24963731
19.  Intervention to reduce excessive alcohol consumption and improve comorbidity outcomes in hypertensive or depressed primary care patients: two parallel cluster randomized feasibility trials 
Trials  2014;15:235.
Background
Many primary care patients with raised blood pressure or depression drink potentially hazardous levels of alcohol. Brief interventions (BI) to reduce alcohol consumption may improve comorbid conditions and reduce the risk of future alcohol problems. However, research has not established their effectiveness in this patient population. This study aimed to establish the feasibility of definitive trials of BI to reduce excessive drinking in primary care patients with hypertension or mild to moderate depression.
Methods
Thirteen general practices in North East England were randomized to the intervention or control arm of one of two parallel pilot trials. Adult patients drinking excessively and diagnosed with hypertension or mild-to-moderate depression received the Alcohol Use Disorders Identification Test (AUDIT) by postal survey. Consenting respondents scoring more than 7 on AUDIT (score range 0 to 40) received brief alcohol consumption advice plus an information leaflet (intervention) or an information leaflet alone (control) with follow-up at six months. Measurements included the numbers of patients eligible, recruited, and retained, and the AUDIT score and systolic/diastolic blood pressure of each patient or the nine-item Patient Health Questionnaire (PHQ-9) score. Acceptability was assessed via practitioner feedback and patient willingness to be screened, recruited, and retained at follow-up.
Results
In the hypertension trial, 1709 of 33,813 adult patients (5.1%) were eligible and were surveyed. Among the eligible patients, 468 (27.4%) returned questionnaires; 166 (9.6% of those surveyed) screened positively on AUDIT and 83 (4.8% of those surveyed) were recruited (50.0% of positive screens). Sixty-seven cases (80.7% of recruited patients) completed follow-up at six months. In the depression trial, 1,044 of 73,146 adult patients (1.4%) were eligible and surveyed. Among these eligible patients, 215 (20.6%) responded; 104 (10.0% of those surveyed) screened positively on AUDIT and 29 (2.8% of those surveyed) were recruited (27.9% of positive screens). Nineteen cases (65.5% of recruited patients) completed follow-up at six months.
Conclusions
Recruitment and retention rates were higher in the hypertension trial than in the depression trial. A full brief intervention trial appears feasible for primary care patients with hypertension who drink excessively. High AUDIT scores in the depression trial suggest the importance of alcohol intervention in this group. However, future work may require alternative screening and measurement procedures.
Trial registration
Current Controlled Trials ISRCTN89156543; registered 21 October 2013.
doi:10.1186/1745-6215-15-235
PMCID: PMC4076249  PMID: 24947447
Alcohol; Screening; Brief intervention; Comorbid; Hypertension; Depression; Primary care; Trial; Preventive; Feasibility
20.  Improving Diabetes care through Examining, Advising, and prescribing (IDEA): protocol for a theory-based cluster randomised controlled trial of a multiple behaviour change intervention aimed at primary healthcare professionals 
Background
New clinical research findings may require clinicians to change their behaviour to provide high-quality care to people with type 2 diabetes, likely requiring them to change multiple different clinical behaviours. The present study builds on findings from a UK-wide study of theory-based behavioural and organisational factors associated with prescribing, advising, and examining consistent with high-quality diabetes care.
Aim
To develop and evaluate the effectiveness and cost of an intervention to improve multiple behaviours in clinicians involved in delivering high-quality care for type 2 diabetes.
Design/methods
We will conduct a two-armed cluster randomised controlled trial in 44 general practices in the North East of England to evaluate a theory-based behaviour change intervention. We will target improvement in six underperformed clinical behaviours highlighted in quality standards for type 2 diabetes: prescribing for hypertension; prescribing for glycaemic control; providing physical activity advice; providing nutrition advice; providing on-going education; and ensuring that feet have been examined. The primary outcome will be the proportion of patients appropriately prescribed and examined (using anonymised computer records), and advised (using anonymous patient surveys) at 12 months. We will use behaviour change techniques targeting motivational, volitional, and impulsive factors that we have previously demonstrated to be predictive of multiple health professional behaviours involved in high-quality type 2 diabetes care. We will also investigate whether the intervention was delivered as designed (fidelity) by coding audiotaped workshops and interventionist delivery reports, and operated as hypothesised (process evaluation) by analysing responses to theory-based postal questionnaires. In addition, we will conduct post-trial qualitative interviews with practice teams to further inform the process evaluation, and a post-trial economic analysis to estimate the costs of the intervention and cost of service use.
