Brief interventions 2.0: a new agenda for alcohol policy, practice and research

Globalization and Health (2024) 20:34 Stewart et al. Globalization and Health https://doi.org/10.1186/s12992-024-01031-1 Open Access DEBATE Brief interventions 2.0: a new agenda for alcohol policy, practice and research Duncan Stewart1* , Mary Madden2 and Jim McCambridge2 Abstract Background Alcohol problems are increasing across the world and becoming more complex. Limitations to international evidence and practice mean that the screening and brief intervention paradigm forged in the 1980s is no longer fit for the purpose of informing how conversations about alcohol should take place in healthcare and other services. A new paradigm for brief interventions has been called for. Brief interventions 2.0 We must start with a re-appraisal of the roles of alcohol in society now and the damage it does to individual and population health. Industry marketing and older unresolved ideas about alcohol continue to impede honest and thoughtful conversations and perpetuate stigma, stereotypes, and outright fictions. This makes it harder to think about and talk about how alcohol affects health, well-being, and other aspects of life, and how we as a society should respond. To progress, brief interventions should not be restricted only to the self-regulation of one’s own drinking. Content can be orientated to the properties of the drug itself and the overlooked problems it causes, the policy issues and the politics of a powerful globalised industry. This entails challenging and reframing stigmatising notions of alcohol problems, and incorporating wider alcohol policy measures and issues that are relevant to how people think about their own and others’ drinking. We draw on recent empirical work to examine the implications of this agenda for practitioners and for changing the public conversation on alcohol. Conclusion Against a backdrop of continued financial pressures on health service delivery, this analysis provokes debate and invites new thinking on alcohol. We suggest that the case for advancing brief interventions version 2.0 is both compelling and urgent. Keywords Alcohol, Global health, Prevention, Health systems, Alcohol policy, Brief interventions Background In an era of restrictions on health budgets and ageing populations, alcohol problems are increasing across the world [1], generating new treatment demand and need for interventions. This is particularly so in low- and middle-income countries (LMICs) where alcohol markets are expanding and harm per litre consumed is greatest *Correspondence: Duncan Stewart 1 School of Social Sciences and Professions, London Metropolitan University, London N7 8DB, UK 2 Department of Health Sciences, University of York, York YO10 5DD, UK [2], whilst within high income countries, alcohol makes health inequalities worse [3]. Substantial mental health comorbidities are increasingly the norm in treatment systems [4], and physical health comorbidities are becoming more visible in older populations [5]. The obvious response to this situation is to make a better case to win more resources, resist cuts and defend what exists. We suggest, however, that this is not enough, and that new thinking is now needed. Health systems struggle to embrace prevention across the board [6]. “Brief interventions” originated in the public health understanding of alcohol. The nature of the challenge has changed in fundamental ways in recent decades, and their limitations are better understood. This makes © The Author(s) 2024. 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The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Stewart et al. Globalization and Health (2024) 20:34 timely a re-appraisal, reconnecting to contemporary public health ideas and evidence. We propose that we should now reimagine the contents and aims of brief interventions, and how they might act in synergy with other efforts to address the avoidable damage done by alcohol. The brief intervention concept A little under half a century ago, the rise of the new public health movement made health promotion and disease prevention central to improving population health. Alcohol was highly relevant to this development. The World Health Organisation brought together alcohol researchers in a major programme that developed the AUDIT screening tool [7] and undertook a randomised trial that demonstrated that it was possible to have conversations with people in primary care that led them to reduce drinking [8]. This represented a new way of responding to alcohol problems; avoiding waiting until treatment for well-established problems was sought. Many of the key research questions identified in a “golden age” of research advances in the late 1980s and early 1990s remain unanswered today [9]. There were theoretical weaknesses in the advice and counselling interventions developed and practitioners did not implement them in routine practice [10]. Much of the available evidence is from high-income countries, with relatively few trials conducted in LMICs [11]. Conflicting findings and the limitations of the large body of international literature have received too little attention [12]. It is perhaps most appropriately interpreted as demonstrating efficacy; recent large trials in naturalistic conditions demonstrate that confident claims of effectiveness are misplaced [12]. As a result, programmes may attain reach, which is itself challenging, but cannot be expected alone to deliver health impacts in populations where they are implemented [13]. The digital alcohol intervention literature has evolved in similar ways, with much promise in early studies, but with near exclusive reliance on selfreported outcomes not routinely included within risk of bias assessments, large trials with different findings than smaller trials, and substantial unexplained heterogeneity in meta-analyses [10]. Over the last 10 years a consensus has taken hold in the field that a change in direction is needed; a chronic disease paradigm is one possibility [14, 15], and more extensive developm (...truncated)