Alcohol and Alcoholism Advance Access published online on October 13, 2007
Alcohol and Alcoholism, doi:10.1093/alcalc/agm139
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An evaluation of National alcohol screening day
1 Division of Behavioral Sciences and Community Health, University of Connecticut Health Center, Institute for Public Health Research, University of Connecticut, 99 Ash Street, MC 7160, East Hartford, CT 06108, USA
2 Institute for Public Health Research, University of Connecticut, 99 Ash Street, MC 7160, East Hartford, CT 06108, USA
3 National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, 5635 Fisher's Lane, Rockville, MD 20852, USA
4 Screening for Mental Health, Inc. and Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
* Author to whom correspondence should be addressed at: Institute for Public Health Research, University of Connecticut, 99 Ash Street, MC 7160, East Hartford, CT 06108, USA. Tel: +1 860-282-8550; Fax: +1 860-282-8505; E-mail: aseltine{at}uchc.edu
Received 26 April 2007; first review notified 28 May 2007; in revised form 23 July 2007; accepted 24 August 2007
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ABSTRACT |
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Aims: Although National Alcohol Screening Day (NASD) became the USA's largest and most visible community-based intervention targeting risky drinking over the past decade, its utility in identifying individuals who are at risk for alcohol problems and in catalyzing behaviour change has not been tested in studies including untreated controls. The purpose of this study was to assess changes in alcohol use three months following NASD participation using a quasi-experimental pretest-posttest control group design. Methods: Participants (N = 713) were recruited from 5 NASD sites in Florida, Massachusetts, and New York, USA. Intervention subjects (N = 318) were recruited at the NASD event; control subjects (N = 395) were recruited at the same locations approximately 1 week after NASD. All participants completed brief surveys at the time of enrollment, and then again 3 months later. Results: Significant decreases in the typical number of drinks consumed per occasion were observed among at-risk drinkers in the intervention group relative to controls in the 3 months following NASD. At-risk NASD participants averaged approximately 5.6 fewer drinks per week than at-risk controls. Conclusions: Findings suggest that exposure to a brief screening program with provision of feedback can result in significant reductions in alcohol consumption among risky drinkers.
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Introduction |
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Alcoholism is a leading cause of morbidity and mortality in the USA, with more than 107,000 alcohol-related deaths reported each year (McGinnis and Foege, 1993
; National Institute on Alcohol Abuse and Alcoholism, 1997; Substance Abuse and Mental Health Services Administration, 2002). Although over 17 million Americans, or 8.5% of the population, meet the criteria for alcohol abuse or dependence, only 10% of them seek treatment each year (U.S. Department of Health and Human Services, 2000). In addition, at-risk drinkers make up a significant portion of the adult population in the US, with 32% exceeding moderate drinking limits on occasion (National Institute on Alcohol Abuse and Alcoholism, 1992). Despite a decrease in the prevalence of alcohol abuse of as much as 10% from 1982 to 1995, the cost to society on account of alcoholism was an estimated $184 billion in 1998 (Harwood, 2000).
Research indicates that screening and brief intervention constitutes one of the most effective preventive strategies for alcohol abuse. More than 30 studies conducted around the world support the efficacy of screening and brief intervention for alcohol problems in their early stage, before addiction and other serious problems occur (D'Onofrio and Degutis, 2002). In a comprehensive review of the literature, the U.S. Preventive Services Task Force concluded that primary care settings are suitable locations for offering screening and behavioural interventions to reduce alcohol misuse by adults, including pregnant women (Whitlock et al., 2004). The Task Force found evidence that reductions in drinking were sustained over periods of 6–12 months and longer, with some evidence that positive health outcomes continued 4 or more years post-intervention. Recent studies suggest that screening and brief intervention can also be effective in reducing alcohol use among emergency department patients (Aseltine et al., 2007; Bazargan-Hejazi et al., 2005) and hospitalized trauma patients (Gentilello et al., 1999).