Discussion
Consistent with UK Medical Research Council guidance and building on previous development research, this pragmatic cluster randomised trial will evaluate the effectiveness of a theory-based complex intervention focusing on changing multiple clinical behaviours to improve quality of diabetes care.
Trial registration
ISRCTN66498413.
doi:10.1186/1748-5908-9-61
PMCID: PMC4049486  PMID: 24886606
21.  The Impact of Brief Alcohol Interventions in Primary Healthcare: A Systematic Review of Reviews 
Aims: The aim of the study was to assess the cumulative evidence on the effectiveness of brief alcohol interventions in primary healthcare in order to highlight key knowledge gaps for further research. Methods: An overview of systematic reviews and meta-analyses of the effectiveness of brief alcohol intervention in primary healthcare published between 2002 and 2012. Findings: Twenty-four systematic reviews met the eligibility criteria (covering a total of 56 randomized controlled trials reported across 80 papers). Across the included studies, it was consistently reported that brief intervention was effective for addressing hazardous and harmful drinking in primary healthcare, particularly in middle-aged, male drinkers. Evidence gaps included: brief intervention effectiveness in key groups (women, older and younger drinkers, minority ethnic groups, dependent/co-morbid drinkers and those living in transitional and developing countries); and the optimum brief intervention length and frequency to maintain longer-term effectiveness. Conclusion: This overview highlights the large volume of primarily positive evidence supporting brief alcohol intervention effects as well as some unanswered questions with regards to the effectiveness of brief alcohol intervention across different cultural settings and in specific population groups, and in respect of the optimum content of brief interventions that might benefit from further research.
doi:10.1093/alcalc/agt170
PMCID: PMC3865817  PMID: 24232177
22.  Alcohol Screening and Brief Intervention for Adolescents: The How, What and Where of Reducing Alcohol Consumption and Related Harm Among Young People 
Aim: The aim of the study was to explore the evidence base on alcohol screening and brief intervention for adolescents to determine age appropriate screening tools, effective brief interventions and appropriate locations to undertake these activities. Methods: A review of existing reviews (2003–2013) and a systematic review of recent research not included in earlier reviews. Results: The CRAFFT and AUDIT tools are recommended for identification of ‘at risk’ adolescents. Motivational interventions delivered over one or more sessions and based in health care or educational settings are effective at reducing levels of consumption and alcohol-related harm. Conclusion: Further research to develop age appropriate screening tools needs to be undertaken. Screening and brief intervention activity should be undertaken in settings where young people are likely to present; further assessment at such venues as paediatric emergency departments, sexual health clinics and youth offending teams should be evaluated. The use of electronic (web/smart-phone based) screening and intervention shows promise and should also be the focus of future research.
doi:10.1093/alcalc/agt165
PMCID: PMC3932830  PMID: 24232178
23.  A Qualitative Study of Alcohol, Health and Identities among UK Adults in Later Life 
PLoS ONE  2013;8(8):e71792.
