The effectiveness of brief interventions in the clinical setting in
reducing alcohol misuse and binge drinking in adolescents: a critical
review of the literature
Tracey Wachtel and Mabel Staniford
Aims and objectives.To investigate the effectiveness of brief interventions for adolescent alcohol misuse and to determine if these interventions are useful in reducing alcohol consumption. To determine if brief interventions could be used successfully by nurses in the clinical setting.
Background.Australian adolescents are consuming risky levels of alcohol in ever increasing numbers. The fiscal, health-related and social costs of this alcohol misuse are rising at an alarming rate and must be addressed as a matter of priority. Brief interventions have been used with some success for adult problem drinkers in the clinical setting. Brief interventions delivered in the clinical setting by nurses who are ‘on the scene’ are therefore a potential strategy to redress the epidemic of adolescent alcohol misuse.
Design.Literature review.
Methods.Multiple databases were searched to locate randomised controlled trials published within the past 10 years, with participants aged 12–25 years. Included studies used brief intervention strategies specific to alcohol reduction. Fourteen studies met these criteria and were reviewed.
Results.A range of different interventions, settings, participant age-ranges and outcome measures were used, limiting gener-alisability to the studied populations. No trials were carried out by nurses and only one took place in Australia. Motivational interviewing (one form of brief intervention) was partially successful, with the most encouraging results relating to harm minimisation. Long-term follow-up trials using motivational interviewing reported significant reductions in alcohol intake and harmful effects, but this may be partially attributed to a normal maturation trend to a steady reduction in alcohol consumption. Conclusions. No single intervention could be confidently recommended due to confounding evidence. However, successful elements of past studies warrant further investigation. These include face-to-face, one-session, motivational interviewing-style brief interventions, focusing on harm minimisation and all with long-term follow-up.
Relevance to clinical practice.The introduction of brief interventions in the hospital setting has the potential to address the epidemic of adolescent alcohol misuse. Nurses are well placed to deliver these interventions, but a standardised approach is required to ensure consistency. Further research is urgently needed to ensure clinical practice is based on the best available evidence and to ensure findings are more relevant to Australian adolescents and to nurses in a clinical setting.
Key words: adolescent, alcohol misuse, binge drinking, brief intervention, motivational interviewing, nursing Accepted for publication:23 June 2009
Authors: Tracey Wachtel, RN, MNg, Grad Cert HD Nursing, MRCNA, Lecturer in Nursing, Clinical Coordinator, School of Nursing and Midwifery, Flinders University, Renmark, South Australia; Mabel Staniford, RN, BNg, Graduate Registered Nurse, Loxton Health Service Inc., Loxton, South Australia, Australia
Correspondence: Tracey Wachtel, RN, MNg, Grad Cert HD Nursing, MRCNA, Lecturer in Nursing, Clinical Coordinator, School of Nursing and Midwifery, Flinders University, Ral Ral Avenue, PO Box 852, Renmark, South Australia, Australia, 5341. Telephone: +61 08 8586 1025.
Introduction
Alcohol, when consumed heavily over a long period, can cause health problems including cirrhosis of the liver, brain injury, dementia and an increased risk of oesophageal, mouth and throat cancer (Beckham 2007). Alcohol misuse is also associated with depression, relationship difficulties and a decreased quality of life (Australian Bureau of Statistics [ABS] 2004–05). In Australia, alcohol, after tobacco, is the second highest cause of drug-related death and hospital admissions (Australian Institute of Health and welfare [AIHW] 2005a) and is outstandingly the main cause of road fatalities (ABS 2004–05).
The fiscal cost of alcohol abuse in Australia, taking into account a reduction in workdays, premature death and crime, has been estimated at about $15 billion annually (Collins & Lapsley 2008a). Furthermore, the healthcare cost of alcohol abuse is estimated at an alarming $2202 million annually (Collins & Lapsley 2008b). Alcohol has been found to be responsible for over 3100 deaths and 72 000 hospitalisations per year in Australia (Chikritzhset al.2003). This problem is increasingly affecting our adolescent population, with 3300 14–17 year-olds admitted to hospital for alcohol-related injury or disease between 1999–2000. Furthermore, between 1993–2002 an estimated 501 under-age drinkers died from injury or disease related to risky alcohol consumption – including ‘binge drinking’ (Child and Youth Health [CYH] 2008).
‘Binge drinking’ is defined as downing five or more standard drinks in one session (Perkins et al. 2001). This practice can lead to alcohol poisoning even death (CYH 2008). In Australia the proportion of 12–15 year-olds con-suming risky levels of alcohol has doubled from approxi-mately 2Æ5% in 1990 to approximately 5% in 2005. A significant increase in high-risk alcohol consumption has also been reported for 16–17 year-olds over the same time period – up from 15–20% (Rocheet al.2007). In addition, 3Æ4% of adolescents drink alcohol in high-risk amounts (AIHW 2005b).
Numerous interventions have been trialled to address alcohol misuse among adolescents (Larimer & Cronce 2002). While some primary prevention strategies have shown protective effects in terms of adolescent drinking (Botvin & Griffin 2004) other trials argue that primary strategies such as information and education alone do not result in decreases in alcohol consumption (Murphyet al.2001). There is a clear need to expand prevention strategies to incorporate second-ary prevention such as brief interventions and to target adolescents who are already problem drinkers (Murphyet al. 2001).
A brief intervention (BI) is described as an action that can motivate a person to change a problem-causing action (Hyman 2006). BI can last from 5–30 minutes and take the form of a discussion, a workbook, pamphlet or other means (Moyer et al.2002). Some studies have reported positive results for brief interventions in reducing alcohol misuse among adults in an office-based setting (Fleminget al.2002, Saitzet al.2003), as well as in the clinical setting (Wilket al.1997, Crawford et al. 2004, Academic ED SBIRT Research Collaborative Group 2007). Brief motivational intervention is also starting to be recognised as an effective method for reducing alcohol use in college students (Larimer & Cronce 2002).
Motivational interviewing is one particular form of brief intervention that has been found to be effective in reducing alcohol intake and related risk-taking behaviour in adults (Beckham 2007). Motivational interviewing (MI) is ‘a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence’ (Monti et al. 2007, p. 1234). MI techniques include reflective listening, communicating respect and using open-ended questions to explore behaviour and focuses on clients’ strengths to make change (Beckham 2007).
Clinical settings may provide an ideal opportunity to reach adolescents in need of intervention for alcohol-related prob-lems (Monti et al. 1999). Providing interventions in the clinical setting capitalises on a ‘teachable moment’ or a ‘window of opportunity’ (Barnettet al. 2002). Adolescents admitted to hospitals and/or emergency departments for alcohol-related emergencies may be particularly receptive to an intervention because the adverse event is current. The patient’s highly emotional and vulnerable state also makes them more receptive to health advice and recommendations (Academic ED SBIRT Research Collaborative Group 2007).
Aims
Adolescent alcohol misuse is increasing and subsequent admissions to hospital for alcohol-related injury or as a direct result of the effects of a binge-drinking episode are high. There are many potential opportunities to deliver brief interventions (BI) in the hospital setting and nurses are well placed to deliver these interventions. However, it is unclear if hospitals in Australia have a standard BI that nurses can confidently implement. A systematic review by Hyman (2006) on nurses’ delivery of BI for high-risk drinkers, found no meta-analyses addressing the issue and subsequently concluded that while brief interventions carried out by nurses are a legitimate task, little has been done to encourage, develop and/or define it. To develop a standard brief intervention we first need to establish if these interventions
are an effective device in the fight against adolescent alcohol misuse and binge drinking.
