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Cunningham J.A., Wild C., Cordingley J. et al.
Alcohol & Alcoholism: 2010, 45(3), p. 258–262.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Cunningham at John_Cunningham@camh.net.
With other similar work, this Canadian study suggests that internet-based programs which offer feedback to the user on their drinking in relation to the population and on the risks they may be running can lead to drinking reductions of the same order as face-to-face advice.
Summary This account also draws on an earlier report of results from the study up to six months after the intervention.
Ideally interventions to address risky drinking would be accessed freely on the user's initiative wherever and whenever they chose. The internet makes this possible for the rising numbers with home access. Internet-based interventions may never be as effective as a face-to-face encounter with a skilled clinician, but in reality most problem drinkers will never receive this sort of help; the internet is a readily accessible alternative.
Conducted in Ontario in Canada, unlike most previous trials the featured study sought to replicate the conditions under which internet interventions would normally be used: by adults from the general population without face-to-face guidance, in their own homes or wherever else they chose. It drew its sample from a telephone survey which (among other things) collected information about the respondent and their drinking from a large, randomly selected sample of Ontario adults. Respondents drinking in a risky manner Score of 4 or more (out of a possible 12) on the three consumption items from the Alcohol Use Disorders Identification Test (AUDIT), a subset of questions known as AUDIT-C. The questions were about frequency and typical intensity of drinking and how often the respondent drinks five or more Canadian standard drinks (68g alcohol or 8.5 UK units) at one sitting. according to the three questions (typical frequency and intensity of drinking and frequency of 'binge' drinking) which form the AUDIT-C survey were asked if they were interested in internet programs which would check their drinking and compare it to that of other Canadians. Interested respondents with home internet access were then asked if they wanted to be mailed details of a study they could join to help develop such a program. In all 397 were sent the details, of whom 185 joined the study and completed the full AUDIT screening survey intended to identify risky drinkers. They also reported their alcohol consumption during a typical week. Participants averaged 40 years of age and nearly half were women. Most were well educated and employed and used the internet daily.
About half the 185 participants were randomly allocated to have password access to the Check Your Drinking program and asked to visit the web site which hosted the program. Completing the program took about 10 minutes. It offered users a personalised drinking profile consisting of charts comparing their drinking to people of the same age, sex and nationality, plus a summary of the severity of their drinking problems. Reminders were sent to anyone who did not access the program within a month. The other half of the sample formed a control group A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar participants for each group. against whom to benchmark the impacts of the program. They were simply sent a non-personalised list of the types of information offered by the program and asked to consider which might be useful. Three, six and 12 months later, all participants were sent a survey form on which to record their impressions either of the site or of the information components and to record their current drinking patterns. At each time point around 9 in 10 responded, Everyone in the baseline sample was included in the analyses regardless of whether they had supplied follow-up data. Those who had not were assumed to still be drinking as they were before the study started. and 86% responded to all three surveys.
Just over 60% of the program-access group actually logged on to the program, but the analysis included everyone offered access regardless of whether they took up the offer. As hoped, at three and six months after the start of the study, they had reduced their AUDIT-C scores and their typical weekly alcohol consumption by significantly more On both measures the trends over the follow-up period to six months differed to a statistically significant degree between the groups. than the control group – a finding entirely due to the 39% of the sample whose high AUDIT scores indicated that they were problem drinkers. Score on the full AUDIT of 11 or more, a suggested cut-off score indicative of problem drinking which divided in half the part of the sample drinking above levels recommended by US authorities as appropriate for brief intervention. Only among this sub-sample did the two indicators of the severity of drinking fall to a statistically significant (if modest) degree after being offered access to the program. For example, consumption fell on average by 10 UK units 82g alcohol. a week from a baseline figure of 38 units 306g alcohol. a week. In contrast, drinking levels remained essentially unchanged among the no-access control group. But after a further six months – 12 months in total after the intervention – the advantage gained by offering access to the program had dissipated; there were no longer statistically significant differences between the groups, even when the comparison was confined to problem drinkers chart.
