Unhealthy alcohol use: screening and behavioral counseling interventions

Article information

Korean J Fam Med. 2025;46(1):20-26
Publication date (electronic) : 2024 November 12
doi : https://doi.org/10.4082/kjfm.24.0115
1Department of Family Medicine and Obesity and Metabolic Health Center, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Korea
2Department of Family Medicine, Seoul National University College of Medicine, Seoul, Korea
3Department of Family Medicine, Healthcare System Gangnam Center, Seoul, Korea
4Department of Family Medicine, St. Vincent’s Hospital, Suwon, Korea
5Department of Family Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
*Corresponding Author: Seung-Won Oh Tel: +82-2-2112-5643, Fax: +82-2-2112-5635, E-mail: sw.oh@snu.ac.kr
Received 2024 May 23; Revised 2024 August 19; Accepted 2024 October 15.

Abstract

Background

Despite the increase in daily alcohol intake in recent decades and the implementation of national health screenings, effective management strategies for alcohol consumption remain outdated. This review evaluates intervention studies on screening and behavioral counseling for unhealthy alcohol use, with the aim of enhancing the effectiveness of interventions and improving health outcomes.

Methods

On the basis of the GRADE (Grading of Recommendations Assessment, Development, and Evaluation)- ADOLOPMENT framework, systematic reviews and randomized controlled trials were examined to investigate the effectiveness of screening and counseling interventions in reducing unhealthy alcohol use. Five key questions were generated, and an evaluation and quality assessment of existing systematic reviews and new evidence related to each key question were conducted.

Results

Updating the U.S. Preventive Services Task Force and Cochrane 2018 reviews, we identified five new randomized trials that evaluated screening and counseling interventions for unhealthy alcohol use. For Key Question 2, the sensitivity and specificity of the new screening studies were consistent with those of prior research. Brief interventions were confirmed to reduce alcohol use (Key Question 4a), although additional research is required for a wider array of health outcomes. One study highlighted the benefits of counseling interventions for newborn health indicators in pregnant women (Key Question 4b). No new evidence was found regarding the harms of screening (Key Question 3) or alcohol use reduction interventions (Key Question 5).

Conclusion

This review supports the continued use of brief interventions to reduce alcohol consumption in high-risk groups and highlights the need for culturally tailored research in Korea.

Introduction

Alcohol consumption is a modifiable risk factor that contributes to a range of diseases, including cardiovascular diseases, alcohol-related cancers, alcoholic hepatitis, and mental health disorders [1-5]. In clinical practice, assessing the history of alcohol use is crucial for identifying and addressing unhealthy alcohol consumption [6]. However, this aspect often receives insufficient attention in physician–patient interactions, with referrals to family medicine physicians for alcohol-related discussions frequently lacking patient initiative [7]. Moreover, patients with significant comorbidities who require interventions for alcohol cessation frequently experience suboptimal follow-up care [8].

The National Health Insurance Service of Korea mandates general health screening for all individuals aged 40 years and above and for employees of any age at least once every 2 years at medical institutions nationwide [9]. This program includes anthropometric assessments, social and medical history questionnaires, and laboratory tests. A key component of this screening is a standardized questionnaire that assesses medical history and lifestyle behaviors, such as smoking, alcohol consumption, and physical activity, aiding in the identification of unhealthy alcohol use.

In Korea, daily alcohol intake nearly doubled from 1998 to 2018, increasing from 8.37 to 14.98 g [10]. However, strategies for managing alcohol consumption require updates [11]. Kim et al. [12] conducted a validation study using the Korean version of the Alcohol Use Disorders Identification Test (AUDIT) in 2014. Despite the presence of established protocols, significant shortcomings remain in the effective identification, intervention, and follow-up care of individuals engaged in unhealthy alcohol use. The U.S. Preventive Services Task Force (USPSTF) recommends screening for unhealthy alcohol use in primary care settings for adults aged 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use [13]. In Korea, the Korean Academy of Family Medicine also recommends that all adults be screened for alcohol abuse and behavioral counseling interventions be conducted according to the results [14]. However, this recommendation was published in 2009, hence the need to review and update existing evidence.