The aim of this paper is to review the effectiveness of brief interventions for adolescent alcohol misuse and binge drink-ing and to determine if they are useful in reducdrink-ing alcohol consumption. This paper also aims to determine if brief interventions could be successfully used by nurses in a clinical setting.
Methods
The article search was conducted between August–October 2008 using the online databases CINAHL, Medline, Ovid full text, Ovid, PsycINFO and Cochrane. Search terms used were: ‘adolescent’, ‘young adult’, ‘binge drinking’, ‘alcohol’, ‘motivational interviewing’, ‘motivational intervention’ and ‘brief intervention’. The number of articles retrieved was initially 299 but only six met the inclusion criteria outlined below. Specific journals that informed the topic were also examined, including: Psychology of Addictive Behaviour, Journal of Consulting and Clinical Psychology, Addictive Behaviours, The American Journal of Drug and Alcohol Abuse and Psychology of Addictive Behaviours. Relevant review and study reference lists were also searched and subsequently yielded a further nine studies. Fourteen research studies that met inclusion criteria (as discussed below) were selected for the review.
Inclusion criteria
Inclusion criteria were as follows: studies needed to be Randomised Control Trials (RCT), to be published in English and to have included brief intervention strategies specific to alcohol, or alcohol-risk reduction. To represent the most up-to-date research, the included studies needed to have been published between 1998–2008. The participant age of 12– 25 years was applied as an inclusion criterion in response to the inclusion age range of some of the trials. The authors predominately focused on the adolescent population, but included studies with older participants, up to 25 years, when there was a large age range that had included adolescents. Initially the search included only studies conducted in health care facilities, but this strategy found only five eligible trials. The inclusion criteria were therefore expanded to include colleges or universities and youth service centres.
Exclusion criteria
Studies were excluded if they were published prior to 1998, were not RCT’s, did not have a control group, the age fell
outside of the 12–25 year criterion, or the sample age was not stated. Studies that used participants of up to 25 years, but did not include those less than 20 years were also excluded. One study (Collins & Carey 2005) met all inclusion criteria but failed to state the age range or the mean age of participants and so was excluded from the review. Papers that included substance use other than alcohol, or did not specifically target alcohol use-reduction or alcohol risk-reduction were also excluded, as were those that did not include an alcohol-reduction intervention. Community-based programs and family interventions were not included because of the difficulty in replicating them in an acute hospital setting.
Critique of the studies
The 14 studies included in this review were subject to critical appraisal using questions from the Critical Appraisal Skills Program (CASP) (Milton Keynes Primary Care Trust 2006). This tool assisted with recognising the validity and reliability of the design and appraising the strengths and weakness of the trials. The critical appraisal process of included studies is summarised in Tables 1 and 2.
In the 14 trials included in this review, 2114 participants, having been placed in either an Alcohol Intervention Group (AIG) or a control group (CG), were analysed. The review used studies from multiple settings, including four Hospital Emergency Departments (ED), seven Colleges or Universities, one Healthcare Clinic and one Youth Service Centre. Twelve studies were conducted in the USA, which included all of the
Table 1 Critical appraisal questions applied to the included studies Question
Q.1 Are the aims of the study clear? Q.2 Is this a randomised control trial (RCT)
and is it appropriate?
Q.3 Were the participants randomised to intervention or control groups? Q.4 Was the sampling appropriate?
Q.5 Were participants, staff & study personnel ‘blind’ to participants’ study group? Q.6 Were participants in all groups followed-up
and data collected in the same way? Q.7 Did the study have enough participants
to minimise the play of chance?
Q.8 Were all the participants who started off in the study accounted for at the end? Q.9 Are the results clearly presented and are
they appropriate?
Q.10 Is this study relevant to your clients and/or practice?
College/University, ED and the Healthcare studies. One study took place in the Netherlands (High School) and one in Australia (Youth Service Centre). This highlights not only the general lack of studies conducted in Hospital and ED settings, but also in Australia. The studies were conducted by psychologists, psychiatrists, research scientists, behavioural scientists, medical doctors and PhD and Masters’ students of the afore-mentioned professions. Many of the trials were conducted by a multidisciplinary team. However, it is interesting to note that no trials were conducted by nurses and therefore results may not be generalisable to nurses undertaking the interventions.
Sample selection and sample size
Most studies required participants to meet a specific alcohol-consumption criterion to be included in the trial. One study included all volunteers, regardless of their alcohol intake (Bailey et al. 2004), while another conducted in an ED excluded intoxicated patients due to a perceived inability to be able to adequately complete the survey or intervention (Maioet al. 2005). The omission of this potentially impor-tant group may have altered the findings. Three of the college trials (Borsari & Carey 2000, Careyet al.2006 & Feldstein & Forcehimes 2007) chose their sample from psychology stu-dents, which may have affected reporting and study findings, as participants quite possibly had greater insight into their own behaviour.
Two of the studies warned that results should be used with caution due to small sample size (Murphy et al. 2001 &
Bailey et al. 2004). Participants’ ages varied in the trials. Adolescents can be placed into three groups, early (10– 13 years), middle (14–16 years) and late adolescence (17– 20 years) (Leifer & Hartston 2004). Three studies (Bailey et al. 2004, Boekeloo et al. 2004 & Spirito et al. 2004) included adolescents from all three adolescent age groups, while two others included only the middle and late adolescent groups in their studies (Maio et al. 2005 & Thush et al. 2007). A further two studies included only late adolescents (Feldstein & Forcehimes 2007 & Monti et al. 2007) while two others used late adolescents and older (Montiet al.1999 & Careyet al.2006). In the remaining trials, three stated a mean age (Borsari & Carey 2000, 2005 & Murphy et al. 2001) and two included participants who were younger than 19 years at selection (Marlattet al.1998, Baeret al.2001). The inconsistency of ages in the studies may have influenced the overall conclusion, as differing adolescent maturation stages could affect participants’ readiness for change and therefore influence trial results.
All studies accounted for each participant at the final follow-up (F/U). However, each trial reported an attrition rate, either at the end of the trial or at each F/U (for those with multiple F/Us). Monetary incentive for participation was offered in nine of the studies (Marlatt et al. 1998, Monti et al. 1999, 2007, Baer et al. 2001, Spirito et al. 2004, Borsari & Carey 2005, Maioet al.2005, Careyet al. 2006 & Feldstein & Forcehimes 2007), with course credit given to participants in three of the studies (Murphy et al. 2001, Careyet al.2006 & Feldstein & Forcehimes 2007). It Table 2 Critical appraisal of reviewed studies
Studies Q.1 Q.2 Q.3 Q.4 Q.5 Q.6 Q.7 Q.8 Q.9 Q.10
Baeret al.2001 4 4 4 4 4 4 4 4 4
Baileyet al.2004 4 4 4 4 4 4
Boekelooet al.2004 4 4 4 4 4 4 4 4 4
Borsari & Carey 2000 4 4 4 4 4 4 4 4 4
Borsari & Carey 2005 4 4 4 4 4 4 4 4 4
Careyet al.2006 4 4 4 4 4 4 4 4
Feldstein & Forcehimes 2007 4 4 4 4 4 4 4 4
Maioet al.2005 4 4 4 4 4 4 4 4 4 4 Marlattet al.1998 4 4 4 4 4 4 4 4 4 Montiet al.2007 4 4 4 4 4 4 4 4 4 4 Montiet al.1999 4 4 4 4 4 4 4 4 4 4 Murphyet al.2001 4 4 4 4 4 4 4 4 Spiritoet al.2004 4 4 4 4 4 4 4 4 4 4 Thushet al.2007 4 4 4 4 4 4 4 4
can be assumed that this could introduce the possibility of bias, as under-reporting may occur when incentives are involved.