Given the featured study's findings, those from other randomised trials of the same intervention, and research on similar interventions which compare a drinker's intake to population norms (so-called 'normative feedback'), the authors concluded that that these types of interventions do curb excessive drinking, at least in the short term. Delivered over the internet, they could contribute to the welfare of problem drinkers of the kind unlikely to access face-to-face treatment. No one intervention will be ideal and appropriate for all problem drinkers. Very brief interventions like the one tested in the featured study could form one pole of an array of internet-based options encompassing more extensive programs derived from cognitive-behavioural therapies, which lend themselves to computerisation. But it is important to acknowledge that despite being pre-filtered And it might be added, despite being sent a reminder if they failed to access it within a month. for their interest in the program, many in the featured study did not access it when given the opportunity; providing access does not guarantee use.
commentary Despite the caveats identified by the authors, this study is at least as convincing as other studies generally accepted as indicative of the effectiveness of the interventions they tested. With some other work, it suggests that internet-based programs which offer feedback to the user on their drinking in relation to the population and on the risks they may be running can have a short-term (up to six months) impact on drinking. It seems entirely possible to seek to extend this impact by offering an e-mail reminder service to visitors to re-check their drinking every few months.
Though only a minority of site visitors may sign up for web-based alcohol programmes, nevertheless the numbers engaged can be very large, and the risk-reductions seem of the order typical in studies of face-to-face advice to drinkers identified in health care settings. In health settings screening programmes typically identify people who are not actually seeking help for drinking problems, 'pushing' them towards intervention and change, while web sites 'pull' in people already curious or concerned about their drinking. As such these two gateways can play complementary roles in improving public health and offering change opportunities to people who would not contact alcohol treatment services. However, in Britain and elsewhere, both tactics reach only a small fraction of the risky-drinking population, leaving the bulk of the public health work to be done by interventions which drinkers generally cannot avoid and do not have seek out, such as price increases and availability restrictions.
High follow-up rates, the methodological rigour of a well conducted randomised trial, and the inclusion of every participant in the analysis regardless of whether they used the program or supplied follow-up data, all lend credence to the findings – but only as they apply to this small, highly self-selected and possibly unrepresentative set of participants. As the authors acknowledged, generally internet programs will be accessed on their own initiatives by people who are at least concerned about their drinking and possibly actively seeking help, yet the featured study instead actively recruited people not seeking help, whose explicit motivation was to contribute to the development of an alcohol program rather than to use it. Of the 2746 risky-drinking respondents identified by the initial survey, just 30% were interested in on-line alcohol programs and in the end just 7% (the 185-strong baseline sample) joined the study. Having gone through several hoops to reach this point, it seems likely that they were a distinctive population motivated to comply with research procedures. Certainly they were considerably younger, better educated and more prosperous than the people who were not interested in on-line alcohol programs.
The participants' commitment to the research seemed reflected in the large proportion prepared to repeatedly supply follow-up data, a major contributor to confidence in the validity of the findings. The main remaining doubt is whether, having been confronted with their abnormally excessive drinking relative to the general population, problem drinkers in the program-access group later understated their continued drinking. Any such tendency should have been minimised by the fact that there was no face-to-face contact with therapists or researchers which might lead participants to feel they had to show they had responded to the program's messages. One gap in the data reported by the study is that we have no indication of the AUDIT-C scores at 12 months – just that they did not differ significantly between program-access and control groups. It leaves open the possibility of a counterproductive trend in the data.
