Drinking patterns and the distribution of alcohol-related harms in Ireland: evidence for the prevention paradox.

BACKGROUND: According to the prevention paradox, the majority of alcohol-related harms in the population occur among low-to-moderate risk drinkers, simply because they are more numerous in the population, although high-risk drinkers have a higher individual risk of experiencing alcohol-related harms. In this study we explored the prevention paradox in the Irish population by comparing alcohol-dependent drinkers (high-risk) to low-risk drinkers and non-dependent drinkers who engage in heavy episodic drinking (HED). METHODS: Data were generated from the 2013 National Alcohol Diary Survey (NADS), a nationally representative cross-sectional survey of Irish adults aged 18-75. Data were available for 4338 drinkers. Respondents dependent on alcohol (as measured by DSM-IV criteria), respondents who engaged in monthly HED or occasional HED (1-11 times a year) and low-risk drinkers were compared for distribution of eight alcohol-related harms. RESULTS: Respondents who were dependent on alcohol had a greater individual risk of experiencing each harm (p < .0001). The majority of the harms in the population were accounted for by drinkers who were not dependent on alcohol. Together, monthly and occasional HED drinkers accounted for 62% of all drinkers, consumed 70% of alcohol and accounted for 59% of alcohol-related harms. CONCLUSIONS: Our results indicate that the majority of alcohol consumption and related harms in the Irish population are accounted for by low- and moderate-risk drinkers, and specifically by those who engage in heavy episodic drinking. A population-based approach to reducing alcohol-related harm is most appropriate in the Irish context. Immediate implementation of the measures in the Public Health (Alcohol) Act (2018) is necessary to reduce alcohol-related harm in Ireland.

Potential Impact of Minimum Unit Pricing for Alcohol in Ireland: Evidence from the National Alcohol Diary Survey.

AIM: One of the main provisions of the Irish Public Health (Alcohol) Bill is the introduction of a minimum unit price (MUP) for alcohol in Ireland, set at €1.00/standard drink. We sought to identify who will be most affected by the introduction of a MUP, examining the relationship between harmful alcohol consumption, personal income, place of purchase and price paid for alcohol. METHOD: A nationally representative survey of 3187 respondents aged 18-75 years, completing a diary of their previous week's alcohol consumption. The primary outcome was purchasing alcohol at <€1.00/standard drink; secondary outcome was purchasing alcohol at <€1.00/standard drink off-sales. Primary exposures were harmful alcohol consumption (AUDIT-C > 5), low personal annual income (<€20,000) and place of purchase (off- or- on-sales). RESULTS: One in seven respondents (14%) spent <€1.00/standard drink, with a median spend of 0.78/standard drink. High-risk drinkers (OR 1.56, 95% CI 1.09-2.23), men (OR 1.95, 95% CI 1.43-2.66), people on low income (OR 1.64, 95% CI 1.20-2.23) and those purchasing alcohol off-sales (OR 21.9, 95% CI 12.5-38.1) were most likely to report purchasing alcohol at <€1.00/standard drink. Forty-four per cent of alcohol consumed was purchased off-sales. Of those purchasing off-sales, 30% bought cheap alcohol. High-risk drinkers, men and those on low income were most likely to report paying < €1.00/standard drink off-sales. CONCLUSION: Heavy drinkers, men and those on low income seek out the cheapest alcohol. The introduction of a MUP in Ireland is likely to target those suffering the greatest harm, and reduce alcohol-attributable mortality in Ireland. Further prospective studies are needed to monitor consumption trends and associated harms following the introduction of minimum unit pricing of alcohol.

Estimating Risk of Alcohol Dependence Using Empirically Validated Ordinal Risk Zones Versus Recommended Binary Risk Zones of the RAPS4: A Validation Study Using Stratum-Specific Likelihood Ratio Analysis.

BACKGROUND: Effective treatment options for alcohol dependence exist; yet, only 10% of people with alcohol dependence receive treatment. The objective of the current study was to examine the performance of previously recommended Rapid Alcohol Problem Screen 4 (RAPS4) risk zones, based on single binary cut-points (RAPS4 ≥ 1; RAPS4 ≥ 2), and empirically identified RAPS4 risk zones to identify people with alcohol dependence so that further diagnostic assessment or interventions can be offered. METHOD: Stratum-specific likelihood ratio (SSLR) and receiver operating characteristic analyses were used to compare the screening performance of empirically identified "risk zones" on the RAPS4 to previously recommended binary cut-points in a general population sample of current drinkers in Ireland (N = 4,267). SSLRs were also used along with the pretest prevalence of alcohol dependence to estimate posttest probabilities of alcohol dependence for the recommended and empirically identified risk zones. RESULTS: The weighted prevalence estimate of alcohol dependence among current drinkers was 6.9% (9.3% men; 4.5% women). The SSLR analysis identified multiple risk zones in the RAPS4, with each of the individual scores (0, 1, 2, 3, 4) retained as 5 separate ordinal risk zones for both men and women. A comparison of the area under the receiver operating characteristic curve showed that the ordinal RAPS4 risk zones performed better than recommended binary thresholds for both men and women. Based on the pretest probability of 9.3% and the identified SSLRs for the ordinal risk zones, the posttest probability of alcohol dependence for men ranged from 1.6% for those in the lower risk zone (RAPS4 = 0) to 86.7% for those in the highest risk zone (RAPS4 = 4). The posttest probability of alcohol dependence for women ranged from 0.4% for those in the lower risk zone to 80% for those in the higher risk zone. CONCLUSIONS: The detection of alcohol dependence may be improved using the empirically identified ordinal RAPS4 risk zones for both men and women. The application of the identified SSLRs, particularly if integrated into a clinical decision support system, may be helpful for clinicians in providing feedback to patients regarding their risk of alcohol dependence.