Cutting consumption without diluting the experience: Preferences for different tactics for reducing alcohol consumption among increasing-and-higher-risk drinkers based on drinking context.

Contexts in which people drink vary. Certain drinking contexts may be more amenable to change than others and the effectiveness of alcohol reduction tactics may differ across contexts. This study aimed to explore how helpful context-specific tactics for alcohol reduction were perceived as being amongst increasing-and-higher-risk drinkers. Using the Behaviour Change Technique Taxonomy, context-specific tactics to reduce alcohol consumption were developed by the research team and revised following consultation with experts in behaviour change. In four focus groups (two online, two in-person), N = 20 adult increasing-and-higher-risk drinkers in the UK discussed how helpful tactics developed for four drinking contexts would be: drinking at home alone (19 tactics), drinking at home with partner or family (21 tactics), in the pub with friends (23 tactics), and a meal out of the home (20 tactics). Transcripts were analysed using constant comparison methods. Participants endorsed four broad approaches to reducing alcohol consumption which encompassed all the individual tactics developed by the research team: Diluting and substituting drinks for those containing less alcohol (e.g. switching to soft drinks or no- or low-alcohol drinks); Reducing external pressure to drink (e.g. setting expectations in advance); Creating barriers to drinking (e.g. not buying alcohol to keep at home or storing it in less visible places), and Setting new habits (e.g. breaking old patterns and taking up new hobbies). Three cross-cutting themes influenced how applicable these approaches were to different drinking contexts. These were: Situational pressure, Drinking motives, and Financial motivation. Diluting and substituting drinks which enabled covert reduction and Reducing external pressure to drink were favoured in social drinking contexts. Diluting and substituting drinks which enabled participants to feel that they were having 'a treat' or which facilitated relaxation and Creating barriers to drinking were preferred at home. Interventions to reduce alcohol consumption should offer tactics tailored to individuals' drinking contexts and which account for context-specific individual and situational pressure to drink.

Evaluating the Acceptability of the Drink Less App and the National Health Service Alcohol Advice Web Page: Qualitative Interview Process Evaluation.

BACKGROUND: The extent to which interventions are perceived as acceptable to users impacts engagement and efficacy. OBJECTIVE: In this study, we evaluated the acceptability of (1) the smartphone app Drink Less (intervention) and (2) the National Health Service (NHS) alcohol advice web page (usual digital care and comparator) among adult drinkers in the United Kingdom participating in a randomized controlled trial evaluating the effectiveness of the Drink Less app. METHODS: A subsample of 26 increasing- and higher-risk drinkers (Alcohol Use Disorders Identification Test score≥8) assigned to the intervention group (Drink Less; n=14, 54%; female: n=10, 71%; age: 22-72 years; White: n=9, 64%) or usual digital care group (NHS alcohol advice web page; n=12, 46%; female: n=5, 42%; age: 23-68 years: White: n=9, 75%) took part in semistructured interviews. The interview questions were mapped on to the 7 facets of acceptability according to the Theoretical Framework of Acceptability: affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy. Alongside these constructs, we also included a question on perceived personal relevance, which previous research has linked to acceptability and engagement. Framework and thematic analysis of data was undertaken. RESULTS: The Drink Less app was perceived as being ethical, easy, user-friendly, and effective for the period the app was used. Participants reported particularly liking the tracking and feedback sections of the app, which they reported increased personal relevance and which resulted in positive affect when achieving their goals. They reported no opportunity cost. Factors such as negative affect when not meeting goals and boredom led to disengagement in the longer term for some participants. The NHS alcohol advice web page was rated as being easy and user-friendly with no opportunity costs. However, the information presented was not perceived as being personally relevant or effective in changing drinking behavior. Most participants reported neutral or negative affect, most participants thought the alcohol advice web page was accessible, and some participants reported ethical concerns around the availability of suggested resources. Some participants reported that it had acted as a starting point or a signpost to other resources. Participants in both groups discussed motivation to change and contextual factors such as COVID-19 lockdowns, which influenced their perceived self-efficacy regardless of their assigned intervention. CONCLUSIONS: Drink Less appears to be an acceptable digital intervention among the recruited sample. The NHS alcohol advice web page was generally considered unacceptable as a stand-alone intervention among the recruited sample, although it may signpost and help people access other resources and interventions.

Do engagement and behavioural mechanisms underpin the effectiveness of the Drink Less app?

This is a process evaluation of a large UK-based randomised controlled trial (RCT) (n = 5602) evaluating the effectiveness of recommending an alcohol reduction app, Drink Less, compared with usual digital care in reducing alcohol consumption in increasing and higher risk drinkers. The aim was to understand whether participants' engagement ('self-reported adherence') and behavioural characteristics were mechanisms of action underpinning the effectiveness of Drink Less. Self-reported adherence with both digital tools was over 70% (Drink Less: 78.0%, 95% CI = 77.6-78.4; usual digital care: 71.5%, 95% CI = 71.0-71.9). Self-reported adherence to the intervention (average causal mediation effect [ACME] = -0.250, 95% CI = -0.42, -0.11) and self-monitoring behaviour (ACME = -0.235, 95% CI = -0.44, -0.03) both partially mediated the effect of the intervention (versus comparator) on alcohol reduction. Following the recommendation (self-reported adherence) and the tracking (self-monitoring behaviour) feature of the Drink Less app appear to be important mechanisms of action for alcohol reduction among increasing and higher risk drinkers.