The current review aims to evaluate current intervention studies on screening and behavioral counseling for unhealthy alcohol use. Through this review, we seek to bridge the gaps in current practices and enhance the effectiveness of interventions, thereby improving health outcomes in the general population.

Methods

Developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE), the GRADE-ADOLOPMENT process, is a globally accepted and implemented process of evidence-based clinical practice guidelines [15]. On the basis of this process, systematic reviews (SRs) and randomized controlled trials (RCTs) were evaluated to investigate the effectiveness of screening and counselling interventions in reducing unhealthy alcohol use.

Key questions

Regarding screening, a comprehensive USPSTF model was used for adaptation. The key questions (KQs) were adopted from the USPSTF’s recommendation statement [13,16].

KQ 1a. Does primary care screening for unhealthy alcohol use in adolescents and adults, including pregnant women, reduce alcohol use or improve other risky behaviors?

KQ 1b. Does primary care screening for unhealthy alcohol use in adolescents and adults, including pregnant women, reduce morbidity or mortality or improve other health, social, or legal outcomes?

KQ 2. What is the accuracy of commonly used instruments to screen for unhealthy alcohol use?

KQ 3. What are the harms of screening for unhealthy alcohol use in adolescents and adults, including pregnant women?

KQ 4a. Do counseling interventions for reducing unhealthy alcohol use, with or without referral, reduce alcohol use or improve other risky behaviors in screen-detected persons?

KQ 4b. Do counseling interventions for reducing unhealthy alcohol use, with or without referral, reduce morbidity or mortality or improve other health, social, or legal outcomes in screen-detected persons?

KQ 5. What are the harms of interventions to reduce unhealthy alcohol use in screen-detected persons?

Evaluation of previous systematic reviews and quality assessments

To inform our investigation into the effectiveness of screening and counseling interventions for reducing unhealthy alcohol use, we conducted a review and quality assessment of relevant SRs.

Selection of systematic reviews

We searched for SRs published since 2018, which is the last update of the USPSTF recommendation. Our search included databases such as MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL), with a focus on English-language literature. SRs were selected based on their relevance to our KQs, specifically those evaluating the benefits and harms of screening and interventions for unhealthy alcohol use in primary care settings. For KQ 4a, we found one SR in the Cochrane Library in addition to the existing USPSTF recommendation [17]. No additional SRs were identified for any of the remaining KQs.

Quality assessment of systematic reviews

The quality of each SR was critically appraised using the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews) checklist [18], a widely recognized tool for evaluating the methodological quality of SRs. This assessment included evaluations of the comprehensiveness of the literature search, justification for excluded studies, risk of bias in included studies, appropriateness of meta-analytical methods, and consideration of the risk of bias when synthesizing results. Each SR was rated as high, moderate, low, or critically low, providing a clear indication of the reliability of the evidence. The assessment resulted in two SRs being rated as high quality overall. However, funding sources for the individual studies included in the review were not clearly stated in the USPSTF review. Therefore, for KQ 4a, we selected the Cochrane review [17].

Primary data search and selection for the update

Search method

RCTs were selected to update the evidence regarding the benefits and harms of screening for unhealthy alcohol use, as well as the interventions to reduce such use among non-dependent individuals in primary care settings. The search strategy used in the USPSTF recommendation statement was adopted [13]. Both the USPSTF and Cochrane reviews were published in 2018, with search periods extending until October and September 2017, respectively. Therefore, we searched for relevant English-language literature published from January 1, 2017, to our search date (May 4, 2023) using the following databases: MEDLINE, PubMed (for publisher-supplied records only), CENTRAL, and PsycINFO. This approach was aimed at extending the evidence from previous SRs. A research librarian developed and executed the search strategy.

