Socioeconomic inequalities in the delivery of brief interventions for smoking and excessive drinking: findings from a cross-sectional household survey in England

Brief interventions for smoking and alcohol associated with the COVID-19 pandemic: a population survey in England

BACKGROUND

Following the onset of the COVID-19 pandemic, in March 2020 health care delivery underwent considerable changes. It is unclear how this may have affected the delivery of Brief Interventions (BIs) for smoking and alcohol. We examined the impact of the COVID-19 pandemic on the receipt of BIs for smoking and alcohol in primary care in England and whether certain priority groups (e.g., less advantaged socioeconomic positions, or a history of a mental health condition) were differentially affected.

METHODS

We used nationally representative data from a monthly cross-sectional survey in England between 03/2014 and 06/2022. Monthly trends in the receipt of BIs for smoking and alcohol were examined using generalised additive models among adults who smoked in the past-year (weighted N = 31,390) and those using alcohol at increasing and higher risk levels (AUDIT score 38, weighted N = 22,386), respectively. Interactions were tested between social grade and the change in slope after the onset of the COVID-19 pandemic, and results reported stratified by social grade. Further logistic regression models assessed whether changes in the of receipt of BIs for smoking and alcohol, respectively, from 12/2016 to 01/2017 and 10/2020 to 06/2022 (or 03/2022 in the case of BIs for alcohol), depended on history of a mental health condition.

RESULTS

The receipt of smoking BIs declined from an average prevalence of 31.8% (95%CI 29.4-35.0) pre-March 2020 to 24.4% (95%CI 23.5-25.4) post-March 2020. The best-fitting model found that after March 2020 there was a 12-month decline before stabilising by June 2022 in social grade ABC1 at a lower level (~ 20%) and rebounding among social grade C2DE (~ 27%). Receipt of BIs for alcohol was low (overall: 4.1%, 95%CI 3.9-4.4) and the prevalence was similar pre- and post-March 2020.

CONCLUSIONS

The receipt of BIs for smoking declined following March 2020 but rebounded among priority socioeconomic groups of people who smoked. BIs for alcohol among those who use alcohol at increasing and higher risk levels were low and there was no appreciable change over time. Maintaining higher BI delivery among socioeconomic and mental health priority groups of smokers and increasing and higher risk alcohol users is important to support reductions in smoking and alcohol related inequalities.

Alcohol and smoking brief interventions by socioeconomic position: a population-based, cross-sectional study in Great Britain

BACKGROUND

Alcohol and smoking brief interventions (BIs) in general practice have been shown to be effective in lowering alcohol and smoking-related harm.

AIM

To assess prevalence of self-reported BI receipt among increasing or higher-risk drinkers and past-year smokers in England, Scotland, and Wales, and associations between intervention receipt and socioeconomic position.

DESIGN & SETTING

Cross-sectional study using data from a monthly population-based survey in England, Scotland, and Wales.

METHOD

The study comprised 47 799 participants (15 573 increasing or higher-risk drinkers [alcohol use disorders identification test consumption score ≥5] and 7791 past-year smokers) surveyed via telephone in 2020-2022 (during the COVID-19 pandemic). All data were self-reported. Prevalence of self-reported BI receipt was assessed descriptively; associations between receipt and socioeconomic position were analysed using logistic regression.

RESULTS

Among adults in England, Scotland, and Wales, 32.2% (95% confidence interval [CI] = 31.8 to 32.7) reported increasing or higher-risk drinking and 17.7% (95% CI = 17.3 to 18.1) past-year smoking. Among increasing or higher-risk drinkers, 58.0% (95% CI = 57.1 to 58.9) consulted with a GP in the past year, and of these, 4.1% (95% CI = 3.6 to 4.6) reported receiving BIs. Among past-year smokers, 55.8% (95% CI = 54.5 to 57.1) attended general practice in the past year; of these, 41.0% (95% CI = 39.4 to 42.7) stated receiving BIs. There was a tendency for patients from socioeconomically disadvantaged backgrounds to receive more alcohol (adjusted odds ratio [aOR] 1.38, 95% CI = 1.10 to 1.73) or smoking BIs (aOR 1.11, 95% CI = 0.98 to 1.26), but for the latter the results were statistically non-significant. Results did not differ notably by nation within Great Britain.

