Alcohol and Alcoholism Advance Access originally published online on November 22, 2005
Alcohol and Alcoholism 2006 41(1):76-83; doi:10.1093/alcalc/agh241
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BRIEF INTERVENTION IN ALCOHOL-POSITIVE TRAFFIC CASUALTIES: IS IT WORTH THE EFFORT?
1 Public Health Agency, Barcelona, Spain and 2 University Hospital Vall d'Hebron, Trauma Area, Barcelona, Spain
* Author to whom correspondence should be addressed at: Agència de Salut Pública, Pl Lesseps, 1, 08023-Barcelona, Spain. Tel.: +34 93 238 45 45; Fax: +34 93 217 31 97; E-mail: amartos{at}aspb.es
(Received 15 July 2005; first review notified 7 September 2005; in final revised form 14 October 2005; accepted 24 October 2005)
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Aims: This study aimed at testing the effectiveness of a brief motivational intervention (BI) compared with a minimal intervention (MI) for reducing alcohol consumption in adult, alcohol-positive traffic casualties. Methods: Patients were recruited at the emergency room of a trauma hospital and screened for alcohol by a qualitative saliva test (positive from a blood alcohol concentration of 0.02 g/l). Positive patients (13.3%) who accepted entering the study were randomly allocated into BI and MI. Baseline assessment was the same for all patients. Blind telephone follow-ups were performed at months 3, 6, and 12, and results were analysed by protocol and by intention-to-treat analysis. Results: After 1 year of follow-up, 67% of the patients had reduced their consumption, the percentage of heavy drinkers had dropped by 47%, and 62% of baseline AUDIT-C positive patients (hazardous drinkers) had become negative. Binge drinking dropped significantly (P < 0.05). Results at month 12 were in line with the previous ones. Conclusions: The effectiveness of BI compared with MI has not been verified, but a significant reduction in consumption has been observed in the whole sample, without significant differences by type of intervention. The persistence and dimension of changes suggest a real effect of both interventions, although the lack of a pure control group does not allow definitive conclusions. Traffic casualties are in a teachable moments to benefit from easy and cheap interventions.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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There is overwhelming evidence on the role of alcohol in traffic crashes, considered to be one of the leading causes of unintentional injuries and avoidable mortality. The probability of drunken driving increases with the amount of consumption and frequency of heavy drinking occasions (Midanik et al., 1996
). There is more probability of drinkers being admitted in an emergency service because of injuries (Cherpitel, 1988) and people admitted with accident injuries are more likely to be under the effects of alcohol than non-injury admissions (MacDonald et al., 1999). Presenting with a positive blood alcohol concentration (BAC) is the best indicator of hazardous consumption among injured patients (Savola et al., 2004). There is a positive correlation between drinking within the 6 h prior to the injury and being admitted because of a traumatic crash (McLeod et al., 1999).
Emergency departments and trauma centres are considered to be in a privileged position to screen and deliver opportunistic brief interventions (BIs) aimed at reducing risks in heavy non-dependent drinkers who would not usually ask for care nor accept a traditional treatment. The aversive experience of a motor vehicle crash represents a ‘teachable moment’ and the post-traumatic acute period is in itself the best ‘window of opportunity’ (Waller, 1990) for educational interventions. The accident has been considered to be a powerful motivating factor and should be used for making the patient aware of the relationship between alcohol and injury, and to advise a change (Longabaugh et al., 1995).
The effectiveness of BI in reducing the alcohol consumption has been shown in primary care (Bien et al., 1993; Ballesteros et al., 2004) and in other settings, including emergency departments and trauma centres (D'Onofrio and Degutis, 2002), where different types of BI, from a brief negotiating interview (D'Onofrio et al., 1998) to BI followed by booster sessions (Longabaugh et al., 2001, Mello et al., 2005), have been tested.
