Claire Garnett

Background: It is important to understand the motives behind why people want to reduce their alcohol consumption to inform messaging for public health campaigns. Objective: This study aimed to identify the motives for reducing alcohol consumption among users of the Drink Less app in the United Kingdom. Methods: Content analysis of Drink Less app users’ responses to the prompt “I want to drink less because...” Users were aged 18 years or older, lived in the United Kingdom, and had downloaded the app between May 20, 2016, and June 24, 2024 (n=2520). Inductive content analysis was conducted to analyze users’ motives to drink less, and the frequencies were stratified by age, sex, and Alcohol Use Disorders Identification Test (AUDIT) score categories. Results: The most common motives to drink less were wanting to improve their physical health (1329/2520, 52.7%), feel better in their body (823/2520, 32.7%), improve their mental well-being (567/2520, 22.5%), regain agency (483/2520, 19.2%), live a different life (321/2520, 12.7%), and have better relationships (309/2520, 12.3%). The motives for drinking less,“improve physical health” and “feel better in their body,” had a lower prevalence among users in higher AUDIT risk zones compared with low-risk, while wanting to “improve their mental well-being,” “regain agency,” “live a different life,” and “have better relationships” had a higher prevalence among users in higher AUDIT risk zones. Conclusions: Users of an alcohol reduction app in the United Kingdom most commonly reported wanting to improve their physical health, feel better in their bodies, and improve their mental well-being as their motives for drinking less alcohol. The pattern of prevalence of different motives varied by AUDIT risk zones, highlighting the importance of tailoring interventions based on what is most likely to be motivating for individuals.

Introduction: Feelings of guilt and remorse after drinking alcohol may act as barriers to seeking support. This study aimed to estimate the prevalence and frequency of such feelings among adults in England who drink at increasing and higher‐risk levels, and differences by socio‐demographic and drinking subgroups. Methods: We analysed data from 40,708 adults (≥ 18 years) who drink at increasing and higher‐risk levels (AUDIT‐C score ≥ 5) from a monthly cross‐sectional survey in England from 2014 to 2022. Feelings of guilt and remorse after drinking in the past 6 months were assessed using the AUDIT. Logistic regression models were used to examine associations with socio‐demographic characteristics, alcohol consumption and harm to oneself or others as a result of drinking. Results: Overall, 13.3% (95% CI 12.9%–13.6%) reported experiencing feelings of guilt or remorse after drinking in the past 6 months. Among those who reported such feelings, 95.3% (95% CI 91.4%–94.9%) experienced them less than once a month. The prevalence of guilt and remorse increased non‐linearly with higher AUDIT‐C scores from 9.3% (95% CI 8.8%–9.9%) among those drinking at the lightest levels within the increasing/higher‐risk range [AUDIT‐C = 5] to 20.9% (95% CI 17.2%–24.8%) among the heaviest [AUDIT‐C = 12]. After adjusting for alcohol consumption and alcohol‐related injury, these feelings were more common among women (aOR 1.38; 95% CI 1.31–1.46) and people from more advantaged social grades (aOR 1.27; 95% CI 1.20–1.36), and much less common among older than younger adults (e.g., ≥ 65 vs. 16–24 years: aOR 0.23; 95% CI 0.20–0.26). Discussion and Conclusions: In England, around one in eight adults who drink at increasing and higher‐risk levels report experiencing guilt or remorse after drinking. These feelings are more common in women, younger adults and those of a more advantaged social grade.

Little is known about the success of alcohol reduction attempts made outside of an experimental setting, and the association between brief alcohol interventions and other evidence-based support and the success of these attempts. This study aimed to answer these questions among risky drinkers using observational data (baseline and 6-month follow-up surveys) from England between 2014 and 2016 (n=3,129). Around one third (31.4%, 95% CI=29.8-33.0) of risky drinkers reported making an alcohol reduction attempt between baseline and 6-month follow-up. Of those making an attempt, nearly two-thirds (64.1%, 95% CI=61.1-67.1) self-reported their attempt was successful. Those who received a brief alcohol intervention in primary care were 3-times more likely to report their attempt was successful (OR adj =3.01, 95% CI=1.87-4.82). No association was detected between using evidence-based support during an attempt and self-reported success (OR adj =0.87, 95% CI=0.47-1.66). A different pattern of results was found when using AUDIT score at 6-month follow-up (adjusted for baseline) as the outcome: receiving (vs. not receiving) a brief alcohol intervention in primary care (B adj =3.56, 95% CI=2.78-4.35) and using (vs. not using) evidence-based support during an alcohol reduction attempt (B adj =1.89, 95% CI=0.72-3.06) was associated with higher AUDIT scores. These findings were not robust to sensitivity analyses, highlighting the importance of using measures focused on more recent alcohol consumption in this type of study design. Further research is needed to unpick these findings and to capture the potential heterogeneity in goals for alcohol reduction attempts.