CONCLUSION

BIs in general practice are more common for smoking than for alcohol. A greater proportion of BIs for alcohol were found to be delivered to people who were from socioeconomically disadvantaged backgrounds and who were increasing or higher-risk drinkers.

Who benefits from alcohol screening and brief intervention? A mini-review on socioeconomic inequalities with a focus on evidence from the United States

Alcohol-attributable mortality contributes to growing health inequalities. Addressing hazardous alcohol use and alcohol use disorders through alcohol screening and brief intervention is therefore a promising public health strategy to improve health equity. In this narrative mini-review, we discuss the extent to which socioeconomic differences exist in the alcohol screening and brief intervention cascade, highlighting the example of the United States. We have searched PubMed to identify and summarize relevant literature addressing socioeconomic inequalities in (a) accessing and affording healthcare, (b) receiving alcohol screenings, and/or (c) receiving brief interventions, focusing predominantly on literature from the Unites States. We found evidence for income-related inequalities in access to healthcare in the United States, partly due to inadequate health insurance coverage for individuals with low socioeconomic status. Alcohol screening coverage appears to be generally very low, as is the probability of receiving a brief intervention when indicated. However, research suggests that the latter is more likely to be provided to individuals with low socioeconomic status than those with high socioeconomic status. Individuals with low socioeconomic status also tend to benefit more from brief interventions, showing greater reductions in their alcohol use. Once access to and affordability of healthcare is ensured and high coverage of alcohol screening is achieved for all, alcohol screening and brief interventions have the potential to enhance health equity by reducing alcohol consumption and alcohol-related health harms.

Impact of the cost-of-living crisis on the nature of attempts to stop smoking and to reduce alcohol consumption in Great Britain: A representative population survey, 2021-2022

BACKGROUND

Smoking and excessive drinking place a strain on household budgets. We aimed to examine the impact of the cost-of-living crisis in Great Britain on the nature of smoking cessation and alcohol reduction attempts, and explore changes in health professionals offering support.

METHODS

Data were from 14,567 past-year smokers and high-risk drinkers (AUDIT-C ≥5) participating in monthly representative surveys, January-2021 through December-2022. We estimated time trends in cost as a motive driving the most recent (smoking cessation/alcohol reduction) attempt, use of paid or evidence-based support, and receipt of GP offer of support for smoking cessation or alcohol reduction, and tested for moderation by occupational social grade.

RESULTS

The proportion of attempts motivated by cost did not change significantly over time among smokers (25.4% [95%CI = 23.8-26.9%]), but increased between December-2021 and December-2022 among high-risk drinkers from less advantaged social grades (from 15.3% [95%CI 12.1-19.3] to 29.7% [20.1-44.1]). The only change in support use was an increase in smokers using paid support, specifically e-cigarettes (from 28.1% [23.7-33.3] to 38.2% [33.0-44.4]). Among those visiting their GP, the proportion who received an offer of support was similar over time among smokers (27.0% [25.7-28.2]) and high-risk drinkers (1.4% [1.1-1.6%]).

CONCLUSIONS

There is limited evidence that the 2021/22 cost-of-living crisis affected the nature of attempts to stop smoking and reduce alcohol consumption, or receipt of GP offer of support. It is encouraging that use of evidence-based support has not declined and that use of e-cigarettes in quit attempts has increased. However, cost is increasingly motivating alcohol reduction attempts among less advantaged drinkers, and rates of GPs offering support, especially for alcohol reduction, remain very low.

Relationship Between Educational Level and Attitudes Towards Alcohol Conversations in Healthcare: A Cross-Sectional Survey Conducted in Four European Countries

Objectives: To examine the association between educational level and attitudes towards alcohol conversations in healthcare using population-based surveys of adults in England, the Netherlands, Norway, and Sweden; and to compare attitudes towards alcohol conversations in healthcare between these four countries. Methods: Cross-sectional surveys were conducted amongst adults in the general population in England (n = 3,499), the Netherlands (n = 2,173), Norway (n = 1,208), and Sweden (n = 3,000). Logistic regression analysis was used to examine associations between attitudes towards alcohol conversations in healthcare and educational level, key demographic variables, alcohol consumption, and country of residence. Results: In all four countries, low educational level (p < 0.001) and male gender (p < 0.001) were associated with holding negative attitudes towards discussing alcohol in healthcare. Risky drinkers had more negative attitudes than low risky drinkers towards discussing alcohol in healthcare (p < 0.001) in all countries except England (p = 0.48), and also reported low levels of perceived honesty and confidence in healthcare (p < 0.001). Conclusion: These findings highlight the importance of considering patients' socio-economic status when developing and implementing alcohol prevention interventions in healthcare.