Although there is no meta-analysis on BIs at accidents and emergency departments to enable clear conclusions, most studies show a significant drop in consumption compared with baseline. Compared with controls, in some cases, there is a significant reduction in consumption (Gentilello et al., 1999; Spirito et al., 2004) and in consequences (Gentilello et al., 1999; Monti et al., 1999; Longabaugh et al., 2001; Mello et al., 2005).
The main aim of the study was to verify the effectiveness of BI compared with minimal intervention (MI) for cutting down on alcohol consumption in adult traffic casualties presenting with a positive BAC (
0.2 g/l) and without alcohol dependence. A complementary aim was to ascertain the possible reduction of alcohol-related trauma following the intervention at 1 year time.
Our main hypothesis was that people injured in an alcohol-related crash might reduce their alcohol consumption or at least stop driving under its influence, if they receive a motivational BI shortly after the deterrent event of the alcohol-attributable crash. BI should be more effective for a stable recovery (reduction in consumption at 1 year) than MI.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Study design
This is a prospective random control study, where the experimental group received a BI and the control group, an MI of simple advice. A pure control group (with no intervention) was not included not only for ethical reasons, but also because previous studies account for the efficacy of opportunistic BIs in general.
The study was conducted over 18 months, between 2001 and 2003, at the emergency room of a level I trauma centre, with the approval of the hospital Ethics Committee and the informed consent of the participating patients.
Studied sample
Patients eligible for screening were 18 year-olds (drivers, passengers, and pedestrians) attending the emergency department because of a traffic crash taking place within 6 h prior to admission. The inclusion criterion consisted of having a positive alcohol test (BAC 0.2 g/l). Exclusion criterion was the fact of being unable to be interviewed or followed-up (reasons being not speaking Spanish, non-residents, very severe medical, psychiatric, or social conditions). Clinical alcohol intoxication, which was seldom, was only a transient exclusion criterion, as the patients could be interviewed once they had clinically recovered. Patients with an AUDIT (Alcohol Use Disorders Identification Test) score of 15 should be referred, after intervention, for further diagnosis and treatment, and excluded from the effectiveness analysis.
Protocol and research procedures
Nursing and social work staff were trained at a 5-h workshop on BI (concepts, model of change, motivational approach) including theory and role-playing. The feasibility of the project design was tested in a pilot study (Rodríguez-Martos et al., 2001), and its execution, including the quality of the interventions, was regularly supervised throughout the study.
Screening was routinely performed, mainly in saliva using the Alcohol-On-Site test, an enzymatic, qualitative reagent which reads positive from a BAC of 0.2 g/l, and has no legal value. Positive patients (inclusion criteria) who did not show exclusion criteria were offered the chance to enter the study. After informed consent they were randomly assigned (by weeks) to BI or MI. Evaluation and counselling were performed mainly on an outpatient basis (73%), before discharge, or at the surgical ward, in cases of admission. If the patient was clinically intoxicated, the procedure was postponed (in case of delayed discharge or hospitalization) or cancelled (discharge before becoming sober). The patient's assessment was performed by several questionnaires and scales: AUDIT and AUDIT-C, Attribution of Injury Scale and Readiness Ruler, and an ad hoc inventory exploring behaviours such as drinking before the event and other traffic crashes. A guide for the interventions, together with support materials was given to the participating nurses. All patients were given an information leaflet, and, in the case of BI, a self-help one too.
The AUDIT (Saunders et al., 1993) is a screening questionnaire capable of identifying from hazardous to dependent drinkers through its 10 items which explore consumption (1–3), alcohol problems (7–10), and dependence (4–6). The cut-offs for the Spanish version (Rubio et al., 1998) in this study are 8 for males and 6 for females. The short form, AUDIT-C (Bush et al., 1998), is made up of the consumption items (item 1 explores frequency; item 2, usual quantity, and item 3, frequency of bingeing). Its cut-offs for the Spanish version (Gual et al., 2002) are 5 for males and 4 for females. It was important to measure the consumption items alone (AUDIT-C) at baseline because they were also used to measure the alcohol consumption during the follow-up.