Study designs and collection of data
All studies included a control group; however, only eight of those were free of any kind of intervention (Marlatt et al. 1998, Borsari & Carey 2000, Murphyet al.2001, Boekeloo et al.2004, Maioet al.2005, Careyet al.2006, Feldstein & Forcehimes 2007 & Monti et al. 2007). One study (Baer et al. 2001) used two control groups: one with high-risk drinking (the same as the intervention group) and the second was a normative group comprised of participants randomly selected from the entire screening pool – regardless of their drinking history. The high-risk control group received a degree of intervention, which was not given to the normative group, thereby making it difficult to accurately compare those findings.
Only six studies clearly stated they were blinded (Monti et al.1999, 2007, Bailey et al. 2004, Boekelooet al.2004, Spirito et al. 2004, & Feldstein & Forcehimes 2007). All studies used self-reporting to collect data from participants by using a set of specific questions (by interview or question-naire) to help answer a research question (Tayloret al.2006, p. 185). This data-collection method has several limitations, including questions that had not been fully understood or had been misinterpreted by participants, low return rates of questionnaires and the fact that group interviews may possibly reduce full and open disclosure (Tayloret al.2006, pp. 220 & 233). Self-reported data may introduce potential bias with the subsequent risk of over- or under-reporting drinking levels and its effects (Tayloret al. 2006, p. 221). Only four trials had collateral verification (Marlatt et al. 1998, Borsari & Carey 2000, Baeret al.2001 & Careyet al. 2006), which may have motivated participants to give more reliable responses.
Framework of review
A critical review framework was used to evaluate the studies. This framework assessed strengths, weaknesses and validity of the studies through explanation, interpretation and anal-ysis (University of New South Wales [UNSW] 2008). As the studies had a range of different interventions, settings, par-ticipant-age ranges and outcome measures, no themes could be identified. Findings are therefore presented in three main sections determined by the time frame of research follow-up: 1 Interventions with short-term follow-up (up to six
months),
2 Interventions with medium-term follow-up (6–12 months) and
3 Interventions with long-term follow-up (longer than 12 months). This is similar to the format used by Foxcroft et al. (2002). Results were tabled to enable analysis and synthesis of the findings from each study and they are presented in Table 3a–c.
Results
Interventions with short-term follow-up (Up to six months)
Five studies used short-term follow-up (Table 3a) and comprised of one Alcohol Intervention Group (AIG) and a control group. In-person follow-ups were conducted in three trials (Borsari & Carey 2000, Baileyet al.2004, & Feldstein & Forcehimes 2007), telephone follow-ups in one (Borsari & Carey 2005) and one conducted follow-ups by both tele-phone (three months) and in person (six months) (Monti et al. 1999). Follow-up periods varied from six weeks (Borsari & Carey 2000)–six months (Montiet al. 1999 & Borsari & Carey 2005). All groups used Motivational Interviewing (MI) techniques and recorded partial success. The most encouraging results were related to harm minimi-sation, with a significant lowering of drink driving, traffic violations, alcohol-related injuries and problems in the MI group when compared to the control group (Monti et al. 1999 & Borsari & Carey 2005). ‘Harm minimisation’ refers to reducing the acute harms that occur with intoxication – including those of health, legal and social harms (Toumbou-rouet al.2005). Montiet al.(1999) conducted their study in an ED and used MI, specifically aimed at reducing the harmful effects of alcohol, while Borsari and Carey (2005) aimed theirs at reducing alcohol use, as well as the alcohol-related problems. Feldstein and Forcehimes (2007) reported a reduction in alcohol-related problems in both groups, but the Alcohol Intervention Group (AIG) reduced problems more than in the control group. However, neither of the other two trials found a reduction in alcohol-related problems (Borsari & Carey 2000, Baileyet al.2004).
Four Alcohol Intervention Groups (AIG) used a single MI session (Montiet al. 1999, Borsari & Carey 2000, 2005 & Feldstein & Forcehimes 2007) while one study required participants to attend four, 30-minute MI sessions, conducted in groups of 10 (Baileyet al.2004). This latter study reported an increase in readiness to reduce alcohol consumption for the AIG and also decreased drinking frequency (while the control increased frequency)…but found that the number of drinks consumed per session was similar to the control and that there was no effect on risk-taking behaviour. A reduction in binge-drinking frequency was reported in two trials
Table 3 Interven tions with (a) short-t erm fol low-up (up to six mont hs); (b) medium -term follo w-up (6–12 mont hs); (c) long ter m follo w-up (longer than 12 mon ths) Aims Desi gn/meth ods Samp le/settings Majo r finding s Study rigou r (a) Bailey et al. 2004, Austra lia To identi fy if a brief m otivati onal interview and cogni tive-be haviour al-bas ed alcoh ol int ervention gro up pro gram is fea sible you ng peo ple at risk of devel oping a prob lem with alco hol and to assess sho rt-term effectiveness o f the interventio n 2 gro up RCT C ontrol Fo rtnigh tly ac cess to an A O D cou nsellor AI G 4 · 10-person group sessi ons using MI tech niques, lastin g 30 –40 minutes Al l Pre-t reatment, Post -treatment, on e & two m o n th fac e-to -fa ce F/U n = 3 4 betw een 12–19 years, (17 female + 1 7 male) Re cruite d via recruit ment-post er in a yout h se rvice centre of a low socio-econ omic are a o f New Sout h Wal es All volunte ers were inc luded regard less of curren t level of alcoh ol int ake AIG group showed incre ase in read iness to redu ce alcoh ol consum pti on, pre-co ntempla tion to contemplati on stage Also redu ced frequ ency of drinki ng at post-tr eatment and 1st F/U asse ssment, while con trol gro up reported inc reases at 2n d F/U No effect on risk-tak ing behaviou r for AIG Control group increased hazardou s drink ing & fre quency of bing e drinki ng compared to AIG Limitati ons Pilot st udy, fa cilitated by auth or of the treatm ent m anual, who also con du cted the po st treat ment asse ssment Small samp le Short F/U period (two m onths) Not a blinded study. 2nd F/U coinci ded wi th Christmas – a socially ac cepted heavier-drinking peri od. No col latera l v erification, se lf-reported data Bo rsari & C arey 2005 NY: USA To evalua te whether Bri ef Mo tivatio nal Inte rventio n (B MI) is superi or to A lcohol Ed ucation (AE ) in re ducing referred st udents’ alco hol use and alcoh ol re lated pro blems 2 gro up RCT C ontrol A E group. Only fa ctual A E given includi ng risk redu ction, no goa l set ting AI G BMI gro up. Person alised feed back, AE related to indi vidual, MI princip les fol lowed Al l Basel ine and three & six month telepho ne F/U n = 6 4 (m ean age = 19 Æ 1 years) Stud ents from 2 college camp uses, referred to alcoh ol pro gram, scori ng 10 or more on an alco hol audi t o r had exp erienced 2 or more bing e drinki ng epi sodes Both gro ups decreased alcoh ol use BMI reduce d alcoh ol–relat ed problems more than A E that was sustain ed at six mon ths BMI demons trate d m ore disclosu re, engagem ent, collabo ration & ben efit than AE Inform ation given in a non-jud gemental setting may facilitate reduct ions Strengt hs Collateral verificati on Rando m sessi ons aud iotaped to assess in tegrity Inter-rate r reliabil ity asse ssed Limitati ons Study not blinded One Interven tionist for bo th groups. May bias re sults Baseline & three mon th F/ U was part of the ir ob ligation Monetar y ince ntive at six m onth F/U
