Robyn Burton

Governance of alcohol-free and low-alcohol (No/Lo) drinks has the potential to influence their public health impact. However, regulation remains poorly understood. This study aimed to identify, summarise and compare formal legal frameworks, non-binding government guidance and recognised self-regulatory frameworks for the labelling, taxation, licensing and condition of sale and marketing of No/Lo drinks across a diverse set of countries. We conducted a desk-based analysis, supplemented by expert input. Eight case study countries (Australia, Finland, Germany, the Netherlands, Norway, Thailand, the United Kingdom [UK] and the United States of America) were selected for their diversity in geography, alcohol consumption and policy environments. Targeted searches identified documents for determining how No/Lo products were regulated in relation to their labelling, taxation, licensing and conditions of sale and marketing. Data were extracted, tabulated and reviewed for accuracy. Regulatory thresholds (%ABV) that determine when drinks fall under alcohol legislation vary widely both across and within countries and definitions of No/Lo products are uncommon. For example, drinks can be labelled as alcohol-free at ≤ 0.05% alcohol by volume (ABV) in the UK, but ≤ 1.15% ABV in parts of Australia. Sales of drinks below defined thresholds generally do not require a premises licence. Marketing restrictions were generally shaped by those for standard alcoholic drinks, although new self-regulatory guidance has been developed in Australia, the Netherlands and the UK. Governance of No/Lo drinks is fragmented and inconsistent, with definitions and regulatory thresholds varying both across countries and between policy areas within countries.

Introduction: Governance of alcohol‐free and low‐alcohol (No/Lo) drinks has the potential to influence their public health impact. However, regulation remains poorly understood. This study aimed to identify, summarise and compare formal legal frameworks, non‐binding government guidance and recognised self‐regulatory frameworks for the labelling, taxation, licensing and condition of sale and marketing of No/Lo drinks across a diverse set of countries. Methods: We conducted a desk‐based analysis, supplemented by expert input. Eight case study countries (Australia, Finland, Germany, the Netherlands, Norway, Thailand, the United Kingdom [UK] and the United States of America) were selected for their diversity in geography, alcohol consumption and policy environments. Targeted searches identified documents for determining how No/Lo products were regulated in relation to their labelling, taxation, licensing and conditions of sale and marketing. Data were extracted, tabulated and reviewed for accuracy. Results: Regulatory thresholds (%ABV) that determine when drinks fall under alcohol legislation vary widely both across and within countries and definitions of No/Lo products are uncommon. For example, drinks can be labelled as alcohol‐free at ≤ 0.05% alcohol by volume (ABV) in the UK, but ≤ 1.15% ABV in parts of Australia. Sales of drinks below defined thresholds generally do not require a premises licence. Marketing restrictions were generally shaped by those for standard alcoholic drinks, although new self‐regulatory guidance has been developed in Australia, the Netherlands and the UK. Discussion and Conclusions: Governance of No/Lo drinks is fragmented and inconsistent, with definitions and regulatory thresholds varying both across countries and between policy areas within countries.

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.

Alcohol-associated liver disease (ALD) is the leading cause of morbidity, disease-adjusted life years lost, and mortality worldwide. The significant burden and cost to the healthcare systems from ALD are largely preventable, given that alcohol use is the most important determinant of risk and severity of ALD. In this article, we will review the emerging evidence for public health policies (minimum unit price of alcohol, limiting, or banning alcohol advertising), aiming to reduce the availability of alcohol at the population level (primary prevention), preventing ALD especially advanced form of cirrhosis in at-risk individuals (secondary prevention), and improving liver outcomes and long-term survival in patients with advanced ALD of cirrhosis and/or alcohol-associated hepatitis (tertiary prevention). We will highlight the critical role of clinicians in promoting the public health policies, widespread screening for alcohol use disorder and for ALD, and integrating liver with addiction care for patients with ALD.