The Attribution of Injury Scale (Longabaugh et al., 1995) measures the attribution of injury to alcohol (range from 1 ‘not at all’ to 7 ‘totally’). The Readiness Ruler (D'Onofrio et al., 1998) measures the preparation for change (range from 1 ‘not ready’ to 10 ‘ready’).
BI, delivered in 15–20 min, is based on the model of change (Prochaska and DiClemente, 1986) and the principles of motivational interviewing (Miller and Rollnick, 1991), and includes the active elements known as FRAMES (feedback, responsibility, advice, menu, empathy and self-efficacy). After feedback, patients were invited to think about the good and bad things derived from their alcohol consumption, make a balance and draw their own conclusions. Patients were given support material, designed to back up the patient's process from contemplation to decision making. MI was delivered in 
5 min, and limited to empathic advice, after comparing the evaluated behaviour with the advisable one. Patients received an information leaflet. Assessment was common to both interventions.
Follow-ups were performed blind by phone at months 3, 6 and 12, exploring the consumption (AUDIT-C) referred to the previous month. At month 12, new traffic events were also recorded. Figure 1 summarizes the study protocol.
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Outcome variables and statistical analysis
Sample size for a statistical significance of 5% and power of 90% was calculated considering a yearly turnover of 4000 traffic casualties at the emergency department, an expected 30% of positive BAC, making up a maximum of 1000–1500 eligible subjects. Refusals and exclusions might reduce the sample to 750–1125 patients. Considering 45% lost-to-follow-up in the worst of cases, the final sample should have been of 200 patients in each group.
The changes in consumption were calculated taking the baseline values of the patients followed-up, at every control, as a common denominator. The following outcomes were evaluated: changes in AUDIT-C score (percentage of patients who reduced, and amount of the reduction), changes in the percentage of patients with a hazardous consumption (AUDIT-C positive), and percentage of patients who, having scored as hazardous drinkers (AUDIT-C positive), did not belong to this category anymore. The score in AUDIT-item 3 (binge drinking) was also independently measured. Concerning accidents, their incidence in the year before the study inclusion was compared with that of the follow-up year. Study results were analysed at each control (month 3, 6, and 12) by protocol (PP) (considering the number of followed-up patients). At 1 year time, results were also analysed by the intention-to-treat principle (ITT), so that all intervened patients were evaluated, regardless of whether followed up or not. In patients who did not have the 12-month follow-up, data of the last available follow-up were used; where there was no follow-up at all, baseline data were used, which was the most frequent case (86%) among lost patients. Therefore, our ITT analysis is close to the ‘worst case’ option proposed by Wutzke et al. (2002).
Quantitative variables were described by the mean and its 95% confidence interval (CI), in the case of a normal distribution, and by the median and its interquartile range (IQR), for a non-normal distribution.
Quantitative variables were analysed by the t-test, Pearson's correlation coefficient, and by the Mann–Whitney test for independent groups and the Wilcoxon test for paired data, as non-parametric tests. For evaluating qualitative variables, the Chi-Square-test and the McNemar test for paired data were used. Comparisons of two dichotomic variables were described by odds ratios (ORs) and their 95% CI. P-values <0.05 were considered significant and all tests of significance were two-tailed. The statistical data analysis was performed with the SPSS 10.0 package.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Traffic casualties numbering 1106 were detected during the enrolment period. Of these, 971 were eligible and 948 could be screened for alcohol. Only 19 patients refused screening, and most of the patients not screened were due to ‘logistic reasons’ (overload of work, early discharge, etc). Eligible patients were mainly men (69.5%) and drivers (67.2%), and their median age was 27 years (IQR: 22–36). The screened sample was homogeneous compared with the eligible but not screened one. One hundred and twenty six patients were alcohol-positive [13.3%, 95% CI (11.1–15.5)]. Being BAC-positive was statistically and independently associated with males [OR = 2.5, 95% CI (1.3–5.4)], hospital admission [OR = 2.7, 95% CI (1.3–5.4)], attending the emergency room at the weekends [OR = 3.7, 95% CI (2.0–6.9)], and being admitted during the night shift [OR = 4.6, 95% CI (2.0–10.3)], or on ‘bank holidays’ or Sunday mornings [OR = 3.6, 95% CI (1.5–8.4)] (Martínez et al., 2004
).