The Moderating Effect of Educational Background on the Efficacy of a Computer-Based Brief Intervention Addressing the Full Spectrum of Alcohol Use: Randomized Controlled Trial

Background

The alcohol-attributable burden of disease is high among socially disadvantaged individuals. Interventional efforts intending to have a public health impact should also address the reduction of social inequalities due to alcohol.

Objective

The aim was to test the moderating role of educational background on the efficacy of a computer-based brief intervention addressing the full spectrum of alcohol use.

Methods

We recruited 1646 adults from the general population aged 18 to 64 years (920 women, 55.9%; mean age 31 years; 574 with less than 12 years of school education, 34.9%) who reported alcohol use in the past year. The participants were randomly assigned a brief alcohol intervention or to assessment only (participation rate, 66.9%, 1646/2463 eligible persons). Recruitment took place in a municipal registry office in one German city. All participants filled out a self-administered, tablet-based survey during the recruitment process and were assessed 3, 6, and 12 months later by study assistants via computer-assisted telephone interviews. The intervention consisted of 3 computer-generated and individualized feedback letters that were sent via mail at baseline, month 3, and month 6. The intervention was based on the transtheoretical model of behavior change and expert system software that generated the feedback letters automatically according to previously defined decision rules. The outcome was self-reported change in number of alcoholic drinks per week over 12 months. The moderator was school education according to highest general educational degree (less than 12 years of education vs 12 years or more). Covariates were sex, age, employment, smoking, and alcohol-related risk level.

Results

Latent growth modeling revealed that the intervention effect after 12 months was moderated by educational background (incidence rate ratio 1.38, 95% CI 1.08-1.76). Individuals with less than 12 years of school education increased their weekly alcohol use to a lesser extent when they received the intervention compared to assessment only (incidence rate ratio 1.30, 95% CI 1.05-1.62; Bayes factor 3.82). No difference was found between groups (incidence rate ratio 0.95, 95% CI 0.84-1.07; Bayes factor 0.30) among those with 12 or more years of school education.

Conclusions

The efficacy of an individualized brief alcohol intervention was moderated by the participants’ educational background. Alcohol users with less than 12 years of school education benefited, whereas those with 12 or more years did not. People with lower levels of education might be more receptive to the behavior change mechanisms used by brief alcohol interventions. The intervention approach may support the reduction of health inequalities in the population at large if individuals with low or medium education can be reached.

Trial Registration

German Clinical Trials Register DRKS00014274; https://www.drks.de/DRKS00014274

Application of a Knowledge, Attitude, Belief, and Practice Model in Pain Management of Patients with Acute Traumatic Fractures and Alcohol Dependence

Objective

To evaluate the outcome of a knowledge, attitude, belief, and practice mode (KABP) in the pain management in patients with acute traumatic fractures complicated with alcohol dependence.

Methods

Twenty-nine alcohol-dependent male patients with acute traumatic fractures and who received surgical treatment between January 2019 and December 2020 were included in this retrospective case-control study. The age range was 30–65 years (average 50.03 ± 7.94). Fracture Type. Six cases of spinal burst fractures and 23 cases of limb trauma fractures. Ten patients were treated with routine nursing (control group), and 19 patients were treated with pain management in KABP mode (experimental group). The control group received traditional pain care, including the conventional numerical rating scale (NRS) pain score system, with focus on symptomatic treatment. On this basis, the experimental group managed pain using KABP, including cognitive behavioral intervention, optimization programs, modification of personal beliefs, and behavior patterns. NRS, self-rated anxiety/depression scale (SAS), and quality of life (SF-36) scale were applied at admission, 1 day before surgery, and 3 months after surgery.