Estimating causal effects for binary outcomes using per-decision inverse probability weighting.

Micro-randomized trials are commonly conducted for optimizing mobile health interventions such as push notifications for behavior change. In analyzing such trials, causal excursion effects are often of primary interest, and their estimation typically involves inverse probability weighting (IPW). However, in a micro-randomized trial, additional treatments can often occur during the time window over which an outcome is defined, and this can greatly inflate the variance of the causal effect estimator because IPW would involve a product of numerous weights. To reduce variance and improve estimation efficiency, we propose two new estimators using a modified version of IPW, which we call "per-decision IPW." The second estimator further improves efficiency using the projection idea from the semiparametric efficiency theory. These estimators are applicable when the outcome is binary and can be expressed as the maximum of a series of sub-outcomes defined over sub-intervals of time. We establish the estimators' consistency and asymptotic normality. Through simulation studies and real data applications, we demonstrate substantial efficiency improvement of the proposed estimator over existing estimators. The new estimators can be used to improve the precision of primary and secondary analyses for micro-randomized trials with binary outcomes.

Randomized controlled trial of a smartphone app designed to reduce unhealthy alcohol consumption.

Background and aims: Unhealthy alcohol use is common and causes tremendous harm. Most people with unhealthy alcohol use will never seek formal alcohol treatment. As an alternative, smartphone apps have been developed as one means to provide help to people concerned about their alcohol use. The aim of this study was to test the efficacy of a smartphone app targeting unhealthy alcohol consumption in a general population sample. Methods: Participants were recruited from across Canada using online advertisements. Eligible participants who consented to the trial were asked to download a research-specific version of the app and were provided with a code that unlocked it (a different code for each participant to prevent sharing). Those who entered the code were randomized to one of two different versions of the app: 1) the Full app containing all intervention modules; or 2) the Educational only app, containing only the educational content of the app. Participants were followed-up at 6 months. The primary outcome variable was number of standard drinks in a typical week. Secondary outcome variables were frequency of heavy drinking days and experience of alcohol-related problems. Results: A total of 761 participants were randomized to a condition. The follow-up rate was 81 %. A generalized linear mixed model revealed that participants receiving the full app reduced their typical weekly alcohol consumption to a greater extent than participants receiving the educational only app (incidence rate ratio 0.89; 95 % confidence interval 0.80 to 0.98). No significant differences were observed in the secondary outcome variables (p > .05). Discussion and conclusion: The results of this trial provide some supportive evidence that smartphone apps can reduce unhealthy alcohol consumption. As this is the second randomized controlled trial demonstrating an impact of this same app (the first one targeted unhealthy alcohol use in university students), increased confidence is placed on the potential effectiveness of the smartphone app employed in the current trial.ClinicalTrials.org number: NCT04745325.

Social smoker identity and associations with smoking and quitting behaviour: A cross-sectional study in England.

BACKGROUND: 'Social smoking' typically occurs predominantly or exclusively in the presence of others who are smoking. Relatively little is known about changes in the prevalence of 'social smoking identity' over time and its association with other smoking-related correlates. METHODS: Data were from the Smoking Toolkit Study, a nationally-representative cross-sectional survey in England. Participants were 26,774 adults who currently smoked or had quit in the past year, surveyed between February-2014 and April-2021. We estimated the proportion identifying as having a social smoking identity, changes over time, and associations with smoking in social situations, cigarette dependence, motivation to stop, quit attempts and success. RESULTS: Of adults who currently smoked or had quit in the past year, 34.0% (95% Confidence Interval (CI)=33.5-34.6) identified as having a social smoking identity. There was a near linear increase in this proportion from 31.9% (95%CI=29.7-34.2) in February-2014 to 36.5% (95%CI=34.1-38.9) in April-2021. Adults who currenty smoked identifying as having a social smoking identity were less cigarette dependent (adjusted B=0.34, 95%CI=0.31-0.37) and more motivated to stop (aOR=1.20, 95%CI=1.15-1.26) than those who did not. Adults who currently smoked or had quit in the past year identifying as having a social smoking identity reported more smoking in social situations (aOR=6.45, 95%CI=6.13-6.80) and past-year quit attempts (aOR=1.22, 95%CI=1.14-1.30) than those who did not. Quit success was not associated with having a social smoking identity among adults who currently smoked or had quit in the past year and who had attempted to quit (aOR=0.90, 95%CI=0.79-1.02). CONCLUSIONS: An increasing proportion, over a third, of adults who currently smoked or had quit in the past year in England identify as having a social smoking identity. Despite being associated with lower dependence, greater motivation to quit and more quit attempts, social smoking identity is not associated with greater quit success, suggesting a complex interplay between identity and smoking-related behaviours.