Of the 126 BAC-positive patients, 85 could receive the intervention. Intervened and non-intervened patients were homogeneous, except for their mean age (26 vs 29 years). Main reasons for not delivering the intervention were again logistical, such as discharge or transfer to another hospital before having had the time or opportunity to deliver the intervention (46%). Patients were randomly distributed by weeks into BI (40) and MI (45), and both groups were homogeneous concerning demographic and evaluation data. The study sample was mainly made up of men (88%), with a median age of 26 (IQR: 21–33), mostly drivers (63.5%) and not in need of inpatient care (67% were discharged after some hours). Half of them scored positive in AUDIT (48%) and in AUDIT-C (54%). Eight patients scored 15 in AUDIT (none scoring 4 in the dependence items) and five were referred for further diagnosis/treatment. Fifty seven percent of the patients attributed the injury to alcohol, at least to some extent (median 2, on the Attribution of Injury Scale, ranging from 1 to 7). Seventy five percent of patients were considering change or were ready to change their alcohol consumption (median 7, on the Readiness Ruler, scoring from 1 to 10). See Table 1.
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At month 12, 67% of the sample could be followed-up; these patients were homogeneous compared with those lost-to-follow-up. Figure 2 shows the flowchart of the study participants.
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No followed-up patient with a baseline
15 AUDIT score (six patients) had to be analysed apart, as none of the three who had been referred had attended other facilities nor scored positive in the dependence items. Sixty seven percent of patients had reduced their alcohol intake (PP analysis), without significant differences by type of intervention [OR = 1.11, 95% CI (0.37–3.35)]. According to the ITT analysis, 47% had reduced consumption, without significant differences by group of intervention [OR = 1.5, 95% CI (0.6–3.6)]. See Table 2.
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The percentage of AUDIT-C positive patients had dropped 47% (60% vs 32%, P < 0.05) 1 year after the intervention (PP), without significant differences by type of intervention, and 62% of the patients, who had scored as hazardous drinkers (AUDIT-C positive) at baseline and were followed-up at month 12, had become negative, again without significant differences by type of intervention. According to the ITT analysis, the percentage of hazardous drinkers had dropped 35.2% (54% vs 35%, P < 0.05), and 50% of former AUDIT-C positive patients had become negative.
The AUDIT-C score, as well as item 3 score independently considered, significantly dropped between baseline and month 12 (1.13 vs 0.77, P < 0.05), without differences by type of intervention. The mean amount of reduction (PP) was of 1.53 points in the AUDIT-C (23%) for the whole followed-up sample. This size was significantly larger among patients who scored positive than among those who scored negative in AUDIT at the study entrance (2.32 vs 0.58, P < 0.05) and/ or AUDIT-C (2–18 vs 0.57, P < 0.05). Among patients who reduced, the mean amount of reduction was 2.89 points (56%) in both groups of intervention. The ITT analysis shows a similar change (20%) and reduction (53%) rate.
Figure 3 shows the evolution of patients at 1 year time, by type of intervention group and by type of statistical analysis (PP or ITT), according to the main study parameters: (i) percentage of patients who reduced, (ii) percentage of patients who become AUDIT-C negative after having been positive at baseline, (iii) the mean reduction, considering the whole sample (those who increased, did not change or reduced), and (iv) the mean reduction among those who reduced.
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These data confirm the trend shown throughout the study, in transversal cuts at month 3, 6 and 12 and not necessarily with the same patients (see Table 3). Altogether, there was an early abrupt drop in consumption at month 3, sustained over the whole study period. The percentage of AUDIT-positive patients significantly (P < 0.05) decreased from baseline to month 3 (54.1% vs 31.6%), to month 6 (54.1% vs 31.4%), and to month 12 (54.1% vs 31.6%), without differences by type of intervention. There was also a significant decrease in consumption measured by the AUDIT-C score (4.9 vs 3.4, P < 0.05). The percentage of patients who reduced was 74% at month 3, 60% at month 6 and 67% at month 12 (see Table 3).
