I wish to thank Neil again for having “triggered” that exchange about Drinkaware's results, because it has forced us to review information and realize that “there is something wrong here.”
My reflections come from the exchange we are having and a couple of excellent articles contributed by Ben Nicholls (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6217805/ )
and Peter Jones (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3992896/), and are the following:
We started from doing an exercise, which from the beginning has “the bias” of being a fiction. As we showed up with a high alcohol consumption, and the rest of the answers we filled: never. Which is very unlikely to happen in the real world.
Anyway, I think we have identified a series of “errors”:
1. I begin by venturing to completely rule out “the technical error” in the Drinkaware results and advice.
2. The AUDIT is not a diagnostic tool but a rapid screening tool to be used in a clinical environment (along with other tools), and not at a population level.
Additionally, a diagnosis of alcohol use disorder requires the administration of a validated diagnostic interview, such as the Composite International Diagnostic Interview or evaluation by a trained specialist.
In our discussions we have mixed two different elements: the weekly alcohol consumption limit guide and the AUDIT that evaluates: Risky consumption, Dependence and Harmful consumption.
I want to remind you that to develop an instrument with international applicability, the creators of the AUDIT assumed that a standard drink contains 10 g. of alcohol.
The problem is that there is a divergence in standard drink sizes and recommended levels of low-risk consumption between countries, so the WHO AUDIT User Manual recommended that the AUDIT be adjusted to the alcohol content of the standard drink in the country in which it is used. Only with such an adjustment will the AUDIT total score accurately reflect the amount of alcohol consumed by the patient.
Ben's article (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6217805/), describing the USAUDIT, suggests that most likely the classic WHO AUDIT should be revised. With which I agree.
Apparently, the USAUDIT would provide greater precision in measuring alcohol consumption than the AUDIT and would identify all alcohol consumption above recommended levels, with no false positives and only a few false negatives, so it would seem like an option more rational, and I think it would partially solve our discussion.
3. Drinkaware: So that everyone can draw their own conclusions, I want to dwell on Drinkaware, an institution that presents itself as the “main alcohol charity in the UK”.
The population and global use of the AUDIT tool, by Drinkaware, without properly taking into account the quantities consumed is a “gross error”. Firstly, because the AUDIT was not designed to be used at a “population” level but rather at a clinical level.
From what we saw in the exercise that many of us have carried out, Drinkaware also “forgot” to properly “highlight” the importance of the amount of weekly alcohol consumption, and only puts it in a “small symbol” in relation to the concept of “alcohol units”, which if the user does not click on it will not be clear what is being talked about when talking about units and what the limits are.
On the other hand, the results obtained with high alcohol consumption (42 units) and the resulting advice (low risk), constitute a scandalous way of misinforming the population.
The fact that the original AUDIT did not include the number of units of alcohol per week does not exempt Drinkaware, whose role is to “increase awareness of the risks/harms of alcohol”, from responsibility to provide “appropriate advice, based on scientific evidence”.
As Neil says: “it's a serious case of misinformation.”
I was also annoyed that Drinkaware focuses only on “problem drinking” and “AUD”, leaving out the total amount of alcohol consumed per week. Which is key. The problem of alcohol is not only in “problematic and dependent consumers”, it is necessary to reduce the total amount consumed at the population level if we want to reduce the impact of alcohol on a health and social level.
Drinkaware approach is very much in line with the alcohol industry's discourse: the problem is the “problematic consumer” not the amount of alcohol consumed per capita in each country.
Is Drinkaware “playing into the hands of the industry”? What information is there about it?
As I said before, Peter Jones has shared the following article:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3992896/ where it is clearly reported that Drinkaware is a tool of the alcohol industry:
In 2006, Drinkaware was established as a charity in the United Kingdom following a memorandum of understanding between the Portman Group and various UK government agencies. This debate piece briefly reviews the international literature on industry social aspects organizations, examines the nature of Drinkaware's activities and considers how the public health community should respond.
Although the British addiction field and the wider public health community have distanced themselves from the Portman Group, they have not done so from Drinkaware, even though Drinkaware was devised by the Portman Group to serve industry interests.
Both long-standing and more recent developments indicate very high levels of industry influence on British alcohol policy, and Drinkaware provides one mechanism of influence.
We suggest that working with, and for, industry bodies such as Drinkaware helps disguise fundamental conflicts of interest and serves only to legitimize corporate efforts to promote partnership as a means of averting evidence-based alcohol policies. We invite vigorous debate on these internationally significant issues and propose that similar industry bodies should be carefully studied in other countries.
Therefore, two different types of actions would fit here:
In relation to AUDIT, I think it would be appropriate to have an exchange with the WHO to share with them what the HIFA Forum has identified and ask if they share our same concerns and if they are thinking about “updating” the AUDIT, as the US has done, and what would be the steps for it.
Regarding Drinkaware, I believe that we have to corroborate the evidence of the relationship with the alcohol industry and alert our audiences to avoid using this tool, because it is “misinforming” thousands of people, and putting their health and lives at risk.
What do you think?
Kind regards,
Dr. Eduardo Bianco
Director, Addiction Training Program for Health Professionals (ATHP)
Email: ebianco@nextgenu.org
Web: NextGenU.org
HIFA profile: Eduardo Bianco is a medical doctor and Cardiologist, Certified Tobacco Cessation Expert with a Masters in Prevention and Treatment of Addictive Disorders. Currently, he is Chair of the World Heart Federation Tobacco Expert Group. Dr. Biancos research examines tobacco control and cessation, and he is a prominent member of several organizations that address tobacco control in Latin America. Dr. Bianco has worked for 25 years in Uruguay and Latin America to promote and train in smoking cessation treatment and tobacco control policies. He is also the former Regional Coordinator for the Americas of the Framework Convention Alliance and former Technical Director of the MOH Center for International Cooperation for Tobacco. ebianco@nextgenu.org