Table 3 (Contin ued) Aims Design /method s Sample/ settings Majo r finding s Study rig our Borsari & C arey 2000 N Y : USA To eval uate feasibility and acceptab ility of an ho ur-long Mo tivatio nal Intervie wing se ssion wit h binge -drinking col lege students, attem pting to replica te a pas t st udy & exam ine medi ating roles on percei ved drinki ng norms with bot h p o sitive & nega tive alcoh ol experien ces 2 group R C T Control No-treatm ent AIG BMI group . Basel ine, custom ised inter vention. 5-com ponent intervention
given All Six
week face-to fa ce F/U n = 6 3 (mea n age = 18.45 years) 59% fema le Sample fr om introdu ctory psycho logy class Participants vol unteered for study Report ed bing e drink ing 2 o r m ore times in past month Sample rate d Bri ef Int er vention a valua ble experien ce Significa nt reduc tions in amoun t o f alcoh ol consum ed & fre quency of binge drinki ng in past month for BI gro up, but not in concurr ent reduc -tion of alcoh ol prob lems Further researc h need ed on medi ating roles Streng ths Participant in terventi on evalua tions Limitati ons One Interven tioni st for both group s Short F/U period (six weeks) Recrui tment may hav e caused b ia s – all psycho logy students wh o signed up for stud y were given subject credit No collatera l verificati on, self-reported data Study not blinded Feldstei n & Forcehi mes 2007 U S A To eval uate the impact of Brief Interven tion on alcoh ol use in undera ge college drinke rs and to exam ine the role of empa thy and alliance with Motiva tional Int erviewi ng (MI) 2 group R T C Control No interventio n, 15 min ute study expla nation on ly AIG MI group . O ne 45 min ute, audio re corded session – option of extra alcoh ol use informa tion. Debri efed at two month
F/U All List
of counselling servic es to use post F/ U. Two m onth face-to face F/U n = 5 5 (aged 18–20 years) 78 Æ 2% fema le Volunt eers from psycho logy students at a Uni Drink onc e in pas t month & re ported binge drinki ng at least once in pas t two week s At two mont h F /U both groups re duced alcoh ol-related prob lems but MI group m ore than Control Only MI had significa nt binge -drinking re ductio ns Findings hi ghlighted impor tance of MI avai l-ability to col lege students Streng ths 3 Doctor al cand idates who had MI traini ng perform ed MI and were blind to samp le Limitati ons Small samp le size Mostly wome n All Psy chology st udents No collatera l verificati on & self-reported data Sample pu t into lot tery, 10% received $50 gift certifi cate Unbal anced gro ups; 40 in MI & only 15 in Control
Tabl e 3 (Con tinued) A ims Design /method s Samp le/settings Majo r finding s Stud y rigour Mo nti et al. 1999 , USA To eval uate the use of brief Mo tivatio nal Intervi ewing (MI ) sessi on to reduc e alco hol-relat ed con sequences & use amo ng adolesc ents treat ed in ED after an alco hol-relat ed ev ent 2 group R C T Cont rol Stan dard Care (SC ) group was the general practice for treatin g Alcoho l-induced teens and included a hand out on avoidin g drinki ng & driving and list of local treatm ent agenc ies (five
minutes) AIG Five
par t M I se ssion (30–35 minutes), informa tion on effec ts of alcoh ol on drivi ng, & person alised feedback
sheet All Baseline
assessm ent, F/U by tele phone at three months and fa ce-to fac e F/U at six mont hs, Hando ut on drink drivi ng, & alcoh ol effects & list of treatm ent agenc ies (SC) n = 9 4 (a g e range 18–1 9 years) Presen ted at 1 hosp ital ED Po sitive bloo d alco hol con tent or a report of drink ing prior to event caus ing tre atment At six months MI recip ients had significa ntl y lower drink driving incid ent, tr affic violat ions, alcoh ol-re lated injuri es & prob lems than control Both gro ups had lo wer alcoh ol consum pti on Stre ngths A ll interve ntionists giv en int ensive MI training and had pra ctice MI sessi on vide otaped Par ticipan ts not ap proac hed unt il passe d Mi ni-mental eval uation Basel ine assessm ent & int ervention in private room , n o family presen t F/U inter view (three & six months ) b y research assi stants blind to tre atment Lim itati ons Mo netary incentive give n Mo dest samp le size, nar row age ran ge & high ref usal rate (b) Bo ekeloo et al. 2004 , Was hington : USA To determi ne whether offi ce-based Brief Mo tivatio nal Interven tio n (BMI) alters adol escent’s bel iefs and alcoh ol use 3 group R C T Cont rol Group 1 – usual care & exit interview AIG Group 2 – 15 minutes audio, self-assessment, exi t interview Group 3 – same as Gr oup 2, plus answer sheet & supp ort services All Teleph one F/U interview at 6 & 12 months n = 409 (age ran ge 12–1 7 years) R ecruited whil e seein g heal thcare provi der for general check -up Ex it interview – alcoh ol bel iefs & self repo rted beh aviour Set ting inc luded 5 man aged care organisa tio ns and prim ary ca re prac tices AIG Group 2 – more bing e drinki ng than group 3 a t 30 day s and three m onths Group 3 – had m ore resista nce to peer press ure to drink AIG had more bi nge drinki ng than Cont rol group Brief offic e-based BMI ineffective in reducing alcoh ol, but may in crease adole scent report ing Stre ngths Onl y one chi ld per family rec ruited into trial R esearchers confirm ed wr itten st ory assessm ent in private room wit hout par ents presen t R esearch assistan ts blin ded
Table 3 (Con tinued ) Aims Desi gn/meth ods Samp le/se ttings Maj or fin dings Study rigou r Carey et al. 20 06, N Y : USA To evalua te the effect iveness of Bri ef Mo tivatio nal Inte rventio ns (B MI) for at risk col lege drinkers 3 gro up RCT C ontrol No tre atment AI G Gr oup 1 – Basic BMI-P ersonal ised feed back, alcohol edu cation & goa l se tting Gr oup 2 – Enhance d BMI (Basi c BMI plus deci sional balan ce exerci se, which they took hom e) Al l Basel ine time line follow back interview (TLFB), 1, 6 & 12-month mail & fac e-to-face F/U n = 509 (age range 18 –25 years) 65 % women 35% men U n i stude nt voluntee rs En rolled in intro psy chology cou rse A t one month, TFBI re duced consum pti on, but no t prob lems Basi c BMI imp roved all dri nking outcomes beyon d TL FB, but enhan ced BMI di d n o t R isk reduc tion was m aintained throug hout fol lowin g year Strengt hs Interven tionists sup ervised Collateral verificati on of se lf-reported data Large sample and lo w at trition rate Limitati ons Course cre dit & m onetary inc entives Participants mostl y wo men Retrospe ctive se lf-reports – recall bias Sample lacke d d iversity, on ly heav y drinke rs used Maio et al. 2005 , US A To determi ne whether Emergency Depart ment-b ased laptop comp uter inter vention redu ces normat ive age-re lated in crease in alcoh ol m isuse, compared with stand ard care 2 gro up RCT C ontrol Stan dard care AI G Lap top-bas ed inter active comp uter progra m wit h sce narios on alcoh ol misu se Al l C omputer bas eline que stionnai re, 3 & 12+ mon ths telepho ne F/U n = 655 (age range 14 –18 years) R ecruited fr o m academ ic me dical centre & a tea ching hosp ital Presen ted at ED withi n 24 hour s post min or inju ry Int oxicated participants excl uded Int ervention not effect ive in decre asing alcoh ol misuse amo ng study popu lation Binge drinki ng amo ng AIG decre ased at three months , bu t ret urned to bas eline at 12 mont hs Strengt hs Research assist ant bl inded to gro ups for F/U & used comp uter pro mpting of quest ions Limitati ons 20% of eligibl e par ticipan ts miss ed or re fused par ticipati on Overall low or no alcoh ol m isuse at bas eline, in toxicated par ticipant s excl uded (du e to being un able to comp lete surv ey & progra m) No col latera l v erification Monetar y ince ntive (po tentia l b ias)
