Follow-up study of people who misuse alcohol: reflections on methodology.

Background Considerable challenges exist for researchers attempting to monitor longitudinally the impact of any intervention on heavy drinkers, therefore they are often excluded from surveys. A particular challenge is the loss of validity through attrition. Aim To describe issues encountered when recruiting and re-contacting difficult to reach heavy drinkers participating in a longitudinal study; and propose strategies to inform the design of future studies to minimise the effects of confounding factors. Discussion Baseline recruitment exceeded targets, but attrition at first follow-up interview was considerable. Baseline alcohol consumption was not predictive of loss to follow-up. A variety of factors affected attrition including abstinence, severe intoxication at interview, deaths, selling of telephone, change of address and incarceration. Conclusion Longitudinal studies that use personal telephones or address details in following up heavy drinkers face considerable challenges to minimise attrition. An important mitigating factor is the use of flexible and experienced interviewers. Implications for practice The anticipated and reactive strategies documented in this paper provide important lessons for costing, designing and collecting data in future studies.

White cider consumption and heavy drinkers: a low-cost option but an unknown price.

AIMS: To compare characteristics of heavy drinkers who do, or do not, drink white cider during their typical drinking week and to contrast white cider drinkers' behaviour with a similar group recruited in comparable settings 4 years previously. To consider if excessive white cider consumption poses a specific health risk. METHODS: Cross-sectional survey of alcohol purchasing and consumption by heavy drinkers consuming white cider in Edinburgh and Glasgow during 2012; comparison of purchasing patterns within Edinburgh in 2008-2009 and 2012. Participants were 639 patients (in- and out-patient settings) with serious health problems linked to alcohol, 345 in Glasgow, 294 in Edinburgh in 2012, and 377 in Edinburgh in 2008-2009. RESULTS: In 2012 white cider consumption was reported by 25% of participants (median consumption (all alcohol) was 249 UK units per week-1 UK unit being 8 g of ethanol). They were more likely to be male and younger. They drank more units of alcohol than non-white cider drinkers and reported more alcohol-related problems. The median price paid for white cider in 2012 was 17 ppu. The period 2008-2012 was associated with decreasing affordability of alcohol, but consumption levels amongst the heaviest drinkers were maintained, associated with an increased proportion of units purchased as white cider. CONCLUSION: White cider makes an important contribution to the weekly intake of heavy drinkers in Scotland, likely facilitated by low price per unit of alcohol. We suggest these characteristics permit this drink to act as a buffer, supporting the continuation of a heavy drinking pattern when affordability of alcohol falls.

Is it my job? Alcohol brief interventions: knowledge and attitudes among future health-care professionals in Scotland.

AIMS: To document knowledge and perceptions relating to the professional role in the area of alcohol misuse within a sample of first year (n = 278) and final year (n = 527) medical, nursing and allied health professional (NAHP) students in Scotland. METHODS: A cross sectional survey design involving self-completed questionnaires administered in autumn 2008 (first year students) and spring 2009 (final year students) through course websites and lectures. RESULTS: Gaps in the knowledge relating to current UK health guidelines were identified but more so among NAHP students than medical students. Exploration of the perceived role in this area of practice identified three broad groups of students: those clear about their role (medical and nursing students), those advocating a role but not identified by fellow students (occupational therapy and pharmacy) and those uncertain of their role (radiographers, speech and language therapists/audiologists and physiotherapy). CONCLUSIONS: Higher education institutions should address the gaps in the knowledge around guidance for alcohol consumption. The effectiveness of brief interventions may depend on it. Additionally, through inter-professional teaching and in collaboration with the relevant professional bodies, more could be done to promote the contribution of practitioners other than those traditionally linked (i.e. medical and nursing) to this important clinical role.

Healthcare and medical graduates of 2009: their reactions to four key proposals in the Scottish Government's strategy for tackling alcohol misuse.

AIMS: This study compares the views of final year medical, and nursing and allied health professional (NAHP) students in relation to four governmental proposals impacting on the sale and purchase of alcohol. METHODS: Against a background of political will to address alcohol abuse in Scotland and moves within the National Health Service promoting a shifting of professional roles, self-completed questionnaires were administered in spring 2009 through course websites and lectures to final year medical and NAHP students. RESULTS: Questionnaires were returned by 406 NAHPs and 121 medical students. Over three quarters of all students agreed with the proposed change to reduce the drink driving limit to 50 mg/100 ml blood. Less support was evident for the raising of the minimum legal purchase age for off-sales (37%), the banning of below cost price promotions of alcohol (47%) and minimum retail pricing (37%). However, there were differences between the NAHP and medical students in the case of the final two proposals; over 60% of the medical students agreed they would have a positive impact. For NAHPs, figures were 41% and 31%, respectively. CONCLUSIONS: Support for four key proposals outlined by the Scottish Government to address alcohol misuse varied. Only the suggestion to lower the drink driving limit received backing overall and within students in these professions. Effectiveness of proposed restrictions on the price of alcohol was less well regarded except by medical students. Evident gaps in knowledge around health guidelines, and the finding that almost half of NAHPs disagreed that they had the appropriate knowledge to advise patients about responsible drinking advice and alcohol misuse problems, suggest a need for improved undergraduate education and continued professional development with respect to public health aspects of alcohol use.