Despite this evidence, screening and brief intervention are currently not routine practices in health care delivery in the USA. Moreover, the success of National Depression Screening Day in providing screening and education related to mental health problems in community settings including libraries, shopping malls, churches, college campuses, and military bases indicates that these activities need not be confined to clinical settings (Greenfield et al., 1997). In an effort to promote alcohol-related education, screening, and the provision of feedback from clinicians in both community and clinical settings, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) formed a partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA) and Screening for Mental Health, Inc., the nonprofit organization that developed National Depression Screening Day, to establish National Alcohol Screening Day (NASD) in 1999. Since that time, NASD has become the nation's largest and most visible community-based intervention targeting risky drinking, involving over 100,000 individuals at more than 2500 sites in 2003 (Dupre et al., 2005). Thirty-four co-sponsoring agencies, including high-profile organizations such as the American Medical Association, the American College of Obstetrics and Gynecology, and the National Collegiate Athletic Association, support and promote the program and encourage their membership to run programs at local sites.
NASD has three primary objectives: first, to administer free and anonymous alcohol screening in a setting accessible to the general public; second, to provide feedback from a clinician regarding participants' drinking behaviour and, if indicated, to refer participants for treatment; and third, to provide public education on the impact of alcohol on health. Despite the tremendous growth in the program over the past decade (Dupre et al., 2005), the utility of NASD in identifying individuals who are at risk for alcohol problems and in catalyzing behaviour change has not been demonstrated. In a previous study of the impact of NASD on participants' drinking behaviour, more than 40% of attendees reported ‘cutting back’ on their drinking 6 months following NASD (Greenfield et al., 2003), although these results were limited by the absence of an untreated comparison group.
The purpose of the present study was to evaluate the impact of NASD among participants at five community sites in Massachusetts, New York City, and Florida. Specifically, we sought to assess changes in ‘risky drinking’ as defined by NIAAA criteria (i.e. the typical number of drinks per week and the frequency of heavy episodic or binge drinking) in the 3 months following NASD participation.
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Methods |
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Sites and participants
Seven hundred and thirteen participants were enrolled (318 intervention, 395 control) across five sites in Massachusetts, New York, and Florida in April 2004. Sites hosting a NASD event in the previous year that met the following criteria were eligible to participate: (i) had screened a minimum of 50 individuals in the 2003 NASD event; (ii) had clinicians available onsite to discuss screening results with participants (as indicated by a minimum of 75% of screening forms from the previous year's event reviewed by a clinician); (iii) served a general community population, as opposed to those in treatment for alcohol or substance abuse; and (iv) were within 2 h driving distance of data collection personnel in Massachusetts, Connecticut, the New York metropolitan area, and south Florida. A total of eight sites in these locations met eligibility criteria, with 5 (63%) agreeing to participate. These events were held in the public areas (e.g. lobbies, common areas) of two community health centres, a community health clinic, a community centre, and a retail establishment, and were staffed by clinicians—typically social workers, psychologists, or substance abuse counselors—from the sponsoring hospital or clinic, or from a local mental health association.
A demographic profile of the sample is presented in Table 1. Approximately 66% (N = 469) of the sample were women, 38% (N = 268) were black, 16% (N = 112) were Hispanic, and 41% (N = 290) were white. Average age was 44.2 (SD = 15.9), with an age range of 18–87 years, and 36% (N = 258) were married. Approximately 15% of study participants (control N = 51; treatment N = 48) screened positive for risky drinking according to NIAAA criteria. Participants averaged less than one heavy drinking episode per month, and roughly 2 drinks per week, with 11% scoring in the ‘hazardous’ or ‘harmful’ range on the AUDIT. While the demographic characteristics of this sample were very similar to those of participants from NASD community events held from 2001 to 2003, the proportion of at-risk drinkers was lower (ranging between 21 and 26% from 2001 to 2003) (Dupre et al., 2005), a discrepancy that may be attributable to the exclusion of treatment centres from the current study.
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Procedures: NASD intervention group
Community sites across the USA registered at no cost for the NASD screening event, held in the spring of 2004. Each site received a kit containing educational and promotional materials, a program manual explaining how to run the event, and a publicity guide. In addition, the federal sponsors and Screening for Mental Health mounted a national press campaign to ensure the event received nationwide television, radio and newspaper coverage.
