Abstract
A distinction is made between the clinical and public health justifications for screening and brief intervention (SBI) against hazardous and harmful alcohol consumption. Early claims for a public health benefit of SBI derived from research on general medical practitioners’ (GPs’) advice on smoking cessation, but these claims have not been realized, mainly because GPs have not incorporated SBI into their routine practice. A recent modeling exercise estimated that, if all GPs in England screened every patient at their next consultation, 96% of the general population would be screened over 10 years, with 70-79% of excessive drinkers receiving brief interventions (BI); assuming a 10% success rate, this would probably amount to a population-level effect of SBI. Thus, a public health benefit for SBI presupposes widespread screening; but recent government policy in England favors targeted versus universal screening, and in Scotland screening is based on new registrations and clinical presentation. A recent proposal for a national screening program was rejected by the UK National Health Service’s National Screening Committee because 1) there was no good evidence that SBI led to reductions in mortality or morbidity, and 2) a safe, simple, precise, and validated screening test was not available. Even in countries like Sweden and Finland, where expensive national programs to disseminate SBI have been implemented, only a minority of the population has been asked about drinking during health-care visits, and a minority of excessive drinkers has been advised to cut down. Although there has been research on the relationship between treatment for alcohol problems and population-level effects, there has been no such research for SBI, nor have there been experimental investigations of its relationship with population-level measures of alcohol-related harm. These are strongly recommended. In this article, conditions that would allow a population-level effect of SBI to occur are reviewed, including their political acceptability. It is tentatively concluded that widespread dissemination of SBI, without the implementation of alcohol control measures, might have indirect influences on levels of consumption and harm but would be unlikely on its own to result in public health benefits. However, if and when alcohol control measures were introduced, SBI would still have an important role in the battle against alcohol-related harm.
Highlights
The term “brief intervention” has been applied both to shorter forms of treatment delivered in specialist alcohol or addiction services and to interventions offered by generalist professionals to individuals who are not seeking help for an alcohol problem but whose alcohol consumption is of concern
Public health benefit presupposes widespread screening Targeted versus universal screening If a population-level benefit of screening and brief intervention (SBI) is possible, the findings of the Sheffield model suggest that it must be based on widespread screening, including nearly the whole population and, the majority of excessive drinkers
The first conclusion from this discussion is that it is impossible to be confident about an answer to the question that forms the title of this article; namely, can SBI lead to population-level reductions in alcohol-related harm? This is because of a lack of empirical evidence as to whether widespread SBI can reduce alcohol-related harm as detectable on population-level, or at least community-level, measures
Summary
The term “brief intervention” has been applied both to shorter forms of treatment delivered in specialist alcohol or addiction services and to interventions offered by generalist professionals to individuals who are not seeking help for an alcohol problem but whose alcohol consumption is of concern. The first well-resourced trial of GP-delivered SBI, resulting in the first good evidence for its effectiveness in any setting, was carried out by Paul Wallace and colleagues using the Medical Research Council GP Research Network [21] They randomly allocated 909 heavy drinking patients from 47 group practices throughout the UK to one of two groups: 1) advice and information about reducing consumption plus a leaflet and up to five additional sessions at the discretion of the GP; or 2) a nonintervention control. GPs and other members of the primary health care team should be encouraged to include counseling about alcohol consumption in their preventive activities” (p.663) If this potential had been realized, it would have resulted in 5.75 million heavy drinking men and 1.55 million heavy drinking women becoming low-risk drinkers since Wallace et al.’s 1988 publication.
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