Effectiveness of a smartphone app (Drink Less) versus usual digital care for reducing alcohol consumption among increasing-and-higher-risk adult drinkers in the UK: a two-arm, parallel-group, double-blind, randomised controlled trial.

Background: Digital interventions, including apps and websites, can be effective for reducing alcohol consumption. However, many are not evidence- or theory-informed and have not been evaluated. We tested the effectiveness of the Drink Less app for reducing alcohol consumption compared with usual digital care in the UK. Methods: In this two-arm, parallel group, double-blind, randomised controlled trial, we enrolled increasing-and-higher-risk drinkers (AUDIT ≥ 8) in the UK, who were motivated to reduce their alcohol consumption and willing to use a digital intervention to do so, via online methods. Participants were randomly assigned (1:1), using an online algorithm, to receive a web link to download the Drink Less app (intervention) or to the NHS alcohol advice webpage (usual digital care). Researchers were masked to group allocation. Participants were followed up at one, three and six months. The primary outcome was self-reported weekly alcohol consumption at six months, adjusting for baseline consumption. The full analytic sample was used in most analyses, though missing data was treated in different ways. The primary, pre-registered intention-to-treat analysis assumed baseline-carried-forwards. Secondary pre-registered analyses also focused on the full analytic sample and used alternatives including multiple imputation and last observation carried forwards. This trial is registered with the ISRCTN registry, ISRCTN64052601. Findings: Between 07/13/2020 and 03/29/2022, 5602 people were randomly assigned to the Drink Less app (n = 2788) or comparator (n = 2814) groups. Six-month follow-up rates were 79% and 80%, respectively. The primary pre-registered conservative intention-to-treat approach assuming non-responders were drinking at baseline levels of consumption, found a non-significant greater reduction of 0.98 units in weekly alcohol consumption in the intervention group at 6-month follow-up (95% CI -2.67 to 0.70). The data were insensitive to detect the hypothesised effect (Bayes factor = 1.17). Data were not missing completely at random, with 6-month follow-up rates differing in terms of education, occupation, and income. We therefore conducted the pre-registered sensitivity analysis using multiple imputation, showing that the Drink Less app resulted in a 2.00-unit greater weekly reduction at 6-month follow-up compared with the NHS alcohol advice webpage (95% CI -3.76 to -0.24). Fewer than 0.1% of participants in both arms who responded to one, three or six-month follow-up reported adverse events linked to participation in the trial. Interpretation: The Drink Less app may be effective in reducing the alcohol consumption in increasing-and-higher-risk drinkers motivated to reduce their consumption. Funding: NIHR Public Health Research Programme.

Methodological Insights on Recruitment and Retention From a Remote Randomized Controlled Trial Examining the Effectiveness of an Alcohol Reduction App: Descriptive Analysis Study.

BACKGROUND: Randomized controlled trials (RCTs) with no in-person contact (ie, remote) between researchers and participants offer savings in terms of cost and time but present unique challenges. OBJECTIVE: The goal of this study is to examine the differences between different forms of remote recruitment (eg, National Health Service [NHS] website, social media, and radio advertising) in the proportion of participants recruited, demographic diversity, follow-up rates, and cost. We also examine the cost per participant of sequential methods of follow-up (emails, phone calls, postal surveys, and postcards). Finally, our experience with broader issues around study advertising and participant deception is discussed. METHODS: We conducted a descriptive analysis of 5602 increasing-and-higher-risk drinkers (Alcohol Use Disorders Identification Test score ≥8), taking part in a 2-arm, parallel group, remote RCT with a 1:1 allocation, comparing the intervention (Drink Less app) with usual digital care (NHS alcohol advice web page). Participants were recruited between July 2020 and March 2022 and compensated with gift vouchers of up to £36 (a currency exchange rate of £1=US $1.26988 is applicable) for completing follow-up surveys, with 4 stages of follow-up: email reminders, phone calls, postal survey, and postcard. RESULTS: The three main recruitment methods were advertisements on (1) social media (2483/5602, 44.32%), (2) the NHS website (1961/5602, 35.01%), and (3) radio and newspapers (745/5602, 13.3%), with the remaining methods of recruitment accounting 7.37% (413/5602) of the sample. The overall recruitment cost per participant varied from £0 to £11.01. Costs were greater when recruiting participants who were men (£0-£28.85), from an ethnic minority group (£0-£303.81), and more disadvantaged (£0-£49.12). Targeted approaches were useful for recruiting more men but less useful in achieving diversity in ethnicity and socioeconomic status. Follow-up at 6 months was 79.58% (4458/5602). Of those who responded, 92.4% (4119/4458) responded by email. Each additional stage of follow-up resulted in an additional 2-3 percentage points of the overall sample being followed up, although phone calls, postal surveys, and postcards were more resource intensive than email reminders. CONCLUSIONS: For remote RCTs, researchers could benefit from using a range of recruitment methods and cost-targeted approaches to achieve demographic diversity. Automated emails with substantial financial incentives for prompt completion can achieve good follow-up rates, and sequential, offline follow-up options, such as phone calls and postal surveys, can further increase follow-up rates but are comparatively expensive. We also make broader recommendations focused on striking the right balance when designing remote RCTs. Careful planning, ongoing maintenance, and dynamic decision-making are required throughout a trial to balance the competing demands of participation among those eligible, deceptive participation among those who are not eligible, and ensuring no postrandomization bias is introduced by data-checking protocols.