Attendees were greeted and asked to complete an initial screening form that consisted of the AUDIT (Babor et al., 2002) as well as a series of demographic and treatment history questions. Screenings were provided without charge to attendees. After attendees filled out the screening form, they were given the opportunity to meet privately with a health professional to review the results of their screen and, if necessary, to receive referral information. Those completing the screening were then invited to participate in an additional baseline survey containing a series of general questions about health, diet, exercise, smoking, as well as their experience of the NASD event, and asked if they would be willing to be re-contacted three months later for follow-up. Of the 409 individuals who completed the initial screening, 318 (78%) agreed to complete the baseline survey (see Figure 1). Study participants were compensated with a movie pass. All attendees provided written informed consent for participation. The procedures used to collect and analyse these data were approved by the Institutional Review Boards of McLean Hospital and the University of Massachusetts-Boston.
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Procedures: control group
Approximately 1 week following the NASD event, research staff visited the same sites participating in the screening day to enroll control group participants. In order to create a comparable control condition, enrollment of controls was conducted under conditions that were as similar as possible to those obtaining during the NASD event. Accordingly, research staff allowed individuals to self-select into the study and did not actively recruit individuals to participate. A display advertising a health survey was set up in the same location as the NASD event at each site; there was no connection between the NASD event and this survey. Those approaching the display were asked to complete a brief general health survey and to provide contact information for a 3-month follow-up. The baseline survey contained a series of general questions about health, diet, exercise, and smoking (that were identical to those completed by NASD participants) in which the three AUDIT questions assessing risky drinking using NIAAA criteria were embedded. To minimize attention to risky drinking and alcohol-related consequences in the no intervention condition, the full AUDIT was not administered to control subjects.
To ensure that NASD participants did not enroll in the control condition, potential controls were asked whether they had participated in any other health screenings or surveys in the past 30 days. The one control participant responding affirmatively was excluded from the study. All participants enrolling in the control condition were compensated with a movie pass.
Three month follow-up
Three months after enrollment, subjects in both the intervention and control groups received a brief self-report questionnaire by mail. Non-respondents were contacted by telephone and given the option to return the questionnaire by mail or complete the survey by phone. Follow-up interviews were conducted by the Center for Survey Research at the University of Massachusetts, Boston. Of the 713 individuals who completed the baseline survey, 458 (64%) participated in the follow-up.
Measures
Screening and baseline survey
The initial screening form was a brief, 1-page questionnaire containing demographic and treatment history information, as well as the 10-item AUDIT (Babor et al., 2002) developed by the World Health Organization. This measure assesses alcohol consumption and related problems and has been shown to correlate with other self-report alcohol screening tests (Saunders et al., 1993; Allen et al., 1997). The first three questions on the AUDIT can be re-coded to assess risky drinking over the past 12 months according to NIAAA criteria (National Institute on Alcohol Abuse and Alcoholism, 2004). These are (i)‘How often do you have a drink containing alcohol?’ measured on a 9-point scale from ‘never’ to ‘7 days a week;’ (ii) ‘How many drinks containing alcohol do you have on a typical day when you are drinking?’ measured on a 13-point scale from ‘none’ to ‘12 or more;’ (iii)‘How often do you have 4 or more (for women)/5 or more (for men) drinks a day?’ measured on a 5-point scale from ‘never’ to ‘daily or almost daily.’ The two primary outcomes used in the analysis were the typical number of drinks consumed per week (the product of items 1 and 2) and the incidence of heavy episodic drinking (item 3), which was re-coded to reflect the monthly frequency of heavy drinking (i.e. 0 for ‘never,’ 0.5 for ‘less than monthly,’ 1 for ‘monthly,’ 4 for ‘weekly,’ and 20 for ‘daily or almost daily’). (Replication of the analysis presented below for heavy episodic drinking using the original ordinal scaling of this measure produced virtually identical contrasts between NASD and control groups).
Both NASD and control subjects also completed a series of general health questions relating to diet, smoking, and exercise adapted from previous national studies of risk behaviours (Wechsler and Isaac, 1992; Johnston et al., 1997).