Study selection

In alignment with the USPSTF recommendation statement (KQs 1–3, 4b, and 5) and the Cochrane review (KQ 4a), we adopted the criteria for selecting studies [13,17]. For KQs 1 and 3 (evaluating the benefits and harms of screening) and KQs 4 and 5 (focusing on interventions), we prioritized the inclusion of RCTs, including cluster randomized trials. Non-RCTs were considered eligible if they included control groups such as usual care, no intervention, minimal control, or attention control groups, ensuring rigorous outcome comparisons. For KQ 2, which pertains to the accuracy of screening tests, we restricted inclusion to studies reporting sensitivity and specificity metrics rather than presenting structured or semistructured clinical interviews.

The study included participants who were adolescents and adults aged 12 years and older. For KQs 1–3, the studies did not select participants based on alcohol use or similar behaviors. Conversely, to assess the effectiveness of interventions on alcohol consumption (KQ 4a), we adopted the eligibility criteria of the Cochrane report. The criteria included RCTs focusing on patients seeking primary or emergency care for reasons not directly related to alcohol use but are identified as hazardous or harmful drinkers through screening tools such as the AUDIT or reports of drinking above recommended levels. Control groups varied from no intervention to usual treatment or minimal information. The primary outcome measured was weekly alcohol consumption in grams while the secondary outcomes included heavy drinking episodes, drinking frequency, and health-related quality of life. Exclusion criteria were established to enhance the applicability of studies to primary care settings. In particular, we excluded studies focusing solely on individuals with alcohol dependence or severe alcohol use disorder (AUD), treatment-seeking individuals, those with concurrent psychotic disorders, patients in emergency settings, and other groups not typically encountered in primary care (e.g., inpatients, court-mandated individuals, and incarcerated persons).

For KQ 2, instruments such as AUDIT, AUDIT-Consumption (AUDIT-C), SASQ (Single-Item Alcohol Screening Questionnaire), and their variants (USAUDIT/USAUDIT-C), along with their translations, were included. Instruments targeting specific subgroups (adolescents, pregnant women, and older adults) were also considered. The USPSTF did not limit the inclusion of studies for KQ 1 and KQs 3–5 based on the screening instruments used. For test performance (KQ 2), studies were required to compare screening tests against a reference standard and not another screening instrument. The approved reference standards included structured or semistructured interviews to assess AUD, along with detailed assessments of alcohol quantity and frequency.

For intervention studies addressing KQs 1, 3, 4, and 5, reporting alcohol usage as an outcome was essential, with a minimum follow-up period of 6 months for all groups except pregnant women. The interventions considered were those conducted in or recruitable from primary care or healthcare systems or those feasible for implementation or referral from such settings. The focus was on counseling interventions to mitigate unhealthy alcohol use; hence, studies aimed at preventing initial usage among non-users or those involving pharmacotherapy treatments were excluded.

The screening process was performed by four reviewers who independently reviewed titles and abstracts for potential inclusion. To ensure reliability, the reviewers cross-checked 10% of the studies and obtained a kappa score of at least 0.95, which confirmed a high level of agreement. Following this initial phase, three reviewers assessed the full-text articles. Any discrepancies in the selection process were resolved through consensus discussions to ensure the cohesive and accurate selection of relevant studies.

Quality assessment

To assess the quality of the included studies, we adopted the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool [19], which comprises four key domains: patient selection, index test, reference standard, and flow and timing. We utilized RevMan ver. 5.4 software (Cochrane, London, UK) to summarize the results and create graphs for presenting the QUADAS-2 assessment outcomes.

Results

Study selection

We identified studies from databases and the bibliographies of relevant articles and collected 6,877 entries, including those from PubMed (n=130), Ovid MEDLINE (n=2,852), PsycInfo–EBSCO (n=3,887), and the Cochrane Library (n=8) (Figure 1, Supplement 1). After removing duplicate articles (n=1,604) and applying the selection criteria during the first screening (n=5,013), we reviewed 260 articles in full text. During the second screening, 255 studies were excluded because they did not meet the eligibility criteria. Finally, five studies (four for KQ 2 and one for KQ 4b) were identified and analyzed, extending the evidence from the previous SRs in this study.

Figure. 1.

Diagram of identification of relevant studies. KQ, Key Question.