Brief interventions for smoking and alcohol associated with the COVID-19 pandemic: a population survey in England.

BACKGROUND: Following the onset of the COVID-19 pandemic, in March 2020 health care delivery underwent considerable changes. It is unclear how this may have affected the delivery of Brief Interventions (BIs) for smoking and alcohol. We examined the impact of the COVID-19 pandemic on the receipt of BIs for smoking and alcohol in primary care in England and whether certain priority groups (e.g., less advantaged socioeconomic positions, or a history of a mental health condition) were differentially affected. METHODS: We used nationally representative data from a monthly cross-sectional survey in England between 03/2014 and 06/2022. Monthly trends in the receipt of BIs for smoking and alcohol were examined using generalised additive models among adults who smoked in the past-year (weighted N = 31,390) and those using alcohol at increasing and higher risk levels (AUDIT score 38, weighted N = 22,386), respectively. Interactions were tested between social grade and the change in slope after the onset of the COVID-19 pandemic, and results reported stratified by social grade. Further logistic regression models assessed whether changes in the of receipt of BIs for smoking and alcohol, respectively, from 12/2016 to 01/2017 and 10/2020 to 06/2022 (or 03/2022 in the case of BIs for alcohol), depended on history of a mental health condition. RESULTS: The receipt of smoking BIs declined from an average prevalence of 31.8% (95%CI 29.4-35.0) pre-March 2020 to 24.4% (95%CI 23.5-25.4) post-March 2020. The best-fitting model found that after March 2020 there was a 12-month decline before stabilising by June 2022 in social grade ABC1 at a lower level (~ 20%) and rebounding among social grade C2DE (~ 27%). Receipt of BIs for alcohol was low (overall: 4.1%, 95%CI 3.9-4.4) and the prevalence was similar pre- and post-March 2020. CONCLUSIONS: The receipt of BIs for smoking declined following March 2020 but rebounded among priority socioeconomic groups of people who smoked. BIs for alcohol among those who use alcohol at increasing and higher risk levels were low and there was no appreciable change over time. Maintaining higher BI delivery among socioeconomic and mental health priority groups of smokers and increasing and higher risk alcohol users is important to support reductions in smoking and alcohol related inequalities.

Prevalence and characteristics of co-occurrence of smoking and increasing-and-higher-risk drinking: A population survey in England.

BACKGROUND: Smoking and drinking alcohol both significantly contribute to mortality and morbidity, and there is a need to characterise the sociodemographic and health-related characteristics (e.g. mental distress) of people who do both in order to target resources. This study reports the prevalence and characteristics of adults in the general population in England who both drink alcohol at increasing-and-higher-risk levels and smoke. METHODS: We used cross-sectional data from a monthly, nationally representative survey of adults in England (n = 37,258; April 2020-March 2022). Weighted data were used to report prevalence and unweighted data were used to report descriptive statistics for sociodemographic and health-related characteristics. RESULTS: The prevalence of both smoking and increasing-and-higher-risk drinking was 4.6% (95% CI = 4.4-4.9; n = 1,574). They smoked a mean of 10.4 (SD = 8.86) cigarettes per day and had a mean AUDIT score of 12.8 (SD = 5.18). Nearly half (48.2%, n = 751) were trying to cut down on their smoking and 28.0% (n = 441) on their drinking. A quarter (25.3%, n = 397) had received General Practitioner advice on smoking while 8.7% (n = 76) had received advice on their drinking. Nearly half (48.6%, n = 745) reported experiencing psychological distress in the past month and 44.6% (n = 529) had a diagnosed mental health condition, both of which were higher than among all adults (28.1% and 29.1%, respectively). CONCLUSION: In England, from April 2020 to March 2022, the prevalence of both smoking and increasing-and-higher-risk drinking was 4.6%. This group appears to experience high rates of mental health problems and targeted support is needed.

Associations between physical activity, sedentary behaviour, and alcohol consumption among UK adults: Findings from the Health Behaviours during the COVID-19 pandemic (HEBECO) study.