Results

The perioperative NRS score of the KABP group was lower than that of the control group, and the postoperative anxiety levels improved. Discharge satisfaction was significantly higher than that in the control group (p < 0.05). There were behaviors promoting health in the experimental group, and five patients expressed abstinence behavior after discharge (p < 0.05).

Conclusion

Patients with alcohol dependence represents a unique set of cases for perioperative pain management. To ensure patient safety, individualized pain management through the application of KABP can significantly reduce postoperative pain and promote the generation of healthy behaviors in patients.

Social Equity in the Efficacy of Computer-Based and In-Person Brief Alcohol Interventions Among General Hospital Patients With At-Risk Alcohol Use: A Randomized Controlled Trial

BACKGROUND

Social equity in the efficacy of behavior change intervention is much needed. While the efficacy of brief alcohol interventions (BAIs), including digital interventions, is well established, particularly in health care, the social equity of interventions has been sparsely investigated.

OBJECTIVE

We aim to investigate whether the efficacy of computer-based versus in-person delivered BAIs is moderated by the participants' socioeconomic status (ie, to identify whether general hospital patients with low-level education and unemployed patients may benefit more or less from one or the other way of delivery compared to patients with higher levels of education and those that are employed).

METHODS

Patients with nondependent at-risk alcohol use were identified through systematic offline screening conducted on 13 general hospital wards. Patients were approached face-to-face and asked to respond to an app for self-assessment provided by a mobile device. In total, 961 (81% of eligible participants) were randomized and received their allocated intervention: computer-generated and individually tailored feedback letters (CO), in-person counseling by research staff trained in motivational interviewing (PE), or assessment only (AO). CO and PE were delivered on the ward and 1 and 3 months later, were based on the transtheoretical model of intentional behavior change and required the assessment of intervention data prior to each intervention. In CO, the generation of computer-based feedback was created automatically. The assessment of data and sending out feedback letters were assisted by the research staff. Of the CO and PE participants, 89% (345/387) and 83% (292/354) received at least two doses of intervention, and 72% (280/387) and 54% (191/354) received all three doses of intervention, respectively. The outcome was change in grams of pure alcohol per day after 6, 12, 18, and 24 months, with the latter being the primary time-point of interest. Follow-up interviewers were blinded. Study group interactions with education and employment status were tested as predictors of change in alcohol use using latent growth modeling.

RESULTS

The efficacy of CO and PE did not differ by level of education (P=.98). Employment status did not moderate CO efficacy (Ps≥.66). Up to month 12 and compared to employed participants, unemployed participants reported significantly greater drinking reductions following PE versus AO (incidence rate ratio 0.44, 95% CI 0.21-0.94; P=.03) and following PE versus CO (incidence rate ratio 0.48, 95% CI 0.24-0.96; P=.04). After 24 months, these differences were statistically nonsignificant (Ps≥.31).

CONCLUSIONS

Computer-based and in-person BAI worked equally well independent of the patient's level of education. Although findings indicate that in the short-term, unemployed persons may benefit more from BAI when delivered in-person rather than computer-based, the findings suggest that both BAIs have the potential to work well among participants with low socioeconomic status.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01291693; https://clinicaltrials.gov/ct2/show/NCT01291693.

Can alcohol consumption in Germany be reduced by alcohol screening, brief intervention and referral to treatment in primary health care? Results of a simulation study

BACKGROUND

Screening, brief intervention and referral to treatment (SBIRT) is a programme to reduce alcohol consumption for drinkers with high alcohol consumption levels. Only 2.9% of patients in primary health care (PHC) are screened for their alcohol use in Germany, despite high levels of alcohol consumption and attributable harm. We developed an open-access simulation model to estimate the impact of higher SBIRT delivery rates in German PHC settings on population-level alcohol consumption.

METHODS AND FINDINGS

A hypothetical population of drinkers and non-drinkers was simulated by sex, age, and educational status for the year 2009 based on survey and sales data. Risky drinking persons receiving BI or RT were sampled from this population based on screening coverage and other parameters. Running the simulation model for a ten-year period, drinking levels and heavy episodic drinking (HED) status were changed based on effect sizes from meta-analyses. In the baseline scenario of 2.9% screening coverage, 2.4% of the adult German population received a subsequent intervention between 2009 and 2018. If every second PHC patient would have been screened for alcohol use, 21% of adult residents in Germany would have received BI or RT by the end of the ten-year simulation period. In this scenario, population-level alcohol consumption would be 11% lower than it was in 2018, without any impact on HED prevalence. Screening coverage rates below 10% were not found to have a measurable effect on drinking levels.