Effectiveness of screening for unhealthy alcohol use (KQ 1)

The USPSTF review found no trials directly examining the effects of screening for unhealthy alcohol use on alcohol consumption or health, social, or legal outcomes. For this KQ, no additional individual studies were identified in the search results.

Accuracy of screening tests (KQ 2)

Following the USPSTF review [16], our analysis included four studies that assessed the efficacy of screening tools for unhealthy alcohol use, thereby highlighting advancements in screening accuracy (Table 1). The Finnish study on adolescents by Liskola et al. [20] demonstrated a sensitivity of 0.931 to 0.952 and a specificity of 0.663 to 0.772 for the AUDIT over 5 points and the AUDIT-C over 3 points, indicating a relatively higher sensitivity but lower specificity for identifying alcohol problem use. Meanwhile, the U.S. studies by Parast et al. [21] showed a sensitivity of 0.89 and specificity of 0.87 using the NIAAA screening guide to predict AUD. US studies by Campbell et al. [22] and Villarosa-Hurlocker et al. [23] on university students further confirmed the accuracy of these tools, with AUROC values ranging from 0.736 to 0.910.

Summary of included studies for Key Question 2

Previously, the USPSTF review evaluated the accuracy of various screening tools for detecting unhealthy alcohol use across diverse populations, focusing on 277,881 participants in 45 studies. Screening instruments such as AUDIT, AUDIT-C, ASSIST (Alcohol, Smoking and Substance Involvement Screening Test), and 1- or 2-item tests showed acceptable sensitivity and specificity. For the screening tool detecting unhealthy use among adults, sensitivity ranged from 0.73 to 0.88 while specificity ranged from 0.74 to 1.00. Lower cutoffs in AUDIT improved sensitivity while AUDIT-C’s sensitivity was similar, but its specificity varied widely. Evidence on pregnant women and older adults was limited, indicating the need for further research on these groups.

We assessed the quality of the included studies using the QUADAS-2 tool. The results are summarized in Supplement 2.

Harms of screening for alcohol use (KQ 3)

The potential harms of screening include stigma, labeling, discrimination, privacy concerns, and interference with the patient–clinician relationship [13]. The USPSTF review did not evaluate studies on the harms of screening for unhealthy alcohol use. Moreover, our search did not yield any new individual studies on this topic.

Effectiveness of counseling intervention to reduce alcohol use (KQ 4a)

Following the Cochrane report [17], our review did not identify any additional research articles after applying the exclusion criteria. The Cochrane 2018 report included 69 trials (across 112 reports). The primary meta-analysis, which included 34 trials involving 15,197 participants with a median age of 43 years, reported a measure of alcohol consumption that could be converted into grams per week for 12 months. This analysis showed that participants who underwent brief interventions consumed, on average, 20 g less alcohol per week than those in the control groups (95% confidence interval [CI], −28 to −12; I2 =73%) (Supplement 3). Despite the substantial heterogeneity among the studies, the CI for the effect estimate accounted for the variability. A sensitivity analysis restricted to 19 trials deemed at low risk of bias for allocation concealment yielded results that were similar to those of the primary meta-analysis. An analysis of 15 trials reporting the outcome of binge drinking frequency (binges/wk at 12 months) provided moderate-quality evidence of a very small impact on binge drinking frequency (mean difference, −0.08 binges/wk; 95% CI, −0.14 to −0.02). The brief intervention reduced the percentage of heavy and binge drinkers compared with minimal or no intervention, albeit with substantial heterogeneity. However, an analysis of 10 trials on drinking intensity showed moderate-quality evidence of no impact at 12 months (mean difference, −0.2 g/drinking/d; 95% CI, −3.1 to 2.7) [17].