Can part of the health damage linked to alcohol misuse in Scotland be attributable to the type of drink and its low price (by permitting a rapid rate of consumption)? A point of view.

This article considers two sets of data describing the extent of consumption of white spirit drinks by a sample of patients who abuse alcohol and the analysis of drink antioxidant content. We present a proposal for discussion that the rapid consumption of alcoholic drinks, low in protective antioxidant compounds, may potentially be more damaging to the body.

Providing web-based feedback and social norms information to reduce student alcohol intake: a multisite investigation.

BACKGROUND: Unhealthy alcohol use among university students is cause for concern, yet the level of help seeking behavior for alcohol use is low within the student population. Electronic brief interventions delivered via the Internet present an alternative to traditional treatments and could enable the delivery of interventions on a population basis. Further evidence is needed of the effectiveness of Internet-delivered interventions and of their generalizability across educational institutions. OBJECTIVE: Our objective was to evaluate the effectiveness across 4 UK universities of a Web-based intervention for student alcohol use. METHODS: In total, 1112 participants took part. Participants were stratified by educational institution, gender, age group, year of study, and self-reported weekly consumption of alcohol and randomly assigned to either the control arm or to the immediate or delayed intervention arms. Intervention participants gained access to the intervention between weeks 1 to 7 or weeks 8 to 15, respectively. The intervention provided electronic personalized feedback and social norms information on drinking behavior accessed by logging on to a website. Participants registered interest by completing a brief screening questionnaire and were then asked to complete 4 further assessments across the 24 weeks of the study. Assessments included a retrospective weekly drinking diary, the Alcohol Use Disorders Identification Test (AUDIT), and a readiness-to-change algorithm. The outcome variable was the number of units of alcohol consumed in the last week. The effect of treatment arm and time on units consumed last week and average units consumed per drinking occasion were investigated using repeated measures multivariate analysis of covariance (MANCOVA). In addition, the data were modeled using a longitudinal regression with time points clustered within students. RESULTS: MANCOVA revealed a main effect of time on units of alcohol consumed over the last week. A longitudinal regression model showed an effect of assessment across time predicting that participants who completed at least 2 assessments reduced their drinking. The model predicted an additional effect of being assigned to an intervention arm, an effect that increased across time. Regression analysis predicted that being male or being assigned to an intervention arm increased the odds of not completing all assessments. The number of units of alcohol consumed over the last week at registration, age, university educational institution, and readiness to change were not predictive of completion. CONCLUSIONS: Delivering an electronic personalized feedback intervention to students via the Internet can be effective in reducing weekly alcohol consumption. The effect does not appear to differ by educational institution. Our model suggested that monitoring alone is likely to reduce weekly consumption over 24 weeks but that consumption could be further reduced by providing access to a Web-based intervention. Further research is needed to understand the apparent therapeutic effect of monitoring and how this can be utilized to enhance the effectiveness of brief Web-based interventions.

The families and friends of heavy drinkers: Caught in the cross-fire of policy change?

INTRODUCTION AND AIMS: Research highlights the need to better understand the impact of alcohol-related harm on families and communities. Scottish policy initiatives to reduce alcohol consumption and alcohol-related harm include the planned introduction of a minimum unit price for alcohol. We aimed to explore existing and proposed changes in alcohol policy, from the standpoint of heavy drinkers, through accounts of their involvement and repercussions for family and friends. DESIGN AND METHODS: Interviews were conducted with 20 heavy drinkers, recruited from hospital alcohol treatment centres in Scotland's two largest cities. Participants were part of a larger longitudinal mixed methods study. Interviews explored experiences of alcohol-related harm and the impact, or potential impact, of alcohol policy changes on drinking patterns, risk-taking, consumption and wellbeing. Data coded for 'family and friends' were thematically analysed using a constant comparison method. RESULTS: Family and friends were portrayed as important for aiding moderation and abstinence, but more often for sustaining continued heavy drinking. Heavy drinkers with complex needs and those living in deprived communities suggested that increased alcohol prices could exacerbate the detrimental effect on their health and social circumstances, and that of their family, should their consumption remain excessive. DISCUSSION AND CONCLUSIONS: Population level policy initiatives to reduce alcohol consumption, such as minimum unit pricing, will impact on the families and social networks of heavy drinkers in addition to the drinker. The most vulnerable may be affected disproportionately. Alcohol policy changes and evaluations need to consider consequences for drinkers, families and communities. [O'May F, Whittaker A, Black H, Gill J. The families and friends of heavy drinkers: Caught in the cross-fire of policy change? Drug Alcohol Rev 2017;36:192-199].