Follow-up survey To assess changes in drinking attributable to NASD participation, the follow-up questionnaires for both the NASD and control groups included the three items from the AUDIT assessing the quantity and frequency of alcohol use. Response categories were modified to capture alcohol use in the 3 months following enrollment (as opposed to past year).
Data analysis
Prior to assessing the impact of NASD participation on changes in drinking behaviour, two sets of preliminary analyses were conducted. First, we assessed the comparability of the NASD group and the control group in terms of the demographic characteristics and drinking characteristics presented in Table 1, using appropriate statistical tests depending on the scaling of the variable in question (e.g. chi-square or t-test). Second, we estimated a series of logistic regression equations to examine whether demographic characteristics or baseline drinking predicted differential attrition between the NASD and control groups.
The effect of NASD on drinking behaviour 3 months following exposure to the program was initially estimated with the following multiple regression model:
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), a simulation-based approach that generates multiple plausible values for each missing element in order to represent the inherent uncertainty in the missing data (see Schafer and Graham, 2002). We used the Markov Chain Monte Carlo (MCMC) method in SAS 9.0 to produce 10 imputed data-sets. Diagnostic plots indicated that the MCMC converged well. With a missing data rate of 36% and 10 iterations, the efficiency of estimates was 97%.
Using the small to moderate effect sizes reported in recent brief intervention trials (Fleming et al., 1999; Ockene et al., 1999; Curry et al., 2003), we estimated that the present study would have power exceeding 0.90 to detect significant differences (P < 0.05) between intervention and control participants.
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Results |
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Baseline comparability of NASD and control group
Preliminary bivariate analyses assessing the comparability of the NASD group and control group in terms of gender, race/ethnicity, age, education, marital status, employment status, health, and drinking characteristics revealed differences in the composition of NASD and control groups for education [t (701) = 2.7, P < 0.05], employment status [
2 (4, N = 701) = 12.2, P < 0.05], health status [t (707) = 2.6, P < 0.05], and exercise frequency [t (703) = 2.5, P < 0.05]. As is indicated in Table 1, members of the NASD group had slightly higher levels of education, were more likely to be employed full time, and reported slightly better baseline health status and more frequent exercise.
Subject attrition and missing data
Thirty-six percent of participants did not complete the 3-month follow-up. Race [2 (3, N = 713) = 33.0, P < 0.05], age [ 2 (1, N = 709) = 14.0, P < 0.05], and heavy drinking [ 2 (1, N = 649) = 8.7, P < 0.05] significantly predicted follow-up participation, with blacks, Hispanics, younger participants, and those with more frequent heavy drinking episodes significantly less likely to complete the follow-up. Separate logistic regression equations predicting attrition were estimated for each characteristic in Table 1, the NASD group indicator variable, and their interaction. None of these interactions attained statistical significance, indicating that there was no differential attrition among NASD and control groups by demographic, socioeconomic, or alcohol consumption patterns. In addition to attrition from baseline to follow-up, 19 participants had missing data on the baseline measure of typical drinks per occasion, and 54 did not report baseline heavy drinking levels. Missing data from both sources—i.e. item non-response and loss to follow-up—were imputed in the following analyses using procedures described above, creating 10 separate datasets with 713 complete cases.
Assessing the effects of NASD participation on subsequent drinking behaviour
Combined results from regression analyses using the 10 imputed datasets are presented in columns I and II of Table 2 and indicate that exposure to NASD did not influence typical weekly drinking (B = –0.678, SE = 0.457) or the frequency of heavy episodic drinking (B = –0.038, SE = 0.194) in the total sample. However, since the principal objective of NASD is to reduce alcohol use among those drinking at high-risk levels, we estimated the effects of the program separately by baseline risk status. A product term for the interaction of NASD participation and baseline risk status, where risk status is coded 1 for those at risk according to NIAAA quantity-frequency guidelines, and 0 otherwise, was added to the equation presented above. Results are presented in columns III and IV of Table 2 and indicate that the impact of NASD participation on subsequent drinking behaviour differed by baseline risk status. At-risk drinkers participating in NASD were significantly more likely than at-risk control subjects to reduce the typical number of drinks per week (B = –6.09, SE = 1.35), although reductions in the frequency of heavy episodic drinking did not achieve statistical significance at the 0.05 level (B = –0.792, SE = 0.486).