Effectiveness of counseling intervention on health, social, and legal outcomes (KQ 4b)

Health, social, and legal outcomes were reported in 41 trials in the previous USPSTF review [13]. However, no specific outcomes were commonly reported across studies. Although some studies reported slight reductions in emergency room visits or alcohol-related consequences, the outcomes, including all-cause mortality, were generally not statistically significant and inconsistently favored the intervention group. We identified one additional RCT that examined the effectiveness of counseling intervention in the health indicators of newborns among pregnant women [24]. This study assessed the efficacy of brief interventions and advice in reducing alcohol consumption among 486 pregnant Argentinean women. The results indicated that both brief intervention and brief advice effectively reduced alcohol consumption relative to the control group. Furthermore, newborns of women who received the intervention exhibited better health indicators, such as weight at birth and gestational age at birth, than those in the nonscreened control group. These findings highlight the potential benefits of these interventions for healthier newborn outcomes.

Harms of alcohol use reduction interventions (KQ 5)

One possible harm of behavioral counseling interventions could be a paradoxical increase in alcohol consumption, although evidence of intervention harms was limited in the USPSTF review [13]. In the six trials that reported on the harms of interventions, the authors found no harms in the intervention and control groups. Furthermore, our search did not yield any additional studies.

Discussion

We conducted a systematic evaluation of the evidence for screening and counseling interventions to address unhealthy alcohol use. After reviewing the systematic analyses by the USPSTF and Cochrane in 2018, we identified five new randomized studies.

Previous SRs confirmed that primary care-feasible screening instruments effectively identify individuals with unhealthy alcohol use and that counseling interventions for those who screen positive are associated with reductions in unhealthy alcohol use among adults [13,17]. For adolescents, the USPSTF concluded that evidence was insufficient to assess the balance between the benefits and harms of screening and brief behavioral counseling interventions. In KQ 2, we identified four additional trials. The sensitivity and specificity of these studies align with prior findings; however, most studies included in the existing SR and the additional studies were conducted on Western populations, with no specific study on Koreans. Societal factors, cultural norms, neighborhoods, and social contexts can influence alcohol misuse [25]. The omission of specific cultural contexts and the challenges posed by the pandemic may limit the applicability of these results to the Korean population [26]. Regarding KQ 4a, moderate-quality evidence continues to support the efficacy of brief interventions in reducing alcohol use among hazardous and harmful drinkers. Nevertheless, further investigations into a broader range of health outcomes must be conducted. The evidence review for KQ 4b highlights a significant research gap, particularly regarding interventions for pregnant women. Digital interventions such as websites, smartphone apps, and computer programs were not examined in this review because our focus was on direct clinical interventions. However, a review reported that digital interventions could lower alcohol consumption, with an average reduction of up to three standard drinks per week relative to control participants [27]. Given recent developments in digital technology and the increasing trends in related studies, further reviews are warranted.

In conclusion, our findings confirm the benefits of screening and brief behavioral counseling interventions for unhealthy alcohol use in adults. Although this review does not propose new guidelines, the additional evidence reviewed does not suggest the need for major changes to existing recommendations. Nonetheless, a critical need is for primary research tailored to the Korean context to develop culturally relevant interventions. Our findings underscore the importance of future research and intervention strategies specifically designed for the Korean setting to strengthen public health initiatives and improve outcomes for individuals with unhealthy alcohol use.

Notes

Conflict of interest

Seung-Won Oh serves as an editor of the Korean Journal of Family Medicine, but has no role in the decision to publish this article. Se-Hong Kim serves as an Editorial Board member of the Korean Journal of Family Medicine, but has no role in the decision to publish this article. Soo Young Kim serves as an Editorial Advisor of the Korean Journal of Family Medicine but has no role in the decision to publish this article. Except for that, no potential conflict of interest relevant to this article was reported.

Funding

This study was partly supported by the project of the Lifetime Health Maintenance Program in the Korean Academy of Family Medicine.

Data availability

Not applicable.

Author contribution

Conceptualization: SWO, SYK. Data curation: WJ, SWO, SHK. Formal analysis: WJ, SWO. Investigation: WJ, SWO, SHK. Methodology: SWO, SYK. Software: WJ, SWO. Validation: WJ, SWO, SHK. Visualization: WJ, SWO. Funding acquisition: SWO, SYK. Project administration: SWO. Writing–original draft: WJ. Writing–review & editing: WJ, SWO, SHK. Final approval of the manuscript: WJ, SWO, SHK, SYK.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.4082/kjfm.24.0115.