Table 3 (Con tin ued) Aims Design /meth ods Samp le/se ttings Majo r finding s Study rig our Monti et al. 2007, USA Efficiency of Bri ef Motiva tional Inte rviewing (MI) sessi on comp ared to standar d feedbac k in the Emergency Departme nt (ED) for reducing alco hol use & prob lems in youn g adults 2 group RCT Cont rol Feed back only Baselin e assessm ent & one to three minute cou ncillor contact, fe edbac k sheet ,one & three mont h telepho ne cont act (5–1 0 m inutes) AIG MI, telepho ne cont act at one m onth (20 minute) and three months (25–30 minute) . N ew feedback sheet maile d All 30–4 5 minute bas eline assessm ent on computer, Given copy of feed back sheet, bas eline assessm ent, 1, 3, 6 & 12-mont h telepho ne F/U n = 198 (age range 18 –24 years) A lcohol positi ve on ED adm it or Reporte d drink ing 6-hrs prior to eve nt initiatin g ED treatm ent or Scored 8 o r higher on A lcohol Use Di sorders Iden tifica tion Test At 12 mont hs: MI partic ipants drank on fewer days, had fewe r heavy dri nking days and fewer drinks per week in past month than feedbac k only Twic e a s man y M I a s Control reliab ly redu ced alcoh ol intake fr om baseli ne to 12 mont hs No difference in alcoh ol-seeki ng, treatm ent, in juries or violat ions Streng ths Couns ellor traini ng (30 hours) Couns ellors blinded to group Participants re ported on counsel lor behavi our Mini-mental exam ination for participants on judge ment & re adiness to consent and participate Limitati ons Monetar y inc entive introdu ces possibili ty of bias (under-reporting) 9 different counci llors Murphy et al. 2001, Aubur n: USA To eval uate efficacy of Brief Alcohol Scree ning and Interven tion for College students (BA SICS) 3 group RCT Cont rol Assessme nt only AIG MI bas ed intervention 1. BASI CS – 50-m inute indivi dual session s M I style, feedbac k sheet discus sed & info on drinki ng giv en 2. Ed ucation group – 50-m inute indivi dual sessi ons (30 minute s video & 2 0 minutes di scussio n), info on dri nking Both gro ups – feed back after baseli ne & F/U All Three & nine mont h face-to face F/U n = 8 4 (mean age = 1 9 Æ 6 years) 54 % female Fro m same U ni. Sc reened usi ng A lcohol Dep endence Sc ale qu estionnai re Par ticipan ts who were cat egorised in the up per 33 % o f ‘number of drink s-per –wee k’ were se lected At three mont hs Nil sig nifica nt differences, but heav ier drinki ng – BASICS redu ced weekly & binge drinki ng At ni ne months Heavi er drinki ng BA SCIS participants show ed greater reduct ions in weekly alcoh ol consum pti on & binge drinki ng than did heavier drink ing cont rol and educ ation participants BASICS rat ed m ore favoura bly than Educati onal group BASICS m ore effi cacious than Ed ucational interventio ns for heav ier drinki ng col lege students Streng ths Interven tions by 3 gradua te psy chologi sts all with BASICS exp erienc e and supervi sed by cli nical psycho logist s Limitati ons Alcoho l Dep endence scale not do ne at three months – est imates from baseli ne for missing data Self report ing & n o collatera l verificati on Small samp le size Short F/U peri od BASICS & Educati on groups given course credit creating possible bias
T able 3 (Con tinued ) Aims Design /meth ods Samp le/settings Maj or fin dings St udy rigour Spiri to et al. 2004 , San tiago: USA To see whether a bri ef Mot ivationa l Interven tion (MI) session would reduce alcoh ol-related con sequences in an Emergency Depart ment (ED ) 2 group RCT Con trol Stan dard Care, five minute s contact , adv ised to stop drinki ng AIG MI se ssion coverin g 6 areas on alcohol related inf ormatio n Par ents complet ed quest ionnai re and par ticipant s self-report on alcoh ol pro blems All 45 minutes bas eline assessm ent, hand out on avoid ing drink dri ving, three m onth (teleph one) F/U and, 6 & 12 mont hs (fa ce-to fac e) F/U n = 152 (age ran ge 13–1 7 years) Presen ted at 1 hosp ital ED Positi ve blood alco hol con tent on adm issio n or Self-re port of alco hol use 6 hour s prior to treatm ent in ED A t 12 m onths: Bo th groups reported redu ced drinki ng qu antity A lcohol related con sequences re mained low (all lo w a t baseline) MI recipients had sig nifica ntly more imp roveme nt on 2 o f 3 out comes comp ared wi th con trol gro up Fut ure research need ed to repl icate finding s MI has pot ential for cli nically mean ingful effect St rengths F/ U b y Research Assis tants blin d to tre atment gro up Prior to inc lusion Par ticipant s need ed to pass Mi ni-Men tal Exam N o t approach ed until Bloo d Alcohol Con centrati on < 0 Æ 1o r had passed mini-me ntal exam inat ion Lim itati ons Mo netary incenti ve Self-reporting wi th no col lateral verific ation C onclusi ons limited due to ref usal rate. Som e par ticipant s miss ed a F/U Thus h et al. 2007 , Ne therlan ds To inve stigat e the effect iveness of a ‘Lea rning to Dr ink’ inter vention pro gram in changi ng the cogni tive determi nates of drinki ng in a effort to moderat e alcoh ol use & the devel opme nt of alcoh ol-related prob lems in at-risk adole scents 2 group RCT Con trol Infor mation sheet only on alco hol effects, risk factors & conseque nces of heav y drinki ng AIG Seven week ly sessi ons (6 · 90 minutes gro up sessi ons (1 par ent sessi on) & 1 indivi dual MI, inclu ding in dividu alised feedback using BASICS) All Alco hol diary for seven week s & several pre-test self-re port que stionnai res, 6 & 12 mont h F /U by mail n = 107 (age ran ge 14–1 8 years) 61 male, 46 female High school st udents Ave rage alcoh ol consum ed by samp le was 9 Æ 11 Dutc h standar d drink s 77 participants repo rted 1 or more bing e-drink ing epi sode in pas t two weeks Som e effec tiveness in chan ging several cognitive determ inants of drinki ng How ever there wa s n o sig nifica nt difference in decreasing drinking in the AIG gro up comp ared to the C ontrol gro up St rengths 4 cou ncillors trained in MI & used same protoco l (all masters or gradua te stud ents in psy chology) Lim itati ons A ttrition rate 16 % R elatively smal l samp le, high ref usal rate N o col latera l verifi cation of self re ported data