A teachable moment for the teachable moment? A prospective study to evaluate delivery of a workshop designed to increase knowledge and skills in relation to alcohol brief interventions (ABIs) amongst final year nursing and occupational therapy undergraduates.

The perceived value of Alcohol Brief Interventions as a tool to address alcohol misuse in Scotland has supported the establishment of a Health Improvement, Efficiency, Access and Treatment, HEAT: H4 Standard to deliver ABIs within certain health care settings. This requires that nursing, medical and allied health professionals are appropriately skilled to deliver these interventions. This study explores the knowledge and attitudes regarding alcohol misuse and related interventions among two cohorts of final year nursing and occupational therapy undergraduate students before, during and following participation in a workshop devoted to ABI delivery. While relatively good knowledge around recommended limits for daily consumption was evident, this did not translate into competence relating to drink unit content. Although there was overwhelming agreement for the role of each profession in ABI delivery, less than half of students in each cohort at the outset of the workshop agreed that they had the appropriate knowledge to advise patients about responsible drinking. In both cohorts, at the three month follow-up stage, this percentage had almost doubled. Newly qualified practitioners perceived a wider role for motivational interviewing, and endorsed interactive delivery of alcohol education throughout all levels of the curriculum.

The enigma of 'harmful' alcohol consumption: evidence from a mixed methods study involving female drinkers in Scotland.

BACKGROUND/AIMS: An appreciation of the drinking patterns of population subgroups may usefully inform tailored interventions. For this purpose, research has highlighted a need to better describe the drinking behaviour of UK women. This study aims to characterise the purchasing and consumption behaviour of female heavy, harmed, drinkers in contact with Scottish health services in two cities and to explore the factors that influence the link to harm. METHODS: Mixed methods study involving cross-sectional survey questionnaires and one-to-one interviews (5). The questionnaires documented (1) demographic data (including derived deprivation score), last week's (or 'typical' weekly) consumption (type, brand, volume, price, place of purchase), self-reported illnesses, and (2) Alcohol-Related Problem Questionnaire score. A total of 181 patients with serious health problems linked to alcohol were recruited within National Health Service (NHS) hospital clinics (in- and outpatient settings), in two Scottish cities during 2012. RESULTS: Median consumption was 157.6 UK units for the recorded week, with almost exclusive purchase from 'off-sale' retail outlets. Preferred drinks were white cider, vodka and white wine. Increasing problems was positively associated with drinking more in the week, being younger and belonging to Glasgow. CONCLUSION: For Scottish women, the current definition of 'harmful' consumption likely captures a fourfold variation in alcohol intake, with gender differences less apparent. While current alcohol-related harm is positively associated with dose and being younger, there is clear evidence of an influence of the less tangible 'Glasgow effect'. Future harm concerns are warranted by data relating to pattern, alcohol dose and cigarette use.

The total margin of exposure of ethanol and acetaldehyde for heavy drinkers consuming cider or vodka.

Heavy drinkers in Scotland may consume 1600 g ethanol per week. Due to its low price, cider may be preferred over other beverages. Anecdotal evidence has linked cider to specific health hazards beyond other alcoholic beverages. To examine this hypothesis, nine apple and pear cider samples were chemically analysed for constituents and contaminants. None of the products exceeded regulatory or toxicological thresholds, but the regular occurrence of acetaldehyde in cider was detected. To provide a quantitative risk assessment, two collectives of exclusive drinkers of cider and vodka were compared and the intake of acetaldehyde was estimated using probabilistic Monte-Carlo type analysis. The cider consumers were found to ingest more than 200-times the amount of acetaldehyde consumed by vodka consumers. The margins of exposure (MOE) of acetaldehyde were 224 for the cider and over 220,000 for vodka consumers. However, if the effects of ethanol were considered in a cumulative assessment of the combined MOE, the effect of acetaldehyde was minor and the combined MOE for both groups was 0.3. We suggest that alcohol policy priority should be given on reducing ethanol intake by measures such as minimum pricing, rather than to focus on acetaldehyde.