Background: Digital interventions can be effective for reducing alcohol consumption. However, most digital interventions that have been evaluated are websites and there is little evidence on the effectiveness of smartphone apps, especially in a United Kingdom context. We developed an evidence- and theory-informed app, Drink Less, to help increasing-and-higher-risk drinkers (Alcohol Use Disorders Identification Test score ≥ 8) reduce their alcohol consumption. Objective: To evaluate the effectiveness of Drink Less for reducing alcohol consumption compared with usual digital care in the United Kingdom. Design: Two-arm, double-blind, parallel-group, randomised controlled trial with 1 : 1 group allocation and an embedded process evaluation, with 6-month follow-up. Setting: Remotely conducted among participants living in the United Kingdom, recruited from July 2020 to March 2022. Participants: Five thousand six hundred and two increasing-and-higher-risk drinkers aged 18+ who had access to an iPhone operating system device and wanted to drink less alcohol. Interventions: Participants were recommended to use the intervention (Drink Less) or recommended the comparator (National Health Service alcohol advice web page). Drink Less is an app-based intervention to help increasing-and-higher-risk drinkers reduce their alcohol consumption. It consists of evidence-based modules (e.g. goal setting, self-monitoring) and was systematically and transparently developed and refined. The National Health Service alcohol advice web page was considered usual digital care and provides tips on cutting down. Main outcome measures: The primary outcome was self-reported weekly alcohol consumption at 6-month follow-up (derived from the extended Alcohol Use Disorders Identification Test – Consumption), adjusted for baseline alcohol consumption. Results: The retention rate at 6-month follow-up was 80%. The data were not missing completely at random with differences detected in educational qualifications, occupation and income, indicating that multiple imputation was the most appropriate analytic approach. This found that Drink Less resulted in a 2.00 United Kingdom unit greater weekly reduction (95% confidence interval −3.76 to −0.24) at 6-month follow-up compared with the National Health Service alcohol advice web page. Compared with the National Health Service alcohol advice web page, Drink Less cost an additional £1.28 per user, when including the sunk costs (already incurred and cannot be recovered), but saved £0.04 per user when considering only the annual maintenance costs. Drink Less costs only an extra £0.64 per additional weekly unit of alcohol reduction, and may be cost saving if sufficient people use the app to cover the sunk costs. There was no statistically significant difference in quality-adjusted life-years between the two groups. Limitations: This trial relied on retrospective self-reported alcohol consumption. Results from the pre-registered sensitivity analysis of multiple imputation were inconsistent with those from the pre-registered primary analysis (a conservative approach to missing data where non-responders were assumed to be drinking at baseline levels), which found a non-significant weekly reduction of 0.98 units (95% confidence interval −2.67 to 0.70) in the intervention compared with comparator group. Multiple imputation was recommended by the independent Data Monitoring Committee based on the pattern of missing data. Conclusions: Drink Less appears effective for reducing alcohol consumption among increasing-and-higher-risk drinkers compared with the National Health Service alcohol advice web page in the United Kingdom, and may be cost saving if widely used in the population. Future work: Drink Less is in a strong position to be promoted widely and provide inexpensive support to increasing-and-higher-risk drinkers in the United Kingdom. Future work should investigate different promotion strategies and ways of implementing the app within healthcare settings and adapting it for other countries. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR127651.

There has been increasing interest in the role of artistic creative activities in supporting emotion regulation. However, there is little research about how demographic factors (such as age, gender, ethnicity, personality, and socioeconomic status) or factors relating to creative engagement (including engagement behaviors and subjective experience of engagement) influence our ability to use artistic creative activities to regulate our emotions. We analyzed data from 40,949 adults and used a structural equation modeling approach to model the relationships among demographic factors, factors relating to engagement, and our use of emotion regulation strategies (ERSs) while engaging in artistic creative activities. We found that women make more use of creative activities to regulate their emotions than do men, as do those of lower socioeconomic status. Training in doing an artistic activity, regular engagement, and enjoyment while engaging are all associated with a greater ability to use artistic activities to regulate our emotions. We also identified relationships between demographic and engagement factors and specific types of ERSs, such as avoidance strategies (e.g., distraction, suppression, or detachment from negative or stressful emotions), approach strategies (e.g., acceptance, reappraisal and problem solving), and self-development strategies (e.g., enhanced self-identity, improved self-esteem, and increased agency). Artistic creative activities are increasingly being recognized as effective ways of regulating emotional responses. Overall, this study provides insight into the interrelationship between individual attributes, modifiable patterns of engagement and emotion regulation when engaging in artistic activities.