T able 3 (Con tinued ) Aims Desi gn/met hods Samp le/settings Majo r finding s Study rig our (c) Baer et al. 2001, US A To exam ine the long-term respon se to an indivi dual preventive in terventi on for high-r isk college dri nkers relative to the natural history of college drink ers 3 gro up RC T C ontrol 1. High-ri sk Control 2. Norm ative group C ontrol AI G BI , bas eline in dividual ised feed back, in forma tion on redu cing risk s o f alco hol, six mon th F/ U (in person ), MI over ph one at two years F/U Al l Basel ine, 1, 2, 3 & 4-yea r qu estionnai re F/U by mail n = 348, ( < 19 years at start of study) En rolled in same lar ge publ ic U ni. Con sumin g 5–6 drinks in one sessi on at least once in las t mon th or expe riencing at least 3 nega tive alcoh ol effect s o n 3–5 occasions over the las t three ye ars Cont rol Grou p Redu ced drinki ng quan tity & nega tive effects, but no change in freque ncy BI Gr oup Significa nt addi tional reduct ions, par ticularly in negat ive conseque nces Rem ission is normati ve BI for high -risk col lege drinkers ca n achi eve long -term benefits, even in cont ext of matur ationa l trends Strengt hs Baseline interviewers were trained Colla teral verificati on & participants rem inded of collatera l re porting Limitati ons Monetar y ince ntive Sample from on ly one large Uni (result s may not be ge neralise d) Self-rep orted data Only 50% respo nse to initial mail out Mar latt et al. 19 98, US A To eval uate efficacy of a Brief Interven tion (BI) design ed to reduce harmf ul drinki ng effects among high -risk col lege students 3 gro up RC T C ontrol N o-treatme nt, F/U , qu estionnai re & in terviews as per A IG gro up AI G BMI, Basel ine 1 hour in terview Gi ven alco hol monito ring ca rd, feedback interview, 40 high-r isk par ticipant s giv en phone call N ormat ive gro up ( n = 151) all-ris k level s, no t in ana lysis, used for natu ral hi story comp arison Al l Basel ine, six m onth one ye ar (telephone) and 2-yea r (fa ce-to face) F/U n = 348 ( < 19 years at select ion) 188 wome n, 160 men Seni or year of hi gh scho ol all enro lled at same Uni. Scre ening questionnaire for high -risk st udents At 2-year Assessmen t Redu ction of drinki ng rates & harmf ul effects in BMI group Both hi gh-risk groups cont inue to have m ore alcoh ol prob lems than Norm ative group , but reduce d their consum pti on over time This shows a ‘develo pmental matur ation’ effec t Wom en had greater decreases in drinki ng prob lems No predicti ve effect shown wit h par ental alcoh ol prob lems More drinki ng & associa ted prob lems in residential st udents Strengt hs Same traini ng & observed pilot interview with feedback Sample comp inter viewer evalua tion quest ions Private int erviews Colla teral reports Large sample size bu t moderate treatme nt group size Limitati ons Students stil l in high school not used Monetar y ince ntives, introdu ces po ssibility o f bias 11extreme at-risk students not in stud y but referred for tre atment Self-rep orted data A IG, Alco hol Inte rventio n G roup; BASIC S, Brie f Alcoho l Scree ning and Inte rventio n for Col lege st udents; BI , Brie f Interven tion; BMI, Brief Motiva tional Inte rventio ns; ED, Emergency Dep artmen t; F/U, Follow Up; MI, Mo tivatio nal Intervi ewing; RC T, Rando mised Control Trial; SA, Self Assessme nt; TFBI , Tim eline Follow Back Inte rvi ew.
(Borsari & Carey 2000 & Feldstein & Forcehimes 2007), with one also finding significant reductions in alcohol consumption, but not in a concurrent reduction of alcohol problems (Borsari & Carey 2000). Because follow-up for the studies was short, it could be concluded that there was insufficient time to assess changes properly that may occur over a longer assessment time-frame, or if any of the changes were sustained.
Interventions with medium-term follow-up (6–12 months) Interventions with medium-term follow-up comprised seven studies (Table 3b). Follow-up periods ranged from nine months (Murphy et al. 2001)–12 months (Boekeloo et al. 2004, Spirito et al. 2004, Maio et al. 2005, Carey et al. 2006, Montiet al.2007 & Thush et al.2007). Three trials compared two alcohol intervention groups (AIG) and a control group (Murphyet al.2001, Boekelooet al.2004 & Carey et al. 2006). Of these, one used an audio program (Boekeloo et al. 2004) and reported it to be ineffective in reducing alcohol consumption, but found when provider prompting was also used (as in their second AIG), it increased adolescent reporting. This could indicate that face-to-face interventions are more effective with adolescents. The other two, three-group trials both used Motivational Interviewing (MI) in at least one of their AIGs. One study (whose AIG groups both used MI) reported reduced alcohol consumption but no reduction in associated problems (Careyet al.2006). The other trial found no significant differences, although there was some reduction in both weekly and binge drinking in the AIG that used MI (Murphy et al. 2001), further highlighting the potential effectiveness of MI over other interventions.
The remaining four studies had one Alcohol Intervention Group (AIG) and a control group (CG) (Spiritoet al.2004, Maioet al. 2005, Monti et al.2007 & Thushet al. 2007). Of those, three used MI (Spirito et al. 2004, Monti et al. 2007 & Thushet al.2007) but only one reported significant results – where twice as many AIG than CG participants reduced their alcohol intake from the baseline to the 12-month review (Monti et al. 2007). However, no differ-ence was found in alcohol-related injury treatment or violations. One study ran two individual MI sessions (one at the beginning and one at the end) and then required participants to attend six, 90-minute group sessions (Thush et al. 2007). The trial reported no significant differences in decreased drinking in the AIG when compared to the control. Spiritoet al.(2004) found that both groups lowered drinking quantity, but the group that had received MI had more improvement.
One of the two group studies used a brief intervention other than motivational interviewing. Maioet al.(2005) used a laptop-based interactive computer program in an ED, where participants chose a cartoon character to play at a party and thereafter made decisions related to drinking. Their decisions resulted in different consequences and interactive feedback was provided at the end. No effective decrease in alcohol misuse was noted. Binge drinking did decrease in the Alcohol Intervention Group at three months, but returned to baseline at 12 months. It is unclear if the initial decrease was due to the intervention, which questioned their alcohol use, or as a result of the injury and reason behind their admission to the ED.
Interventions with long-term follow-up (longer than 12 months)
Two trials (Table 3c) provided long-term follow-up (Marlatt et al.1998 & Baeret al.2001). Both had one AIG (providing a single Motivational Interviewing session) and a control group; but also included a second normative control group (chosen from the entire screening pool as a normative comparison). Baer et al. (2001) reported significant reduc-tions in the negative consequences of high-risk drinking and in the quantity of consumption over the four-year follow-up. The greatest effect was found in a reduction of the negative consequences of drinking. It also found that the high-risk control group drinkers, although they continued to drink more than the normative group, steadily reduced the quantity of alcohol intake and associated problems over time. This may be attributed to a normal maturation trend whereby adolescents reduce high-risk drinking as they get older. This maturation trend was also evident in the second long-term study (Marlattet al.1998), which reported at the final two-year follow-up a reduction in drinking rates and harmful effects in the AIG, when compared to the no-treatment control group.
