Commentary

Effective public health approaches for alcohol problems target whole populations, or large numbers of people who are drinking “not much too much,” because this is the group in which most of the harm occurs. Most studies support the idea of the “J shaped curve,” where moderate consumption of alcohol reduces mortality because of the reduction in some forms of cardiovascular disease. ¹ This effect is seen in people >50 years of age, and means that reductions in moderately heavy drinking towards “safe” levels may have disproportionate health gains in this group.

The study by Fleming et al targets an appropriate group of people. All are well over 50 years of age (this study is a welcome extension of previous work into elderly populations) and the selection criteria require that they are all drinking “not much too much.” In this sample, the least severely affected are drinking within “safe” limits, and many of them will be the “pre-problem drinkers” that we should be targeting. The sample is heterogeneous, but this is an advantage because it covers most types of potentially harmful drinking.

These patients were recruited through opportunistic screening and subsequently treated in general practice, but the methodology would be applicable in any community setting. The intervention itself is simple, brief, and comfortingly translatable to the “real world.” The results at 1 year are worthwhile, and it will be interesting to see if they are sustained in the longer term. The control group shows that general health advice does not translate into changes in drinking behaviour, and specific advice related to alcohol in the context of the patient's own usage is necessary. Furthermore, in the control group, some evidence showed that “untreated” problem drinking worsened.

This study should encourage primary care workers and community mental health workers to make screening for alcohol use and brief intervention part of the normal package of care. A little goes a long way!