Aims: To assess the prevalence of drink-driving among adults in Germany and subgroups, and potential associations with sociodemographic or drinking characteristics. Methodology: Cross-sectional population survey of 5,153 respondents aged 18+ years in Germany (June–November 2021). We assessed self-reported drink-driving, defined as, in the past month, driving a motorised vehicle within 1 hour of consuming 2 or more alcoholic beverages. Regression models were used to examine sociodemographic and drinking characteristics associations with self-reported drink-driving among adults in Germany who drank alcohol and reported driving a motorised vehicle in the past month. Results: The prevalence of self-reported drink-driving was 4.1 % (95 % CI 3.6–4.7) among adults in Germany, and 5.7 % (95 % CI 5.0–6.5) among adults who were alcohol users and reported driving a motorised vehicle in the past month. Lower odds of drink-driving were found for women vs men (adjusted odds ratio (OR_adj) = 0.63, 95 % CI 0.45–0.88), people with low vs middle income (OR_adj = 0.82, 95 % CI 0.72–0.94), people living in rural vs urban areas (OR_adj = 0.38, 95 % CI 0.27–0.54), and people consuming low vs medium alcohol levels (OR_adj = 0.28, 95 % CI 0.18–0.44). There was no clear association with age or education level. Conclusions: Roughly 4 in 100 adults drank and drove in the past month in Germany. This is a public health issue requiring further study and potentially more targeted interventions.

Background: There is a growing public health evidence base focused on understanding the links between drinking contexts and alcohol consumption. However, the potential value of developing context-based interventions to help people drinking at increasing and higher risk levels to cut down remains underexplored. Digital interventions, such as apps, offer significant potential for delivering context-based interventions as they can collect contextual information and flexibly deliver personalized interventions while addressing barriers associated with face-to-face interventions, such as time constraints. Objective: This early phase study aimed to identify the best method for collecting information on the contexts of alcohol consumption among users of an alcohol reduction app by comparing 2 alternative drinking diaries in terms of user engagement, data quality, usability, and acceptability. Methods: Participants were recruited using the online platform Prolific and were randomly assigned to use 1 of the 2 adapted versions of the Drink Less app for 14 days. Tags (n=31) included tags for location, motivation, and company that participants added to drink records. Occasion type (n=31) included a list of occasion types that participants selected from when adding drink records. We assessed engagement and data quality with app data, usability with a validated questionnaire, and acceptability with semistructured interviews. Results: Quantitative findings on engagement, data quality, and app usability were good overall, with participants using the app on most days (tags: mean 12.23, SD 2.46 days; occasion type: mean 12.39, SD 2.12 days). However, around 40% of drinking records in tags did not include company and motivation tags. Mean usability scores were similar across app versions (tags: mean 72.39, SD 8.10; occasion type: mean 74.23, SD 6.76). Qualitative analysis found that both versions were acceptable to users and were relevant to their drinking occasions, and participants reported increased awareness of their drinking contexts. Several participants reported that the diary helped them to reduce alcohol consumption in some contexts (eg, home or lone drinking) more than others (eg, social drinking) and suggested that they felt less negative affect recording social drinking contexts out of their home. Participants also suggested the inclusion of “work drinks” in both versions and “habit” as a motivation in the tags version. Conclusions: There was no clearly better method for collecting data on alcohol consumption as both methods had good user engagement, usability, acceptability, and data quality. Participants recorded sufficient data on their drinking contexts to suggest that an adapted version of Drink Less could be used as the basis for context-specific interventions. The occasion type version may be preferable owing to lower participant burden. A more general consideration is to ensure that context-specific interventions are designed to minimize the risk of unintended positive reinforcement of drinking occasions that are seen as sociable by users.

SUMMARY: Micro-randomized trials are commonly conducted for optimizing mobile health interventions such as push notifications for behavior change. In analyzing such trials, causal excursion effects are often of primary interest, and their estimation typically involves inverse probability weighting (IPW). However, in a micro-randomized trial, additional treatments can often occur during the time window over which an outcome is defined, and this can greatly inflate the variance of the causal effect estimator because IPW would involve a product of numerous weights. To reduce variance and improve estimation efficiency, we propose two new estimators using a modified version of IPW, which we call “per-decision IPW.” The second estimator further improves efficiency using the projection idea from the semiparametric efficiency theory. These estimators are applicable when the outcome is binary and can be expressed as the maximum of a series of sub-outcomes defined over sub-intervals of time. We establish the estimators’ consistency and asymptotic normality. Through simulation studies and real data applications, we demonstrate substantial efficiency improvement of the proposed estimator over existing estimators. The new estimators can be used to improve the precision of primary and secondary analyses for micro-randomized trials with binary outcomes.