INTRODUCTION: The COVID-19 pandemic and attendant lockdowns have had a substantial negative effect on alcohol consumption and physical activity globally. Pre-pandemic evidence in the adult population suggests that higher levels of physical activity were associated with higher levels of drinking, but it is unclear how the pandemic may have affected this. Therefore, this study aims to assess the association between alcohol consumption and physical activity in a UK cohort established during the COVID-19 pandemic. METHODS: Analyses utilized data from the Health Behaviours during the COVID-19 pandemic (HEBECO) study involving 2,057 UK adults (≥18 years). Participants completed self-report measures of alcohol consumption [frequency, quantity, frequency of heavy episodic drinking (HED) and AUDIT-C score] and physical activity [moderate-vigorous physical activity (MVPA), frequency of muscle strengthening activity (MSA) and sedentary behaviour] between November 2020 and January 2021. Ordinal logistic regression models were conducted, adjusting for sociodemographic factors. RESULTS: Fifteen percent of the sample reported abstinence from drinking. Overall, 23.4% of participants drank ≥4 times/week, 13.9% drank more than 6 units/single drinking occasion (HED), 7.5% reported HED daily/almost daily and 4.2% scored ≥11 on AUDIT-C. MSA 3 days/week compared with no MSA was significantly associated with higher odds of alcohol frequency [OR (95 CI%) = 1.41 (1.04-1.91)], quantity [OR (95 CI%) = 1.38 (1.02-1.87)], HED [OR (95 CI%) = 1.42 (1.05-1.94)] and possible dependence [OR (95 CI%) = 1.47 (1.05-2.06)]. The association of MVPA and sedentary behaviour with drinking measures was not significant (p>0.05). CONCLUSION: In contrast with previous research, MSA rather than aerobic physical activity was associated with increased alcohol consumption during the COVID-19 pandemic. It is conceivable that during lockdown while drinking was used as a coping strategy, limited opportunities for aerobic exercise made MSA a more convenient form of physical activity. To guide public health interventions, more research is required to examine the temporal relationship between different forms of physical activity and alcohol consumption.

Bot or Not? Detecting and Managing Participant Deception When Conducting Digital Research Remotely: Case Study of a Randomized Controlled Trial.

BACKGROUND: Evaluating digital interventions using remote methods enables the recruitment of large numbers of participants relatively conveniently and cheaply compared with in-person methods. However, conducting research remotely based on participant self-report with little verification is open to automated "bots" and participant deception. OBJECTIVE: This paper uses a case study of a remotely conducted trial of an alcohol reduction app to highlight and discuss (1) the issues with participant deception affecting remote research trials with financial compensation; and (2) the importance of rigorous data management to detect and address these issues. METHODS: We recruited participants on the internet from July 2020 to March 2022 for a randomized controlled trial (n=5602) evaluating the effectiveness of an alcohol reduction app, Drink Less. Follow-up occurred at 3 time points, with financial compensation offered (up to £36 [US $39.23]). Address authentication and telephone verification were used to detect 2 kinds of deception: "bots," that is, automated responses generated in clusters; and manual participant deception, that is, participants providing false information. RESULTS: Of the 1142 participants who enrolled in the first 2 months of recruitment, 75.6% (n=863) of them were identified as bots during data screening. As a result, a CAPTCHA (Completely Automated Public Turing Test to Tell Computers and Humans Apart) was added, and after this, no more bots were identified. Manual participant deception occurred throughout the study. Of the 5956 participants (excluding bots) who enrolled in the study, 298 (5%) were identified as false participants. The extent of this decreased from 110 in November 2020, to a negligible level by February 2022 including a number of months with 0. The decline occurred after we added further screening questions such as attention checks, removed the prominence of financial compensation from social media advertising, and added an additional requirement to provide a mobile phone number for identity verification. CONCLUSIONS: Data management protocols are necessary to detect automated bots and manual participant deception in remotely conducted trials. Bots and manual deception can be minimized by adding a CAPTCHA, attention checks, a requirement to provide a phone number for identity verification, and not prominently advertising financial compensation on social media. TRIAL REGISTRATION: ISRCTN Number ISRCTN64052601; https://doi.org/10.1186/ISRCTN64052601.

How Notifications Affect Engagement With a Behavior Change App: Results From a Micro-Randomized Trial.