Supplement 1.

Search strategy on PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, and PsycInfo–EBSCO

kjfm-24-0115-Supplementary-1.pdf
Supplement 2.

Summary of risk of bias assessment on newly added studies for Key Question 2 (Quality Assessment of Diagnostic Accuracy Studies-2 tool)

kjfm-24-0115-Supplementary-2.pdf
Supplement 3.

Comparison of quantity of drinking (g/wk) at 12 months between brief intervention versus control.

kjfm-24-0115-Supplementary-3.pdf

References

1. Krittanawong C, Isath A, Rosenson RS, Khawaja M, Wang Z, Fogg SE, et al. Alcohol consumption and cardiovascular health. Am J Med 2022;135:1213–30.
2. Yoo JE, Han K, Shin DW, Kim D, Kim BS, Chun S, et al. Association between changes in alcohol consumption and cancer risk. JAMA Netw Open 2022;5e2228544.
3. Hosseini N, Shor J, Szabo G. Alcoholic hepatitis: a review. Alcohol Alcohol 2019;54:408–16.
4. Makela P, Raitasalo K, Wahlbeck K. Mental health and alcohol use: a cross-sectional study of the Finnish general population. Eur J Public Health 2015;25:225–31.
5. Lima F, Sims S, O'Donnell M. Harmful drinking is associated with mental health conditions and other risk behaviours in Australian young people. Aust N Z J Public Health 2020;44:201–7.
6. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med 1998;158:1789–95.
7. Spithoff S, Kahan M. Primary care management of alcohol use disorder and at-risk drinking: Part 2: counsel, prescribe, connect. Can Fam Physician 2015;61:515–21.
8. Stewart S, Swain S, ; NICE, ; Royal College of Physicians, London. Assessment and management of alcohol dependence and withdrawal in the acute hospital: concise guidance. Clin Med (Lond) 2012;12:266–71.
9. Shin DW, Cho J, Park JH, Cho B. National general health screening program in Korea: history, current status, and future direction. Precis Future Med 2022;6:9–31.
10. Kim SY, Kim HJ. Trends in alcohol consumption for Korean adults from 1998 to 2018: Korea National Health and Nutritional Examination Survey. Nutrients 2021;13:609.
11. Lee S, Kim J, Kim JS. Current status of Korean alcohol drinking in accordance with the Korean alcohol guidelines for moderate drinking based on facial flushing. Korean J Fam Med 2023;44:129–42.
12. Kim CG, Kim JS, Jung JG, Kim SS, Yoon SJ, Suh HS. Reliability and validity of alcohol use disorder dentification test-Korean revised version for screening at-risk drinking and alcohol use disorders. Korean J Fam Med 2014;35:2–10.
13. O’Connor EA, Perdue LA, Senger CA, Rushkin M, Patnode CD, Bean SI, et al. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: an updated systematic review for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality; 2018.
14. The Korean Academy of Family Medicine. Korean lifetime health maintenance program. 3rd ed. The Korean Academy of Family Medicine; 2009.
15. Schunemann HJ, Wiercioch W, Brozek J, Etxeandia-Ikobaltzeta I, Mustafa RA, Manja V, et al. GRADE Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol 2017;81:101–10.
16. US Preventive Services Task Force, Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, et al. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA 2018;320:1899–909.
17. Beyer FR, Campbell F, Bertholet N, Daeppen JB, Saunders JB, Pienaar ED, et al. The Cochrane 2018 review on brief interventions in primary care for hazardous and harmful alcohol consumption: a distillation for clinicians and policy makers. Alcohol Alcohol 2019;54:417–27.
18. Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017;358:j4008.
19. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011;155:529–36.
20. Liskola J, Haravuori H, Lindberg N, Niemela S, Karlsson L, Kiviruusu O, et al. AUDIT and AUDIT-C as screening instruments for alcohol problem use in adolescents. Drug Alcohol Depend 2018;188:266–73.
21. Parast L, Meredith LS, Stein BD, Shadel WG, D’Amico EJ. Identifying adolescents with alcohol use disorder: optimal screening using the national institute on alcohol abuse and alcoholism screening guide. Psychol Addict Behav 2018;32:508–16.
22. Campbell CE, Maisto SA. Validity of the AUDIT-C screen for at-risk drinking among students utilizing university primary care. J Am Coll Health 2018;66:774–82.
23. Villarosa-Hurlocker MC, Schutts JW, Madson MB, Jordan HR, Whitley RB, Mohn RC. Screening for alcohol use disorders in college student drinkers with the AUDIT and the USAUDIT: a receiver operating characteristic curve analysis. Am J Drug Alcohol Abuse 2020;46:531–45.
24. Gimenez PV, Lichtenberger A, Cremonte M, Cherpitel CJ, Peltzer RI, Conde K. Efficacy of brief intervention for alcohol consumption during pregnancy in Argentinean women: a randomized controlled trial. Subst Use Misuse 2022;57:674–83.
25. Sudhinaraset M, Wigglesworth C, Takeuchi DT. Social and cultural contexts of alcohol use: influences in a social-ecological framework. Alcohol Res 2016;38:35–45.
26. Oh CM, Kim Y, Yang J, Choi S, Oh K. Changes in health behaviors and obesity of Korean adolescents before and during the COVID-19 pandemic: a special report using the Korea youth risk behavior survey. Epidemiol Health 2023;45e2023018.
27. Kaner EF, Beyer FR, Garnett C, Crane D, Brown J, Muirhead C, et al. Personalised digital interventions for reducing hazardous and harmful alcohol consumption in community-dwelling populations. Cochrane Database Syst Rev 2017;9:CD011479.