Increasing alcohol consumption among older individuals is a public health concern. Lay understandings of health risks and stigma around alcohol problems may explain why public health messages have not reduced rates of heavy drinking in this sector. A qualitative study aimed to elucidate older people's reasoning about drinking in later life and how this interacted with health concerns, in order to inform future, targeted, prevention in this group. In 2010 a diverse sample of older adults in North East England (ages 50–95) participated in interviews (n = 24, 12 male, 12 female) and three focus groups (participants n = 27, 6 male, 21 female). Data were analysed using grounded theory and discursive psychology methods. When talking about alcohol use older people oriented strongly towards opposed identities of normal or problematic drinker, defined by propriety rather than health considerations. Each of these identities could be applied in older people's accounts of either moderate or heavy drinking. Older adults portrayed drinking less alcohol as an appropriate response if one experienced impaired health. However continued heavy drinking was also presented as normal behaviour for someone experiencing relative wellbeing in later life, or if ill health was construed as unrelated to alcohol consumption. Older people displayed scepticism about health advice on alcohol when avoiding stigmatised identity as a drinker. Drinking patterns did not appear to be strongly defined by gender, although some gendered expectations of drinking were described. Identities offer a useful theoretical concept to explain the rises in heavy drinking among older populations, and can inform preventive approaches to tackle this. Interventions should engage and foster positive identities to sustain healthier drinking and encourage at the community level the identification of heavy drinking as neither healthy nor synonymous with dependence. Future research should test and assess such approaches.
doi:10.1371/journal.pone.0071792
PMCID: PMC3737127  PMID: 23940787
24.  Psychosocial Interventions for Alcohol Use Among Problem Drug Users: Protocol for a Feasibility Study in Primary Care 
JMIR Research Protocols  2013;2(2):e26.
Background
Alcohol use is an important issue among problem drug users. Although screening and brief intervention (SBI) are effective in reducing problem alcohol use in primary care, no research has examined this issue among problem drug users.
Objective
The objective of this study is to determine if a complex intervention including SBI for problem alcohol use among problem drug users is feasible and acceptable in practice. This study also aims to evaluate the effectiveness of the intervention in reducing the proportion of patients with problem alcohol use.
Methods
Psychosocial intervention for alcohol use among problem drug users (PINTA) is a pilot feasibility study of a complex intervention comprising SBI for problem alcohol use among problem drug users with cluster randomization at the level of general practice, integrated qualitative process evaluation, and involving general practices in two socioeconomically deprived regions. Practices (N=16) will be eligible to participate if they are registered to prescribe methadone and/or at least 10 patients of the practice are currently receiving addiction treatment. Patient must meet the following inclusion criteria to participate in this study: 18 years of age or older, receiving addiction treatment/care (eg, methadone), or known to be a problem drug user. This study is based on a complex intervention supporting SBI for problem alcohol use among problem drug users (experimental group) compared to an “assessment-only” control group. Control practices will be provided with a delayed intervention after follow-up. Primary outcomes of the study are feasibility and acceptability of the intervention to patients and practitioners. Secondary outcome includes the effectiveness of the intervention on care process (documented rates of SBI) and outcome (proportion of patients with problem alcohol use at the follow-up). A stratified random sampling method will be used to select general practices based on the level of training for providing addiction-related care and geographical area. In this study, general practitioners and practice staff, researchers, and trainers will not be blinded to treatment, but patients and remote randomizers will be unaware of the treatment.
Results
This study is ongoing and a protocol system is being developed for the study. This study may inform future research among the high-risk population of problem drug users by providing initial indications as to whether psychosocial interventions for problem alcohol use are feasible, acceptable, and also effective among problem drug users attending primary care.
Conclusions
This is the first study to examine the feasibility and acceptability of complex intervention in primary care to enhance alcohol SBI among problem drug users. Results of this study will inform future research among this high-risk population and guide policy and service development locally and internationally.
doi:10.2196/resprot.2678
PMCID: PMC3742410  PMID: 23912883
complex intervention; screening; brief intervention; alcohol; methadone maintenance; primary health care; general practice; substance-related disorders
25.  Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN): study protocol for a cluster randomized factorial trial 
Background
The European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.
Methods/design
In a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals’ role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling.
Discussion
Effective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.
Trial registration
ClinicalTrials.gov. Trial identifier: NCT01501552
doi:10.1186/1748-5908-8-11
PMCID: PMC3564747  PMID: 23347874
Alcohol; Screening; Brief interventions; Primary healthcare; Training and support; Financial reimbursement; Internet; Implementation

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