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Patients who had been followed up at month 3, and 6 and 12 (N = 45), showed a drop in AUDIT-C score, always significant compared with baseline (5 vs 3.6, 5 vs 3.7, and 5 vs 3.8, respectively; P < 0.05), without differences by type of intervention.
The AUDIT consumption items developed in the sense of a reduction both in amount and frequency of the alcohol intake. Binge drinking (item 3), which is strongly related to the injury risk (McLeod et al., 1999), dropped significantly from baseline to month 3 (1.1 vs 0.8, P < 0.05) and month 12 (1.1 vs 0.8, P < 0.05).
The PP analysis showed a significant association between a positive AUDIT/AUDIT-C score, at baseline, and an improvement in all the study outcomes at months 3 and 6. At month 12, the differences fell short of statistical significance in the PP analysis, but were statistically significant in the ITT analysis (see Table 2).
Concerning traffic accidents, 35% of the sample followed up at month 12 had suffered another crash in the year preceding the study entrance, and 14% had suffered a new accident in the year following the study entrance. This means a 60% (P < 0.05) drop in the accident rate during the follow-up period. This measure was not related to any other outcome variable.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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This is the first study on early identification and BI in an emergency department in Spain. Other studies have been performed in the emergency and trauma setting, but only three have concentrated on motor vehicle crashes (MVC) (Sommers et al., 2001
; Runge et al., 2002; Mello et al., 2005), and only the latter and ours have worked mainly at the ER.
The results are referred to adult traffic casualties who entered the emergency room with a positive BAC (inclusion criteria) within the 6 h after the crash. Half of them were also identified as hazardous drinkers by the AUDIT, which underlines the fact that being admitted with a positive BAC means a predictive factor of alcohol problems (Savola et al., 2004). Most of them contemplated, or were ready, to change.
The hypothesis of the study on the effectiveness of BI compared with MI has not been verified, maybe because of the small study sample and insufficient statistical power.
The overall reduction in consumption shown in previous analyses of the study (Rodríguez-Martos et al., 2003, 2005) was anyway confirmed: almost 70% of casualties had reduced consumption compared with baseline, the percentage of hazardous drinkers had dropped 47%, and 62% of the former hazardous drinkers (AUDIT/AUDIT-C positive) had become negative. Those who reduced, had halved their intake and the whole sample of patients had significantly (P < 0.05) reduced binges. There was a significant superiority of results by type of patient (AUDIT/AUDIT-C positive or negative), hazardous drinkers benefiting significantly more from any intervention, but not by type of intervention.
At 1 year time, patients who received a BI had not developed better than those receiving a MI. Assuming the effectiveness of BIs in general, repeatedly shown by research, we also might conclude that BI and MI work the same. This was also the conclusion reached by Forsberg et al. (2000), comparing the two types of intervention. The lack of differences between BI and MI, both effective compared with controls, had already been reported by Babor and Grant (1992). Nevertheless, in the absence of non-intervened controls, it could be argued that the results might also be attributed to chance, a regression toward mean, the deterrence effect of the crash, the assessment after the injury, or if they mean a real effect of any specific intervention on somebody who has just undergone an aversive event. The difficulty of disaggregating effects has been mentioned earlier (Sommers et al., 2005). In studies performed at the emergency department the reduction of consumption after the intervention is usually significant for the global sample of injured patients, compared with baseline, especially in the short-term (Cuijpers et al., 2004), although the spontaneous trend among non-intervened patients (Dunn et al., 2003) is to return to baseline or surpass it, while the experimental group maintains or increases the reduction over time (Gentillelo et al., 1999). In some studies with no differences between experimental and control group (standard care), the latter had received advice on alcohol (Monti et al., 1999; Spirito et al., 2004).