Discussion
The 14 studies included in this critical review used a range of different interventions over short, medium and long-term follow-ups, thereby confounding the findings. Varied settings, participant age ranges and a range of different outcome measures all had the potential to affect the outcomes of individual trials and therefore limit generalisability to the studied populations. Twelve studies used a Motivational Intervention (MI) style of intervention, seven of which reported reduced alcohol frequency and amount (Marlatt et al.1998, Borsari & Carey 2000, Baeret al.2001, Murphy
et al.2001, Spiritoet al.2004, Careyet al.2006, Montiet al. 2007). Two studies specifically found a reduction in binge-drinking episodes (Borsari & Carey 2000 & Feldstein & Forcehimes 2007) and seven reported a decrease in harmful alcohol effects (Marlattet al.1998, Montiet al.1999, Baer et al.2001, Spiritoet al.2004, Borsari & Carey 2005, Carey et al.2006 & Feldstein & Forcehimes 2007).
Two studies that had held multiple Motivational Interview sessions for its participants reported no significant results in relation to alcohol misuse; however, they did find an increase in readiness to reduce alcohol intake (Baileyet al. 2004 & Thushet al.2007). Both trials that used a brief intervention other than MI (Boekeloo et al. 2004 & Maio et al. 2005) found the intervention ineffective for reducing alcohol misuse for adolescents. It could be hypothesised from this result that MI is more effective in reducing adolescent alcohol misuse than the other brief interventions reviewed (which consisted of an interactive lap-top computer scenario and an audio-session scenario about alcohol misuse). However, as there were only two trials with which to make a comparison and because the MI studies had varying outcomes, it remains inconclusive.
The short-term follow-up studies all used Motivational Interviewing as an intervention and reported some positive results – especially in the area of harm minimisation. Binge drinking also reduced in two trials (Borsari & Carey 2000 & Feldstein & Forcehimes 2007) with some reduction in frequency and in the amount of alcohol consumed. The short follow-up period of these trials may have affected the findings, as there was only a limited time to assess the interventions. However, it can be concluded from these studies that MI interventions can have some success in reducing alcohol consumption and harm minimisation over the short term. The long-term follow-up trials both reported significant reductions in alcohol intake and harmful effects. However, they also found that a normal maturation trend contributed to a steady reduction in the quantity of alcohol consumption and its associated problems.
Overall, it is difficult to make a definitive conclusion on the effectiveness of any one Brief Intervention in reducing alcohol misuse and binge drinking among adolescents. Although most studies used motivational interviewing type brief interventions, no intervention designs were the same, making it difficult to recommend any particular one as being superior. It can be said that MI appeared to have more success than other brief intervention types and that even a single-session intervention can produce positive results. An important finding was that face-to-face delivery of the intervention might possibly be more effective for adolescents than audio or laptop-computer delivery.
Two earlier systematic reviews addressing the prevention of alcohol misuse by adolescents reported similar difficulties to those identified by this review. A lack of reliable evidence was reported more than 10 years ago by Foxcroft et al. (1997), who could not really recommend any one prevention program over another to prevent alcohol misuse. A more recent review by the same authors (Foxcroft et al. 2002) found that culturally-based interventions, as well as The Strengthening Families program by Spoth (2000, cited in Foxcroft et al. 2002) had potential value; however, they would both be difficult to replicate in an acute hospital setting. They also recommended an international register be established on drug and alcohol prevention interventions, complete with ratings in terms of their relative safety, efficacy and effectiveness (Foxcroftet al.2002).
Implications for nursing practice and further
research
Health care settings provide an ideal opportunity to reach adolescents who are in need of intervention for their alcohol misuse (Montiet al.1999). Adolescents admitted for alcohol-related emergencies may be particularly receptive to an intervention because of the current nature of the event and the patient’s highly emotional state (Montiet al.1999). Brief interventions (including motivational interviewing) are par-ticularly suited to the emergency department and hospital setting due to their brevity. The intervention combines personal feedback with an empathetic approach (Miller & Rollnick 2001), both of which are well in a nurse’s scope of practice. Any admission to the Emergency Department due to alcohol-misuse/alcohol-induced injury or illness, therefore, provides an ideal opportunity to reach adolescents who may benefit from an intervention.
The diversity of interventions discussed in this review makes it difficult to recommend one as superior to the others. Further research comparing similar interventions, settings and trial designs is therefore required to evaluate their effectiveness and to assist with the development of a standardised intervention in Australian hospitals. Qualitative studies could also be useful to investigate; that is, from the perspective of the adolescent, why some interventions are more effective than others and thereby providing greater insight into the development of a truly successful intervention. In particular, nursing research conducted in Australia is needed to ensure that the findings are relevant to Australian adolescents and to our nurses in the clinical setting.
Although this paper is unable to endorse any of the reviewed studies confidently, it can, however, recommend
elements to be included in trial designs for future research. These are: face-to-face, one-session, motivational interview-ing-style brief interventions aimed at harm minimisation and using long-term follow-up. It could be hypothesised that by combining these elements into one intervention, a successful outcome in reducing alcohol use and minimising harm among adolescents could be attained.
Conclusion
In Australia the number of adolescents consuming risky levels of alcohol is increasing at an alarming rate, with the number of adolescent hospital admissions as a result of alcohol-related injury or disease becoming extremely high. These admissions create many opportunistic moments to conduct brief interventions in the hospital setting, with nurses being well placed to deliver them. Described as an action that can motivate a person to change a problem-causing action, Brief Interventions have been found to incorporate a legitimate role for nurses, but little has been done to develop and define this role. Adolescents admitted to an Emergency Department with alcohol-related issues usually have only a short stay. Any intervention used by nurses in a clinical setting needs to be simple, quick, effective and inexpensive and to be based on the best available evidence. Further Australian research is urgently needed to ensure recommendations are relevant to Australian adolescents and nurses in a clinical setting, so that we can begin to address the alarming social and financial cost of teenage binge drinking.
Acknowledgement
We wish to acknowledge Leonie Porter-Nocella for her assistance during the editing stage of this paper.
Contributions
Study design: MS; data collection and analysis: MS & TW; manuscript preparation: TW & MS.
Conflict of interest
There were no conflicts of interest in the preparation and writing of this paper.
References
Academic ED SBIRT Research Collaborative Group (2007) The impact of screening, brief intervention and referral for treatment
on emergency department patients’ alcohol use.Annals of Emer-gency Medicine50, 699–710.
Australian Bureau of Statistics (2004–05)Alcohol Consumption in Australia: A Snapshot, no. 4832.0.55.001. ABS, Canberra. Australian Institute of Health and Welfare (2005a) A Picture of
Australia’s Children, AIHW Cat. No. PHE 58. AIHW, Canberra. Australian Institute of Health and Welfare (2005b)2001 National Drug Strategy Household Survey: detailed findings 2002, AIHW Cat. No. PHE 41. AIHW, Canberra.
Baer JS, Kiviahan DR, Blume AW, McKnight P & Marlatt A (2001) Brief intervention for heavy-drinking college students: 4-year fol-low-up and natural history.American Journal of Public Health91, 1310–1316.
Bailey KA, Baker AL, Webster RA & Lewin TJ (2004) Pilot ran-domized controlled trial of a brief intervention group for adoles-cents.Drug and Alcohol Review23, 157–166.
Barnett NP, Lebeau-Craven R, O’Leary TA, Colby SM, Woolard R & Rohsenow DJ (2002) Predictors of motivation to change after medical treatment for drinking-related events in adolescents. Psychology of Addictive Behaviours16, 106.
Beckham N (2007) Motivational interviewing with hazardous drinkers.Journal of the American Academy of Nurse Practitioners
19, 103–110.