BACKGROUND: Drink Less is a behavior change app to help higher-risk drinkers in the United Kingdom reduce their alcohol consumption. The app includes a daily notification asking users to "Please complete your drinks and mood diary," yet we did not understand the causal effect of the notification on engagement nor how to improve this component of Drink Less. We developed a new bank of 30 new messages to increase users' reflective motivation to engage with Drink Less. This study aimed to determine how standard and new notifications affect engagement. OBJECTIVE: Our objective was to estimate the causal effect of the notification on near-term engagement, to explore whether this effect changed over time, and to create an evidence base to further inform the optimization of the notification policy. METHODS: We conducted a micro-randomized trial (MRT) with 2 additional parallel arms. Inclusion criteria were Drink Less users who consented to participate in the trial, self-reported a baseline Alcohol Use Disorders Identification Test score of ≥8, resided in the United Kingdom, were aged ≥18 years, and reported interest in drinking less alcohol. Our MRT randomized 350 new users to test whether receiving a notification, compared with receiving no notification, increased the probability of opening the app in the subsequent hour, over the first 30 days since downloading Drink Less. Each day at 8 PM, users were randomized with a 30% probability of receiving the standard message, a 30% probability of receiving a new message, or a 40% probability of receiving no message. We additionally explored time to disengagement, with the allocation of 60% of eligible users randomized to the MRT (n=350) and 40% of eligible users randomized in equal number to the 2 parallel arms, either receiving the no notification policy (n=98) or the standard notification policy (n=121). Ancillary analyses explored effect moderation by recent states of habituation and engagement. RESULTS: Receiving a notification, compared with not receiving a notification, increased the probability of opening the app in the next hour by 3.5-fold (95% CI 2.91-4.25). Both types of messages were similarly effective. The effect of the notification did not change significantly over time. A user being in a state of already engaged lowered the new notification effect by 0.80 (95% CI 0.55-1.16), although not significantly. Across the 3 arms, time to disengagement was not significantly different. CONCLUSIONS: We found a strong near-term effect of engagement on the notification, but no overall difference in time to disengagement between users receiving the standard fixed notification, no notification at all, or the random sequence of notifications within the MRT. The strong near-term effect of the notification presents an opportunity to target notifications to increase "in-the-moment" engagement. Further optimization is required to improve the long-term engagement. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/18690.

The effect of question order on outcomes in the orbital core outcome set for alcohol brief interventions among online help-seekers (QOBCOS): Findings from a randomised factorial trial.

Objective: A core outcome set (COS) has been developed in alcohol brief intervention (ABI) research through international consensus. This study aimed to estimate order effects among questions in the COS. Methods: Individuals aged 18 or older who searched online for alcohol-related help were invited to complete the COS. The order of questions was randomised following a factorial design. Primary outcomes were order effects among the COS items and patterns of attrition. Results: Between 21/10/2020 and 26/11/2020, we randomised 7334 participants, of which 5256 responded to at least one question and were available for analyses. Current non-drinkers were excluded. We found evidence of higher self-reported average consumption and odds of harmful and hazardous drinking was found among those who first answered questions on recent consumption and impact of alcohol use. Lower self-reported recent consumption was found among those first asked about average consumption. Quality of life (QoL) was reported lower among those who first responded to when questions on impact of alcohol use were asked first, which in turn was lower among those who first answered question on when average consumption and QoL were asked first. Attrition was lowest when average consumption was asked first, and highest when QoL or impact of alcohol use was asked first. Median completion time for the COS was 4.3 min. Conclusions: Question order affects outcomes and attrition. If the aim is to minimize attrition, consumption measures should be asked before QoL and impact of alcohol use; however, this order impacts self-reported alcohol consumption and so researchers should be guided by study priorities. At a minimum, all participants should be asked the same questions in the same order. Trial registration: The trial was prospectively registered (ISRCTN17954645).

Practitioner and digitally delivered interventions for reducing hazardous and harmful alcohol consumption in people not seeking alcohol treatment: a systematic review and network meta-analysis.

AIM: To compare the effectiveness of practitioner versus digitally delivered interventions for reducing hazardous and harmful alcohol consumption. DESIGN: Systematic review and network meta-analysis comprising comprehensive search for randomised controlled trials, robust screening and selection methods and appraisal with the Cochrane Risk of Bias tool. Network meta-analyses were conducted in Stata using random effects, frequentist models. The confidence in network meta-analysis (CINeMA) tool was used to assess confidence in effect sizes. SETTING: Online or community or health settings where the intervention was immediately accessible without referral. PARTICIPANTS: Non treatment-seeking hazardous or harmful drinkers. MEASUREMENTS: Primary outcome was mean difference in alcohol consumption (g/wk); secondary outcome was number of single high intensity drinking episodes. Baseline consumption was analysed as a covariate. FINDINGS: Of 201 included trials (94 753 participants), 152 reported a consumption outcome that could be converted to grams/week; 104 reported number of single high intensity drinking episodes. At 1 and 6 months, practitioner delivered interventions reduced consumption more than digitally delivered interventions (1 month: -23 g/wk (95% CI, -43 to -2); 6 months: -14 g/wk [95% CI, -25 to -3]). At 12 months there was no evidence of difference between practitioner and digitally delivered interventions (-6 g/wk [95% CI, -24 to 12]). There was no evidence of a difference in single high intensity drinking episodes between practitioner and digitally delivered interventions at any time point. Effect sizes were small, but could impact across a population with relatively high prevalence of hazardous and harmful drinking. Heterogeneity was a concern. Some inconsistency was indicated at 1 and 6 months, but little evidence was apparent at 12 months. CONCLUSION: Practitioner delivered interventions for reducing hazardous and harmful alcohol consumption are more effective than digitally delivered interventions up to 6 months; at 12 months there is no evidence of a difference.