Regional Variation in Analytical Techniques used in the Diagnosis and Monitoring of Porphyria: a Case for Harmonisation?

BACKGROUND: The Royal College of Pathologists of Australasia (RCPA) Porphyrin Quality Assurance Program assesses the measurement of urine, faecal, plasma and whole blood porphyrins and their components plus urinary porphobilinogen and delta aminolaevulinic acid and has laboratories enrolled from around the world. It was observed that there was a wide scatter in results submitted to some subsections of the program. METHODS: A detailed questionnaire covering the analytical techniques used in the diagnosis of porphyria was sent to all laboratories enrolled in the RCPA Porphyrin Quality Assurance Program. Additionally, self-enrolment data over a five year period was examined for trends/changes in standardisation, reagent sources and analytical technique. RESULTS: Twenty of the 45 laboratories enrolled in the Porphyrin Quality Assurance Program completed the survey, providing a snapshot of the analytical techniques used world-wide. Post survey self enrolment data indicated only little or no noticeable changes to analytical standardisation of techniques despite the continual lack of agreement of results in subsections of the External Quality Assurance program. CONCLUSIONS: While some aspects of porphyria testing are relatively consistent between laboratories, other diagnostic techniques vary widely. A wide variety of individualised reference intervals and reporting techniques is currently in use world-wide. While most of the participants in the survey are regional reference centres specialising in the diagnosis of porphyria and, as such, their diagnostic capability is not in question, international guidelines or global harmonisation of analytical techniques should allow better inter-laboratory comparisons to be made, ultimately improving diagnostic accuracy.

The price of a drink: levels of consumption and price paid per unit of alcohol by Edinburgh's ill drinkers with a comparison to wider alcohol sales in Scotland.

AIM: To compare alcohol purchasing and consumption by ill drinkers in Edinburgh with wider alcohol sales in Scotland. DESIGN: Cross-sectional. SETTING: Two hospitals in Edinburgh in 2008/09. PARTICIPANTS: A total of 377 patients with serious alcohol problems; two-thirds were in-patients with medical, surgical or psychiatric problems due to alcohol; one-third were out-patients. MEASUREMENTS: Last week's or typical weekly consumption of alcohol: type, brand, units (1 UK unit 8 g ethanol), purchase place and price. FINDINGS: Patients consumed mean 197.7 UK units/week. The mean price paid per unit was £0.43 (lowest £0.09/unit) (£1 = 1.6 US$ or 1.2€), which is below the mean unit price, £0.71 paid in Scotland in 2008. Of units consumed, 70.3% were sold at or below £0.40/unit (mid-range of price models proposed for minimum pricing legislation by the Scottish Government), and 83% at or below £0.50/unit proposed by the Chief Medical Officer of England. The lower the price paid per unit, the more units a patient consumed. A continuous increase in unit price from lower to higher social status, ranked according to the Scottish Index of Multiple Deprivation (based on postcode), was not seen; patients residing in postcodes in the mid-quintile paid the highest price per unit. Cheapness was quoted commonly as a reason for beverage choice; ciders, especially 'white' cider, and vodka were, at off-sales, cheapest per unit. Stealing alcohol or drinking alcohol substitutes was only very rarely reported. CONCLUSIONS: Because patients with serious alcohol problems tend to purchase very cheap alcohol, elimination of the cheapest sales by minimum price or other legislation might reduce their consumption. It is unknown whether proposed price legislation in Scotland will encourage patients with serious alcohol problems to start stealing alcohol or drinking substitutes or will reduce the recruitment of new drinkers with serious alcohol problems and produce predicted longer-term gains in health and social wellbeing.

How 'sensible' is the UK Sensible Drinking message? Preliminary findings amongst newly matriculated female university students in Scotland.

BACKGROUND: Current levels and patterns of alcohol drinking continue to cause concern, particularly amongst young females. Effective interventions remain elusive. The aim of this study was to investigate the levels of knowledge relating to UK 'Sensible Drinking' guidelines, definitions of binge drinking and attitude to drink labelling initiatives amongst female school leavers enrolling at university. METHODS: Non-standardized questionnaires were administered and completed by researchers during the process of matriculation (response rate 94%; n = 180). RESULTS: The survey revealed that recommended daily guidelines for women were not recalled by 54% of participants; 52% could not quote the unit content of their favoured alcoholic drink, whereas only 14% reported the use of the UK unit system to guide drinking. Personal quantitative definitions of binge drinking varied by a factor of 18. CONCLUSION: A rewording of the UK Sensible Drinking message to one recognizing the needs of different population groups and their particular language of consumption measure is timely.