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To better convey the magnitude of intervention effects we re-parameterized this model to yield contrasts between low-risk controls, low-risk NASD participants, and at-risk NASD participants, with at-risk controls serving as the comparison group. These contrasts are presented in columns V and VI of Table 2. Results from the re-parameterized model indicate that NASD at-risk participants drank, on average, almost six fewer drinks per week than at-risk controls at the 3-month follow-up net of baseline drinking levels. The clinical significance in this reduction was reflected in the numbers of individuals in each experimental group exceeding NIAAA at-risk limits (National Institute on Alcohol Abuse and Alcoholism, 2004
) at follow-up: only 27% of those in the NASD group continued to exceed the NIAAA at-risk limits for weekly drinks at follow-up, compared to 43% of controls. Separate analyses (not shown) indicated that most of the change in typical weekly drinks among at-risk NASD participants was due to decreases in the average number of drinks consumed on a typical day (B = –1.44, SE = 0.324, P < 0.05), as opposed to the number of days per week on which alcohol was consumed. |
Discussion |
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NASD is the USA's first large-scale community-based program designed to identify, provide feedback to, and refer for treatment members of the general public who engage in risky drinking. Research on NASD suggests that it is effective in reaching previously untapped segments of the population whose drinking patterns are identified as unhealthy (Greenfield et al., 2003
; Dupre et al., 2005). Despite the widespread implementation of the NASD program in community, college, and primary care settings across the USA over the past 7 years, there have been no experimental or quasi-experimental studies examining changes in drinking that may be associated with this intervention. The present study sought to assess the impact of NASD on drinking behaviour in a community sample and observed significant reductions in alcohol consumption among NASD participants drinking at risky levels compared to similar untreated controls. The magnitude of the reduction in weekly alcohol consumption was substantial, approaching six drinks per week. Although the NASD intervention is limited to screening and the provision of feedback from a clinician, as opposed to a structured brief intervention (e.g. Bernstein et al., 1997; D'Onofrio et al., 2005a), these results are consistent with the magnitude of effects observed in the US Preventive Medicine Task Force's review of brief interventions (i.e. between 2.9 and 8.7 drinks) (Whitlock et al., 2004). Thus, NASD appears to be a relatively low-cost, non-labour-intensive method for sharing information about, and potentially altering, alcohol use behaviours in high risk populations.
This study bolsters the already considerable evidence of the efficacy of screening and brief interventions in reducing risky drinking among patients in a variety of medical contexts (Fleming et al., 1997; Aseltine et al., 2007) and extends this to community populations. In addition, it offers a note of caution to researchers and clinicians seeking to examine the impact of brief interventions in comparison to ‘untreated’ controls who receive screening and assessment during recruitment. Such studies, which essentially use a NASD-type intervention for the control condition, typically observe significant declines in drinking among control subjects at follow-up (Fleming et al., 1997; Whitlock et al., 2004; D'Onofrio et al., 2005b). Consequently, this design feature is apt to substantially raise the bar for efforts to demonstrate the efficacy of brief interventions in reducing subsequent alcohol consumption.
Findings and implications from this study should be considered in the context of its limitations. The study utilized a quasi-experimental design and was not a randomized trial. With voluntary, community-based interventions such as NASD, however, the randomization of participants to experimental conditions is neither ethical nor feasible. Instead, control subjects were recruited from the same locations within 1 day to 2 weeks of the NASD event to create a similar yet untreated comparison group. The data presented in Table 1 indicate that assignment to intervention and control conditions produced comparable experimental groups despite the absence of randomization.