The Effect of the First UK COVID-19 Lockdown on Users of the Drink Less App: Interrupted Time Series Analysis of Sociodemographic Characteristics, Engagement, and Alcohol Reduction.

BACKGROUND: The first UK COVID-19 lockdown had a polarizing impact on drinking behavior and may have impacted engagement with digital interventions to reduce alcohol consumption. OBJECTIVE: We examined the effect of lockdown on engagement, alcohol reduction, and the sociodemographic characteristics of users of the popular and widely available alcohol reduction app Drink Less. METHODS: This was a natural experiment. The study period spanned 468 days between March 24, 2019, and July 3, 2020, with the introduction of UK lockdown measures beginning on March 24, 2020. Users were 18 years or older, based in the United Kingdom, and interested in drinking less. Interrupted time series analyses using generalized additive mixed models (GAMMs) were conducted for each outcome variable (ie, sociodemographic characteristics, app downloads and engagement levels, alcohol consumption, and extent of alcohol reduction) for existing (downloaded the app prelockdown) and new (downloaded the app during the lockdown) users of the app. RESULTS: Among existing users of the Drink Less app, there were increases in the time spent on the app per day (B=0.01, P=.01), mean units of alcohol recorded per day (B>0.00 P=.02), and mean heavy drinking (>6 units) days (B>0.00, P=.02) during the lockdown. Previous declines in new app downloads plateaued during the lockdown (incidence rate ratio [IRR]=1.00, P=.18). Among new app users, there was an increase in the proportion of female users (B>0.00, P=.04) and those at risk of alcohol dependence (B>0.00, P=.01) and a decrease in the proportion of nonmanual workers (B>-0.00, P=.04). Among new app users, there were step increases in the mean number of alcohol units per day (B=20.12, P=.03), heavy-drinking days (B=1.38, P=.01), and the number of days the app was used (B=2.05, P=.02), alongside a step decrease in the percentage of available screens viewed (B=-0.03, P=.04), indicating users were using less of the intervention components within the app. CONCLUSIONS: Following the first UK lockdown, there was evidence of increases in engagement and alcohol consumption among new and existing users of the Drink Less app.

Prevalence and characteristics of hazardous and harmful drinkers receiving general practitioners' brief advice on and support with alcohol consumption in Germany: results of a population survey.

OBJECTIVE: The German treatment guideline on alcohol-related disorders recommends that general practitioners (GPs) offer brief advice on, and support with, reducing alcohol consumption to hazardous (at risk for health events) and harmful (exhibit health events) drinking patients. We aimed to estimate the implementation of this recommendation using general population data. DESIGN: Cross-sectional analysis of data (2021/2022) of a nationwide, population-based household survey. SETTING: Germany. PARTICIPANTS: Population-based sample of 2247 adult respondents who reported hazardous or harmful drinking according to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; score women: 4-12 and men: 5-12). MAIN OUTCOME MEASURE: Ever receipt of 'brief GP advice on, or support with, reducing alcohol consumption'. Differences in the likelihood of ever receiving advice and/or support (yes/no) relative to respondents' sociodemographic, smoking and alcohol consumption characteristics were estimated using logistic regressions. RESULTS: Ever receipt of GP advice on/support with reducing drinking was reported among 6.3% (95% CI=5.3% to 7.4%), and the offer of support among 1.5% (95% CI=1.1% to 2.1%) of the hazardous and harmful drinking respondents. The likelihood of having ever received advice/support was positively associated with being older (OR=1.03 per year, 95% CI=1.01 to 1.04), a current or former (vs never) smoker (OR=2.36, 95% CI=1.46 to 3.80; OR=2.17, 95% CI=1.23 to 3.81) and with increasing alcohol consumption (OR=1.76 per score, 95% CI=1.59 to 1.95). One in two harmful drinking respondents (AUDIT-C score 10-12) reported appropriate advice/support. The likelihood was negatively associated with being woman (eg, OR=0.32, 95% CI=0.21 to 0.48), having a medium or high (vs low) education and with increasing household income. CONCLUSIONS: A small proportion of hazardous and harmful drinking people in Germany report having ever received GP advice on, or support with, reducing alcohol consumption. The implementation of advice/support seems to be linked to specific socio-demographic characteristics, tobacco smoking and alcohol consumption level. Health policy measures should aim to increase alcohol screening, brief intervention rates and awareness for at-risk populations in primary care. TRIAL REGISTRATION NUMBER: DRKS00011322, DRKS00017157.

Exploring changes in temporary abstinence in increasing and higher risk drinkers in England and Dry January participation in users of the Try Dry app in the UK between 2020 and 2021.