CONCLUSIONS

Large-scale implementation of SBIRT in PHC settings can yield substantial reductions of alcohol consumption in Germany. As high screening coverage rates may only be achievable in the long run, other effective alcohol policies are required to achieve short-term reduction of alcohol use and attributable harm in Germany. There is large potential to apply this open-access simulation model to other settings and for other alcohol interventions.

Prevalence and correlates of receipt by smokers of general practitioner advice on smoking cessation in England: a cross-sectional survey of adults

BACKGROUND AND AIMS

Advice from a general practitioner (GP) can encourage smokers to quit. This study aimed to estimate the prevalence and correlates of receipt of GP advice on smoking, what type of advice and support was offered and characteristics and quitting activity associated with different types of advice.

DESIGN/SETTING

Data were collected between 2016 and 2019 in a series of monthly cross-sectional surveys of representative samples of the adult population in England.

PARTICIPANTS

A total of 11 588 past-year smokers.

MEASUREMENTS

Participants reported whether they had received advice or offer of support for smoking cessation from their GP in the last year. Socio-demographic and behavioural characteristics and past-year quit attempts and cessation were also recorded.

FINDINGS

One in two [47.2%, 95% confidence interval (CI) = 46.1-48.3%] past-year smokers who reported visiting their GP in the last year recalled receiving advice on smoking, and one in three (30.1%, 95% CI = 29.1-31.1%) reported being offered cessation support. The most common form of support offered was stop smoking services (16.5%, 95% CI = 15.7-17.3%) followed by prescription medication (8.1%, 95% CI = 7.5-8.7%); 3.7% (95% CI = 3.3-4.1%) reported having been recommended to use e-cigarettes. Smokers who were older, non-white, more addicted, and smoked five or more cigarettes/day had consistently higher odds of receiving advice or support. There were some differences by region, housing tenure, presence of children in the home and high-risk drinking in the types of advice/support received. There were no significant differences by sex, occupational social grade, disability, type of cigarettes smoked, or survey year. Advice with any offer of support was associated with higher odds of attempting to quit than advice alone [adjusted odds ratio (ORadj ) = 1.52, 95% CI = 1.30-1.76]. Advice alone was associated with higher odds of quit attempts than no advice in smokers with higher (ORadj  = 1.34, 95% CI = 1.10-1.64) but not lower occupational social grade (ORadj  = 0.90, 95% CI = 0.75-1.08).

CONCLUSIONS

In England, a minority of smokers receive support from their GP to stop smoking. Those who do are more likely to be older, non-white and more addicted to cigarettes. Advice plus offer of support appears to be associated with increased odds of making a quit attempt, while advice without offer of support appears only to be associated with increased odds of making a quit attempt in higher occupational social grade smokers.

Computerized Clinical Decision Support System for Prompting Brief Alcohol Interventions with Treatment Seeking Smokers: A Sex-Based Secondary Analysis of a Cluster Randomized Trial

Although brief alcohol intervention can reduce alcohol use for both men and women, health care providers (HCPs) are less likely to discuss alcohol use or deliver brief intervention to women compared to men. This secondary analysis examined whether previously reported outcomes from a cluster randomized trial of a clinical decision support system (CDSS)-prompting delivery of a brief alcohol intervention (an educational alcohol resource) for patients drinking above cancer guidelines-were moderated by patients' sex. Patients (n = 5702) enrolled in a smoking cessation program at primary care sites across Ontario, Canada, were randomized to either the intervention (CDSS) or control arm (no CDSS). Logistic generalized estimating equations models were fit for the primary and secondary outcome (HCP offer of resource and patient acceptance of resource, respectively). Previously reported results showed no difference between treatment arms in HCP offers of an educational alcohol resource to eligible patients, but there was increased acceptance of the alcohol resource among patients in the intervention arm. The results of this study showed that these CDSS intervention effects were not moderated by sex, and this can help inform the development of a scalable strategy to overcome gender disparities in alcohol intervention seen in other studies.