In the current study, the persistence and dimension of changes, both in the PP and in the ITT analysis, suggest a real effect of both BI and MI after the crash. Significant differences compared with controls have mainly been reported for extended vs one-time intervention (Longabaugh et al., 2001; Mello et al., 2005) or for interventions on subjects identified as hazardous or harmful drinkers (Gentillelo et al., 1999; Cuijpers et al., 2004; Spirito et al., 2004). In our study, baseline hazardous drinkers (AUDIT/AUDIT-C positive) had significantly better results than those who had scored negative, meaning that patients who reduced were those who really needed to. The percentage of patients who reduced consumption was significantly (P < 0.05) higher among outpatients than inpatients, questioning the idea of severe long-term hospitalized patients being more motivated to change (Sommers et al., 2005).
Concerning the reduction in new crashes, although patients reduced 60% their accident rate compared with the year prior to the study entrance, chance cannot be ruled out when samples are small, official data are not accessible and follow-up does not cover more than 1 year (Dinh-Zarr et al., 2004).
Limitations
The control group in this study also received an intervention (MI) for ethical reasons and, the effectiveness of BIs in general was assumed, because the aim was mainly to verify the superiority of BI vs MI. However, the backlash of this design is that it precludes definitive conclusions on the effectiveness of interventions compared with no intervention (pure control).
The small sample size, lower than that foreseen for a sufficient statistical power, does not allow discarding significant differences as a bigger sample would.
This low size is partly due to the low percentage of BAC-positive cases, much lower than expected, according to the literature, but coincident with a substancial drop in the prevalence of alcohol-positive crashes in the city.
The percentage of follow-up at 1 year time was lower than advisable, although homogeneity between lost and followed-up patients and the intention-to-treat analysis could compensate for the attrition bias (Wutzke et al., 2002). Low follow-up rates, even lower than ours, are frequent in emergency room studies, and constitute one of the handicaps met by research in this setting. A pioneer study in this field (Gentilello et al., 1999) followed up 54% of patients at 1 year. Nevertheless, it has to be admitted that the low follow-up rate together with the small sample size in this study constitute its major weakness.
The lack of factual information might call into question the credibility of the self-report, although other studies have shown the concordance between the AUDIT score obtained by patients and relatives (Donovan et al., 2004). Moreover, any information bias should have rather affected the baseline data (fear of legal consequences) more than the follow-up information and would have resulted in smaller changes in consumption.
In conclusion, this study shows a sustained reduction in alcohol consumption in BAC-positive traffic casualties, after even an opportunistic MI, especially among patients who actually needed it (hazardous and harmful drinkers). These findings might be explained by a combination of the assessment, the intervention, the level of the patient's alcohol problems, and the moderating effect of the crash (Mello et al., 2005). The results of the present study, in spite of its limitations, support the idea of incorporating early identification and BI in the medical care of casualties, especially if they present with a positive BAC (D'Onofrio and Degutis, 2002). The results of the studies on BI at the emergency or trauma setting are not homogeneous, and the difficulties of working in this setting pose methodological problems which can hamper the statistical significance of the study outcomes (Dill et al., 2004). However, many studies show sustained benefits, concerning alcohol-related problems (mostly significant compared with controls) and concerning drinking (not always significant compared with controls) (Cherpitel and Rodríguez-Martos, 2005).
Injured patients are in a teachable moment to benefit from easy and cheap interventions. Generalizing simple advice to all traffic casualties identified as hazardous drinkers might contribute to the curbing of the risky consumption of alcohol and its consequences.
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ACKNOWLEDGEMENTS |
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This study has received a partial support from the Fondo de Investigación Sanitaria (01/0903; G03/005,CO3/09) and another from the Servei Català de Trànsit. We are grateful to the collaborators who performed the interventions: R. Benedit, J. Capilla, F. Galeano, C. Gómez, M. López, H. Quesada, T. Rodríguez-Martos, and A. Vilella, and to Dr J. Ballesteros for his advice on statistical methods.
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