Boekeloo BO, Jerry J, Lee-Ougo WI, Worrell KD, Hamburger EK, Russek-Cohen E & Snyder MH (2004) Randomized trial of brief office-based interventions to reduce adolescent alcohol use. Archive of Pediatrics & Adolescent Medicine158, 635–642. Borsari B & Carey KB (2000) Effects of a brief motivational
inter-vention with college student drinkers.Journal of Consulting and Clinical Psychology68, 728–733.
Borsari B & Carey KB (2005) Two brief alcohol interventions for mandated college students.Psychology of Addictive Behaviours
19, 296–302.
Botvin GJ & Griffin KW (2004) Life skills training: empirical pre-dictions and future directions.Journal of Primary Prevention25, 211.
Carey KB, Carey MP, Maisto SA & Henson JM (2006) Brief moti-vational interventions for heavy college drinkers: a randomized control trial.Journal of Consulting and Clinical Psychology74, 943–954.
Chikritzhs T, Catalano P, Stockwell T, Donath S, Ngo H, Young D & Matthews S (2003)Australian Alcohol Indicators: Patterns of Alcohol Use and Related Harms for Australian States and Terri-tories 1990–2001. National Drug Research Institute, Perth, WA. Child and Youth Health (CYH) Children, Youth and Women’s
Health Service (2008) Alcohol and Young People, available at URL: http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx? p=243&np=163&id=2118 (accessed 20 October 2008).
Collins SE & Carey KB (2005) Lack of effect for decisional balance as a brief motivational intervention for at-risk college drinkers. Addictive Behaviours30, 1425–1430.
Collins D & Lapsley HM (2008a)The Costs of Tobacco, Alcohol and Illicit Drug Abuse to Australian Society in 2004/05, National Drug Strategy Monograph Series No. 64. Commonwealth of Australia, Canberra.
Collins D & Lapsley HM (2008b)The Avoidable Costs of Alcohol Abuse in Australia and the Potential Benefits of Effective Policies
to Reduce the Social Costs of Alcohol, National Drug Strategy Monograph Series No. 70, Commonwealth of Australia, Canberra. Crawford MJ, Patton R, Touquet R, Drummond C, Byford S, Barrett B, Reece B, Brown A & Henry JA (2004) Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial.The Lancet
364, 1334.
Feldstein SW & Forcehimes AA (2007) Motivational interviewing with underage college drinkers: a preliminary look at the role of empathy and alliance.The American Journal of Drug and Alcohol Abuse33, 737–746.
Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA & Barry KL (2002) Brief physician advice for problem drinkers: long term efficacy and benefit-cost analysis.Alcoholism: Clinical and Experimental Research26, 36–43.
Foxcroft D, Lister-Sharp D & Lowe G (1997) Alcohol misuse pre-vention for young people: a systematic review reveals methodo-logical concerns and lack of reliable evidence of effectiveness. Addiction92, 531–537.
Foxcroft D, Ireland D, Lowe G & Breen R (2002) Primary prevention for alcohol misuse in young people.Cochrane Database of Sys-tematic Reviews 2002, Issue 3. Art. No: CD003024. DOI: 10.1002/14651858.CD003024.
Hyman Z (2006) Brief interventions for high-risk drinkers.Journal of Clinical Nursing15, 1383–1396.
Larimer ME & Cronce JM (2002) Identification, prevention and treatment: a review of individual-focused strategies to reduce problematic alcohol consumption by college students [Special Issue].Journal of Studies on Alcohol, (Supplement)14, 148. Leifer G & Hartson HJ (2004)Growth and development across the
lifespan: A health promotion focus. Elsevier Science, Portland. Maio RF, Shope JT, Blow FC, Gregor MA, Zakrajsek JS, Weber JE
& Nypaver MM (2005) A randomized controlled trial of an emergency department-based interactive computer program to prevent alcohol misuse among injured adolescents’. Annals of Emergency Medicine45, 420–429.
Marlatt GA, Baer JS, Kivlahan DR, Dimeff LA, Larimer ME, Quigley LA, Somers JM & Williams E (1998) Screening and brief inter-vention for high-risk college student drinkers: results from a 2-year follow-up assessment. Journal of Consulting and Clinical Psy-chology66, 604–615.
Miller WR & Rollnick S (2001)Motivational Interviewing: Prepar-ing People to Change Addictive Behaviour. Guilford Press, New York.
Milton Keynes Primary Care Trust (2006) 10 Questions to help you make Sense of Randomized Control Trials. Available at URL: http://www.phru.nhs.uk/Doc_Links/rct%20appraisal%20tool.pdf (accessed 30 August 2008).
Monti PM, Colby SM, Barnett NP, Spirito A, Rohsenow DJ, Myers M, Woolard R & Lewander W (1999) Brief intervention for harm reduction with alcohol-positive older adolescents in a Hospital
Emergency Department.Journal of Consulting and Clinical Psy-chology67, 989–994.
Monti PM, Barnett NP, Colby SM, Gwaltney CJ, Spirito A, Rohse-now DJ, Myers M & Woolard R (2007) Motivational interviewing versus feedback only in emergency care for young adult problem drinking.Addiction102, 1234–1243.
Moyer A, Finney JW, Swearingen CE & Vergun P (2002) Brief interventions for alcohol abuse: a meta-analytic review of con-trolled investigations in treatment-seeking and non-treatment-seeking populations.Addiction97, 279–292.
Murphy JG, Duchnick JJ, Vuchinich RE, Davison JW, Karg RS, Olson AM, Smith AF & Coffey TT (2001) Relative efficacy of a brief motivational intervention for college student drinkers. Psy-chology of Addictive Behaviours15, 373–379.
Perkins HW, DeJong W & Linkenbach J (2001) Estimated blood alcohol levels reached by ‘binge’ and ‘nonbinge’ drinkers: a survey of young adults in Montana.Psychology of Addictive Behaviours
15, 317–320.
Roche AM, Bywood P, Borlagdon J, Lunnay B, Freeman T, Lawson L, Tovell A & Nicholas R (2007)Young People and Alcohol: The Role of Cultural Influences. National Centre for Education and Training on Addiction, Adelaide.
Saitz R, Horton NJ, Sullivan LM, Moskowitz MA & Samet JH (2003) ‘Addressing alcohol problems in primary care: a cluster randomised, controlled trial of a systems intervention: the screen-ing and intervention in primary care (SIP) study.Annals of Internal Medicine138, 372.
Spirito A, Monti M, Barnett NP, Colby SM, Sindelar H, Rohsenow DJ, Lewander W & Myers M (2004) A randomized clinical trial of a brief motivational intervention for alcohol-positive adolescents treated in an Emergency Department.The Journal of Pediatrics
143, 396–402.
Taylor B, Kermode S & Roberts K (2006)Research in Nursing and Health Care: Evidence for Practice, 3rd edn. Thompson, Victoria, Australia.
Thush C, Wiers RW, Thiunissen N, Van den Bosch J, Opdenacker J, van Empelen P, Moerbeek M & Feron FJM (2007) A randomized clinical trial of a targeted intervention to moderate alcohol-related problems in at-risk adolescents.Pharmacology, Biochemistry and Addictive Behaviour86, 368–376.
Toumbourou JW, Beyers JM, Catalano RF, Hawkins JD, Arthur MW, Evans-Whipp T, Bond L & Patton G (2005) Youth alcohol and other drug use in the United States and Australia: a cross-national comparison of three state-wide samples.Drug and Alco-hol Review26, 515–523.
University of New South Wales (UNSW) (2008)The Learning Centre website,Sydney, viewed 28 October 2008, http://www.lc.unsw. edu.au/onlib.critrev.html
Wilk AI, Jensen NM & Havighurst TC (1997) Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers.Journal of General Internal Medicine12, 274.