Article information Continued

Figure. 1.

Diagram of identification of relevant studies. KQ, Key Question.

Table 1.

Summary of included studies for Key Question 2

No. Author (country) Year Target population Sample size Measure Definition of unhealthy alcohol use Discriminatory accuracy (AUROC, SS, SP)
1 Liskola et al. [20] (Finland) 2018 Adolescence (12–19 y) 621 AUDIT, AUDIT-C Alcohol problem use AUDIT ≥5 (SS, 0.931; SP, 0.772), AUDIT-C ≥3 (SS, 0.952; SP, 0.663)
2 Parast et al. [21] (USA) 2018 Adolescence (12–18 y) 892 NIAAA screening guide AUD SS, 0.89; SP, 0.87
3 Campbell et al. [22] (USA) 2018 University student 389 AUDIT-C At-risk consumption AUROC, 0.910; SS, 0.903; SP, 0.774; cut-off, 5
4 Villarosa-Hurlocker et al. [23] (USA) 2020 Undergraduate student 382 AUDIT, AUDIT-C, AUDIT-US, AUDIT-US-C DSM-5 AUD AUDIT: AUROC, 0.820 (0.777–0.864); men, 0.831 (0.757–0.905); women, 0.820 (0.767–0.873)
AUDIT-C: AUROC, 0.736 (0.685–0.787); men, 0.742 (0.652–0.833); women, 0.736 (0.685–0.787)
AUDIT-US: AUROC, 0.817 (0.773–0.860); men, 0.822 (0.746–0.898); women, 0.814 (0.760–0.868)
AUDIT-US-C: AUROC, 0.744 (0.692–0.795); men, 0.734 (0.61–0.826); women, 0.745 (0.682–0.808)

AUDIT-C is a shortened version of the AUDIT. The “C” in AUDIT-C stands for “Consumption.” AUDIT-3 refers to a specific subset of the AUDIT, focusing on the third question of the original AUDIT questionnaire. AUDIT-US refers to a version of the AUDIT that has been adapted for use in the United States. AUDIT-C-4 or AUDIT-3-4 refers to a combination of the AUDIT-C, or AUDIT-3 with the fourth questions from, respectively.

AUROC, area under the receiver operating characteristic; SS, sensitivity; SP, specificity; AUDIT, Alcohol Use Disorders Identification Test; NIAAA, National Institute on Alcohol Abuse and Alcoholism; DSM, Diagnostic and Statistical Manual of Mental Disorders.