BACKGROUND: We looked at changes in the prevalence of increasing and higher risk drinkers reporting a reduction attempt motivated by temporary abstinence and changes in prevalence of use of the official app accompanying Dry January between 2020 vs 2021, following the onset of the COVID-19 pandemic. We also explored potential shifts in the sociodemographic composition of both groups. METHODS: We analysed data from: i) 1863 increasing and higher risk drinkers (defined as ≥ 8 on the AUDIT) responding to a nationally representative survey of adults in England in January and February 2020 and 2021, and ii) 104,598 users of the 'Try Dry' app, the official aid to those participating in Dry January 2020 and 2021 in the UK. We used logistic regression to examine shifts in the prevalence of increasing and higher risk drinkers reporting a reduction attempt motivated by temporary abstinence and explored whether there were shifts in the characteristics of this group in terms of AUDIT score, number of last year reduction attempts, smoking status, living alone, living with children, reducing alcohol consumption due to future health motives, age, sex, and occupational social grade between 2020 and 2021. We used t-tests and chi-squared tests to compare the prevalence of users of the 'Try Dry' app in 2020 and 2021 and examine whether the two groups differed in terms of age and sex. RESULTS: The proportion of increasing and higher risk drinkers reporting a reduction attempt motivated by temporary abstinence increased from 4% in 2020 to 8% in 2021 (OR = 2.07, 95% CI = 1.38-3.11, p < .001) with no changes detected in sociodemographic composition. The number of Try Dry app users in 2021 increased by 34.8% relative to 2020. App users in 2021 were two years older on average [p < .001, d = .02], with a 2% increase in the proportion of female app users [p < .001, vs. < .01]. CONCLUSIONS: Higher participation in Dry January 2021 relative to 2020 indicates increased engagement with a period of temporary abstinence following the COVID-19 related lockdowns in England and the UK, which is positive in the wider context of increasing alcohol consumption throughout the pandemic.

Characterising smoking and smoking cessation attempts by risk of alcohol dependence: A representative, cross-sectional study of adults in England between 2014-2021.

Background: There is a strong shared association between smoking tobacco and drinking alcohol. This study aimed to compare smoking prevalence and smoking characteristics in drinkers who were versus were not at risk of alcohol dependence in England. Methods: We used cross-sectional data from a monthly, nationally representative survey of adults in England (weighted n=144,583) collected between 2014-2021. Smoking and smoking cessation attempt characteristics were regressed on to alcohol dependence (drinkers at risk versus not at risk), adjusting for survey year. Findings: Past-year smoking prevalence was 63·3% (95% CI=59·7-66·8) among drinkers at risk of alcohol dependence compared with 18·7% (95% CI=18·4-18·9) among those not at risk, and 19·2% (95% CI=18·8-19·7) among non-drinkers. Among past-year smokers, drinkers at risk of alcohol dependence (versus not at risk) smoked more cigarettes per day (B=3·0, 95% CI=2·3-3·8) and were more likely to smoke their first cigarette within 5 (versus >60) minutes of waking (OR=2·81, 95% CI=2·25-3·51). Interpretation: In a representative sample of adults in England, a graded effect was observed where smoking prevalence increased with level of alcohol consumption. Past-year smokers at risk of alcohol dependence had higher levels of cigarette dependence than drinkers not at risk. Therefore, smokers at risk of alcohol dependence are a high priority group to target to reduce smoking prevalence as part of the NHS long-term plan. Funding: Cancer Research UK and the National Institute for Health Research.

Perceived risk factors for severe Covid-19 symptoms and their association with health behaviours: Findings from the HEBECO study.

Risk perceptions are important influences on health behaviours. We used descriptive statistics and multivariable logistic regression models to assess cross-sectionally risk perceptions for severe Covid-19 symptoms and their health behaviour correlates among 2206 UK adults from the HEBECO study. The great majority (89-99%) classified age 70+, having comorbidities, being a key worker, overweight, and from an ethnic minority as increasing the risk. People were less sure about alcohol drinking, vaping, and nicotine replacement therapy use (17.4-29.5% responding 'don't know'). Relative to those who did not, those who engaged in the following behaviours had higher odds of classifying these behaviours as (i) decreasing the risk: smoking cigarettes (adjusted odds ratios, aORs, 95% CI = 2.26, 1.39-3.37), and using e-cigarettes (aORs = 5.80, 3.25-10.34); (ii) having no impact: smoking cigarettes (1.98; 1.42-2.76), using e-cigarettes (aORs = 2.63, 1.96-3.50), drinking alcohol (aORs = 1.75, 1.31-2.33); and lower odds of classifying these as increasing the risk: smoking cigarettes (aORs: 0.43, 0.32-0.56), using e-cigarettes (aORs = 0.25, 0.18-0.35). Similarly, eating more fruit and vegetables was associated with classifying unhealthy diet as 'increasing risk' (aOR = 1.37, 1.12-1.69), and exercising more with classifying regular physical activity as 'decreasing risk' (aOR = 2.42, 1.75-3.34). Risk perceptions for severe Covid-19 among UK adults were lower for their own health behaviours, evidencing optimism bias. These risk perceptions may form barriers to changing people's own unhealthy behaviours, make them less responsive to interventions that refer to the risk of Covid-19 as a motivating factor, and exacerbate inequalities in health behaviours and outcomes.