Relatedly, the substantial effect of NASD participation on alcohol use observed in this study may be attributable to the motivational processes fostering participation, since individuals who seek out NASD events and choose to participate in screening with feedback from a clinician may be at a higher state of readiness to change relative to those recruited into brief intervention studies in physicians' offices. Such motivational processes may constitute a critical distinction between intervention and control groups and raise concerns that intervention effects may at least be partly attributable to selection processes. While the comparability of intervention and control subjects at baseline provides some comfort regarding selection effects, variables reflecting motivational and/or self-selection processes could account for some portion of intervention effects.
These findings are also limited by the short-term nature of this study, as the absence of data beyond 3 months post-intervention raises questions about the persistence of the reductions in risky drinking among NASD participants. Further, attrition analyses suggest that the heaviest drinkers from the baseline sample were less likely to participate in the 3-month assessment. To adjust for the selective attrition of at-risk drinkers we employed multiple imputation procedures. These adjustments had a marked effect on our results: analysis of complete cases yielded a NASD effect among at-risk drinkers of 7.5 fewer drinks per week, in contrast to the reduction of 5.9 drinks per week derived from analysis of multiple imputed data. As a result, we believe that the use of multiple imputation procedures has greatly improved the degree to which these findings generalize to the populations likely to attend NASD.
Finally, one might also question whether these findings can be attributed to regression to the mean, or the tendency for those with extreme values on some variable to move toward the mean of the distribution in subsequent observations. The reduction in the number of control subjects exceeding NIAAA low-risk weekly drinking limits at follow-up (only 43% remaining at risk) is clearly consistent with regression to the mean effects. Although this tendency could explain some portion of the reduction in drinking in the at-risk groups from baseline to follow-up, regression to the mean would not account for the substantially greater and statistically significant reduction in drinking among those in the intervention group relative to controls (Shadish et al., 2002).
Despite these limitations, the present article provides the only quasi-experimental study of the impact of NASD on drinking among community participants. Results suggest that this screening program offers an efficient, broad-based intervention with the potential to foster decreases in alcohol consumption in a manner to which individuals are receptive.
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ACKNOWLEDGEMENTS |
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The authors are grateful for the contributions and assistance of Barbara Kopans, Sharon Pigeon, Connie DiCocco and Marcia Pinck. This work was funded by a cooperative agreement with the National Institute of Alcohol Abuse and Alcoholism and the Substance Abuse and Mental Health Services Administration (5U18AA012A20-05).
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References |
|---|
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TOPABSTRACTIntroductionMethodsResultsDiscussionReferences |
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Allen J. P., Litten R. Z., Fertig J. B., et al. A review of research on the alcohol use disorders identification test (AUDIT). Alcoholism: Clinical and Experimental Research (1997) 21:613–619.[CrossRef][Web of Science][Medline]
Aseltine R. H. The impact of screening, brief intervention, and referral for treatment on emergency department patients' alcohol use. Annals of Emergency Medicine. with the Academic ED SBIRT Research Collaborative. (in press).
Babor T. F., Higgins-Biddle J. C., Saunders J. B., et al. The Alcohol Use Disorders Identification Test (AUDIT) (2001) 2nd Edition. World Health Organization Geneva, Switzerland. Document number WHO/MSD/MSB/01.6a.
Bazargan-Hejazi S., Bing E., Bazargan M., et al. Evaluation of a brief intervention in an inner-city emergency department. Annals of Emergency Medicine (2005) 46:67–76.[Web of Science][Medline]
Bernstein E., Bernstein J., Levenson S. Project ASSERT: An ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Annals of Emergency Medicine (1997) 30:181–189.[CrossRef][Web of Science][Medline]
Curry S. J., Ludman E. J., Grothaus L. C., et al. A randomized trial of a brief primary-care-based intervention for reducing at-risk drinking practices. Health Psychology (2003) 22:156–165.[CrossRef][Web of Science][Medline]
D'Onofrio G. D., Degutis L. C. Preventive care in the emergency department: Screening and brief intervention for alcohol problems in the emergency department: A systematic review. Academic Emergency Medicine (2002) 9:627–638.[CrossRef][Web of Science][Medline]
D'Onofrio G. D., Degutis L. C., Fiellin D. A., et al. Emergency practitioner-performed brief interventions for harmful and hazardous drinkers in the emergency department. Academic Emergency Medicine (2005a) 12(suppl 1):59–60.