The featured study adds to a small literature suggesting that such interventions can reduce drinking. Its most important predecessors were a pair of Dutch studies. The first was a randomised trial similar to the featured study, which established that in tightly controlled conditions, an internet-based self-help intervention (one considerably more extensive than in the featured study) did reduce drinking. A subsequent 'real world' study established that similar drinking reductions were seen when the intervention was made freely available to the general public. As in the featured study, a major question was whether the results would apply outside of a research context and in particular with people of the kind who decline participation in research. The featured study throws up another concern: whether the drinking reductions seen six months post-intervention in both the randomised and the real-world study would have dissipated by 12 months.
A review of computer-based alcohol services for the general public has rehearsed the advantages: immediate, convenient access for people (the majority in developed nations) connected to the internet; consequently able to capitalise on what may be fleeting resolve; anonymous services sidestep the embarrassment or stigma which might deter help-seeking; such services are available to people unwilling or less able to talk about their problems to a stranger; generally they are free and entail no travel costs or lost income due to time off work; very low operating cost per user if widely accessed; easily updated. In consumption terms, the drinking problems of web site users are comparable to those of drinkers who seek treatment, yet few have received professional help, perhaps partly because their higher socioeconomic status and greater resources have enabled them to restrict the consequential damage. People who actually engage with web-based assessments of their drinking problems have more severe problems than those who just visit and leave. Including the randomised trial which paved the way for the featured study, the review found eight studies which evaluated the effectiveness of computer-based interventions for the general public. In all but one the users significantly improved on at least one of the alcohol-related measures recorded by the studies.
A particular role for alcohol self-help sites may be to offer an easy, quick and accessible way for drinkers to actualise their desire to tackle their problems, especially when that desire is allied with the resources to implement and sustain improvements without face-to-face or comprehensive assistance. After conducting the Project MATCH trial, some of the world's leading alcohol treatment researchers argued that "access to treatment may be as important as the type of treatment available". The implication is that in cultures which accept 'treatment' as a route to resolving unhealthy and/or undesirable drinking, having convincing-looking and accessible 'treatment doors' to go through may be more important than what lies behind those doors, as long as this fulfils the expectations of the client or patient. This is likely to be especially the case for people who retain a stake in conventional society in the form of marriages, jobs, families, and a reputation to lose. These populations – the kind attracted to self-help alcohol therapy web sites – have more of the 'recovery capital' resources needed to themselves do most of the work in curbing their drinking.
The best known British alcohol self-help web site is the Down Your Drink site run by a team based at University College London, an initiative originally funded by the Alcohol Education and Research Council and now by the Medical Research Council's National Prevention Research Initiative. In 2007 this was revised to offer a menu of programmes from a one-hour brief intervention to several weeks, but also to generally give the user greater control over the use they made of the site. The approach remained based on principles and techniques derived from motivational interviewing and cognitive-behavioural therapies.
The previous version had been structured as six consecutive modules to be accessed weekly. An analysis of data provided by the first 10,000 people who registered at the site after piloting ended in September 2003 revealed that most were in their 30s and 40s, half were women, nearly two-thirds were married or living with a partner, just 4% were unemployed, and most reported occupations from higher socioeconomic strata. As an earlier study commented, site users were predominantly middle class, middle aged, white and European. Six in 10 either did not start the programme, or completed just the first week. About 17% completed the six weeks. Of these, 57% returned an outcome questionnaire. Compared to their pre-programme status, on average they were now at substantially lower risk, functioning better, and living much improved lives. The sample had been recruited over about 27 months, a registration rate of about 4500 a year. By way of comparison, in England during 2008/09, around 100,000 adults were treated Statistics from the National Alcohol Treatment Monitoring System (NATMS) 1st April 2008 – 31st March 2009. Department of Health and National Treatment Agency for Substance Misuse, 2010. for their alcohol problems at conventional services. User profile and site usage had been similar during the earlier pilot phase. Results from surveys sent to pilot programme completers indicated that three quarters had never previously sought help for their drinking.
Thanks for their comments on this entry in draft to John Cunningham of the Centre for Addiction and Mental Health in Toronto, Canada. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 23 August 2010
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