Practical demonstration of personal daily consumption limits: a useful intervention tool to promote responsible drinking among UK adults?

AIM: The aim of this study was to investigate the utility of a short, practical pouring exercise as a means of illustrating the details of the UK 'Sensible Drinking' guidelines. METHODS: Participants (N = 297, 53% male) recruited at four Edinburgh employment sites, each completed a short non-standardized questionnaire and poured their 'usual measure of wine or spirit' into a glass (purchased from four 'high street' outlets). The actual and estimated unit content of their poured drinks and reactions to feedback were noted. Participants were informed of their daily limit of consumption in terms of this drink. RESULTS: On average, drinks contained 2.05 UK units. Only 27% (N = 79) of respondents estimated the unit content of their drink within 10% of the true value. Of drinkers, 20.5% (N = 61) indicated that the results of the pouring test would influence their future pouring (70% of these were women). When informed of daily limits of consumption in terms of personal drink measure, 46% (N = 132) of drinkers indicated they would usually exceed this. CONCLUSION: A practical demonstration of health guidelines presented in terms of personal drinking habits may contribute to dissemination of responsible drinking messages. Preliminary evidence suggests women may be particularly open to this approach. The utility of this intervention is underscored by recent figures highlighting the increasing preference for home drinking.

'Binge drinking? It's good, it's harmless fun': a discourse analysis of accounts of female undergraduate drinking in Scotland.

Binge drinking in young people, particularly females and students, is a source of some concern to those engaged in health education. The concept is usually defined in terms of quantities of alcohol consumed within a relatively short space of time. Research suggests that reasons for drinking are varied, and are likely to be influenced by culture and context. This study aimed to explore issues important to female undergraduate students in Scotland. Semi-structured interviews were carried out with 19 participants who were asked to describe what they understand by the term 'binge drinking', why they drink and what might trigger excessive consumption. Discourse analysis was used to explore the possible 'functions' of what was said, as well as the content. Participants showed sensitivity to how others might interpret their responses. They described binge drinking in terms of its behavioural effects rather than quantities consumed. Crucially, they positioned themselves outside the categories of 'serious' or 'anti-social' drinkers. These findings have important implications for our understanding of factors influencing drinking behaviour in this group of people, which in turn impacts on the potential design of health-enhancing interventions. The study also demonstrates the usefulness of a discourse analytic approach to accounts of drinking behaviour.

Descriptors and accounts of alcohol consumption: methodological issues piloted with female undergraduate drinkers in Scotland.

Excessive drinking among young women continues to attract adverse media attention and is the target of UK government-led initiatives. Reliable research on alcohol consumption is needed to inform/evaluate public health interventions. This pilot study, investigating descriptors of alcohol drinking in female Scottish undergraduate students, comprised: (i) self-completed questionnaire survey (n = 95) and (ii) interview plus test pouring of a 'drink' (n = 19). Self-reports by 70% of drinkers (n = 90) indicated alcohol consumption for the 'week past' meriting classification as 'binge' drinking, and 83% of this group reported drinking in this fashion at least fortnightly. However, binge drinking may be underestimated since poured drinks were measured to be on average double the alcohol content of a standard drink, drinking often occurred outwith licensed premises and respondents preferred to quantify consumption in (fractions of) bottles, rather than glasses. Qualitative analysis showed that interviewees oriented to drinking as an accountable practice but were unaware of the clinical definition of binge drinking. They defined it in terms of the effect of alcohol consumed on individual behaviour, not in absolute quantities. Given the unreliability of self-reported consumption, future health surveys and initiatives should consider 'quantifying' alcohol in a way more meaningful to the population of interest, in terms of effect.

Reported levels of alcohol consumption and binge drinking within the UK undergraduate student population over the last 25 years.

Results of a literature review of 18 studies investigating the drinking behaviour of undergraduate students at UK universities over a period of 25 years are presented. While comparison between studies is complicated by inconsistencies in the terms employed to describe drinking behaviour, it is concluded that significant numbers of both male and female students are reported to exceed sensible weekly consumption guidelines. Recorded levels of binge drinking among both female and male students are extremely variable between studies. Further research is needed to clarify this position. However, if the most recent research evidence is substantiated, female and male binge drinking levels may exceed those of their peers in the general population and their US counterparts. The reported ramifications of harmful drinking for the health and well-being of students are reviewed. A possible link between poor academic performance and alcohol consumption appears tenuous and merits further investigation. Evidence relevant to the view that the drinking behaviour of female students is changing is considered.