D'Onofrio G. D., Pantalon M. V., Degutis L. C., et al. Development and implementation of an emergency department practitioner-performed brief intervention for hazardous and harmful drinkers in the emergency department. Academic Emergency Medicine (2005b) 12:211–218.[Medline]
Dupre M. E., Aseltine R. H., Wallenstein G. V., et al. An overview of national alcohol screening day: Trends from 2001 to 2003. Alcohol Research and Health (2005) 28:23–26.[Web of Science]
Fleming M. F., Barry K. L., Manwell L. B., et al. Brief physician advice for problem alcohol drinkers. Journal of the American Medical Association (1997) 277:1039–1045.
Fleming M. F., Manwell L. B., Barry K. L., et al. Brief physician advice for alcohol problems in older adults: a randomized community-based trial. Journal of Family Practice (1999) 48:378–384.[Web of Science][Medline]
Gentilello L. M., Rivara F. P., Donovan D. M., et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Annals of Surgery (1999) 230:473–480.[CrossRef][Web of Science][Medline]
Greenfield S. F., Keliher A., Sugarman D., et al. Who comes to voluntary, community-based alcohol screening? Results of the first annual national alcohol screening day, 1999. American Journal of Psychiatry (2003) 160:1677–1683.
Greenfield S. F., Reizes J. M., Magruder K. M., et al. Effectiveness of community-based screening for depression. American Journal of Psychiatry (1997) 154:1391–1397.[Abstract]
Harwood H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods, and Data. (2000) Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism. http://www.niaaa.nih.gov.
Johnston L. D., O'Malley P. M., Bachman J. G. National Survey Results on Drug use from the Monitoring the Future Study, 1975–1995. Vol II: College Students and Young Adults (1997) Bethesda, MD: National Institute on Drug Abuse. NIH Publication number 98–4140.
McGinnis J. M., Foege W. H. Actual causes of death in the United States. Journal of the American Medical Association (1993) 270:2207–2212.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). Ninth Special Report to the U.S. Congress on Alcohol and Health (1997) Rockville, MD: NIAAA. http://www.niaaa.nih.gov.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). The Economic Costs of Alcohol and Drug Abuse in the United States, 1992 (1998) Rockville, MD: NIAAA. http://www.niaaa. nih.gov.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). Helping Patients with Alcohol Problems: A Health Practitioner's Guide (2004) Bethesda, MD: NIAAA. http://www.niaaa.nih.gov/publications/Practitioner/HelpingPatients.htm.
Ockene J. K., Adams A., Hurley T. G., et al. Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work? Archives of Internal Medicine (1999) 159:2198–2205.
Rubin D. B. Multiple Imputation for Nonresponse in Surveys (1987) Wiley New York.
Saunders J. B., Asland O. G., Babor T. F., et al. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction (1993) 88:791–804.[CrossRef][Web of Science][Medline]
Schafer J. L., Graham J. W. Missing data: Our view of the state of the art. Psychological Methods (2002) 7:147–177.[CrossRef][Web of Science][Medline]
Shadish W., Cook T., Campbell D. Experimental and Quasi-Experimental Designs for Generalized Causal Inference (2002) Boston, MA: Houghton Mifflin.
Substance Abuse and Mental Health Services Administration. Results from the 2001 National Household Survey on Drug Abuse: Volume I. Summary of National Findings (2002) Rockville, MD: Office of Applied Studies. NHSDA Series H-17, DHHS Publication No. SMA 02–3758.
U.S. Department of Health and Human Services. Healthy People 2010 (2000) 2nd edn. Washington, DC: U.S. Government Printing Office. With "Understanding and Improving Health" and "Objectives for Improving Health". 2 vols.
Wechsler H., Isaac N. "Binge" drinkers at Massachusetts colleges: Prevalence, drinking style, time trends, and associated problems. Journal of the American Medical Association (1992) 267:2929–2931.
Whitlock E. P., Pollen M. R., Green C. A., et al. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine (2004) 140:557–568.
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