Elsevier

Drug and Alcohol Dependence

Volume 178, 1 September 2017, Pages 571-578
Drug and Alcohol Dependence

Review
Are brief alcohol interventions targeting alcohol use efficacious in military and veteran populations? A meta-analysis

https://doi.org/10.1016/j.drugalcdep.2017.05.029Get rights and content

Highlights

  • Rates of hazardous and harmful alcohol use are high in military populations.

  • Brief alcohol interventions (BAIs) appear to be effective in the general population.

  • This is the first meta-analysis of BAIs in military and veteran populations.

  • Existing BAIs do not seem to be efficacious in military and veteran populations.

  • Research on BAIs is lacking in serving military populations.

Abstract

Background

Rates of hazardous and harm-related drinking are higher in the military and veteran populations compared to the general population. Brief alcohol interventions (BAIs) targeting alcohol use appear to reduce harmful drinking in the general population. However, less is known about the efficacy of BAIs targeting alcohol in military and veteran populations.

Methods

A systematic review and meta-analysis was conducted to assess the type and efficacy of BAIs used to reduce alcohol use in military and veteran populations conducted from 2000 onwards. The meta-analysis was conducted using a standardised outcome measure of change in average weekly drinks (AWDs) from baseline to follow-up.

Results

The search revealed 10 papers that met the search criteria, and that reported data on 11 interventions included in the systematic review. 8 papers (reporting on 9 different interventions) were included in the meta-analysis after 2 papers were excluded for which the relevant outcome data were not available. There was no overall effect of BAIs; a non-significant weekly drink reduction of 0.95 drinks was found (95% CI, −0.17 to 2.07). This lack of efficacy persisted regardless of military group (conscripts, serving or veterans) and method of delivery (i.e., face-to-face, web-based or written information). Furthermore, sensitivity analyses revealed this small drink reduction was driven mainly by a single study.

Conclusions

Based on these findings, existing BAIs do not seem to be efficacious in reducing alcohol use in military populations, despite some encouraging results from one electronic intervention which was of extensive duration.

Introduction

A high prevalence of hazardous and harmful alcohol use has repeatedly been reported in the US and the UK forces (Bray et al., 2009, Fear et al., 2007). In the US Army, the prevalence of binge drinking (i.e., ≥4 or ≥5 drinks on one occasion, for women and men respectively) is 43% (Stahre et al., 2009), compared to 23% in the general population (Substance Abuse and Mental Health Services Administration, 2011). Even when controlling for age and gender, U.S. military personnel drink more than the general population (Bray et al., 2009). Similarly, both hazardous drinking (drinking which increases the risk of mental or physical harm) and harmful drinking (which results in consequences to mental or physical health) (Babor and Higgins-Biddle, 2001), are higher in the UK military compared to the general population. 67% of men and 49% of women in the UK Armed Forces drink at least at a hazardous level (Fear et al., 2007), compared to 38% of men and 15% of women in the general population (Coulthard et al., 2002).

It is worth noting, however, that data from other countries do not seem to reflect the same situation. While rates of hazardous and harmful drinking are not reported, there seems to be lower levels of ‘risky drinking’ (i.e., >2 drinks per day) among Australian serving and former Defence Force members (Waller et al., 2015) and a lower prevalence of alcohol use disorders in the German military (Trautmann et al., 2016), compared to the general population.

The literature on alcohol interventions in the general population shows promising results in tackling hazardous and harmful drinking, in particular in relation to brief alcohol interventions (BAIs). A systematic review of systematic reviews suggested that face-to-face BAIs are effective in reducing hazardous drinking in primary healthcare settings (O’Donnell et al., 2014). Computer-delivered alcohol interventions are also promising, with a meta-analysis of randomised controlled trials (RCTs) showing an overall significant reduction of alcohol use in the general population (effect size (d) 0.20, p < 0.001) and which did not show heterogeneity between studies of diverse characteristics (Rooke et al., 2010).

According to WHO/AUDIT guidelines, BAIs are of short duration (less than ten minutes) (Babor and Higgins-Biddle, 2001) and can be delivered face-to-face (Bertholet et al., 2005) or online (Kypri et al., 2004). The content is variable but should include brief advice, skills training and practical advice to reduce drinking, and follow-up (Babor and Higgins-Biddle, 2001). These interventions are not designed for use in those with alcohol dependence/alcohol use disorder, who generally require more intensive management (Babor and Higgins-Biddle, 2001).

Many BAIs focus on providing personalised normative feedback (PNF), which compares the subject’s drinking to the general population norm (i.e., a social norms comparison). This approach aims to challenge misconceptions of peer behaviour by contrasting what one perceives to be the drinking norm with the actual norm. For example, in the general population, young people tend to overestimate the drinking behaviour of their peers, and these perceived norms strongly predict their alcohol consumption (Borsari and Carey, 2003). Correcting overestimations of peer drinking norms using PNF results in a reduction in drinking in college students (Miller et al., 2013).

While BAIs have been used in the military to tackle alcohol use, a meta-analysis looking at overall effects of these has yet to be carried out in this population. Military and veteran populations are unique and differ from the general population, not least in their exposure to an entrenched drinking culture (Jones and Fear, 2011). However, like in the general population, misperceptions of peer drinking exist in military and veteran populations. Both veterans and active duty service members tend to overestimate their peers’ drinking, and these misperceptions predict greater personal drinking (Neighbors et al., 2014, Pedersen et al., 2016). As a result, though only in its infancy, research is now looking at the most effective ways of employing PNF interventions to reduce drinking in military and veteran populations (e.g., Pedersen et al., 2016).

This systematic review aimed to explore which BAIs have been used in the military and to conduct a meta-analysis to determine whether these interventions are efficacious in reducing alcohol use in military and veteran populations.

Section snippets

Search strategy

The literature search was conducted in March 2017 using Medline, EMBASE and PsycINFO electronic databases to identify relevant studies published since January 2000. The search terms used were: alcohol AND (army OR armed forces OR armed services OR veterans OR soldiers OR raf OR royal air force* OR military OR navy) AND (intervention OR prevention). The search was applied to include articles where search terms appeared in the title, abstract or keywords. The de-duplicate function was applied.

Inclusion criteria

  • 1.

    The

Study selection

The search identified 1487 abstracts. Screening of these resulted in the exclusion of 1389 abstracts which were not relevant, or which were literature reviews, with 98 abstracts remaining. The full texts were screened, resulting in the exclusion of a further 88 articles which did not meet the inclusion criteria. This resulted in a total number of 10 papers reporting data on 11 interventions that were included for systematic review (1 paper (Pemberton et al., 2011) reported data on 2 separate

Discussion

This systematic review identified a small number of studies (n = 10) that have investigated the efficacy of interventions (n = 11) targeted to alcohol consumption at a hazardous level in the military. A meta-analysis (of n = 8 studies, n = 9 interventions) showed no efficacy of brief alcohol interventions in terms of AWD. Only one of 11 interventions showed a significant effect, which was an intensive rather than brief alcohol intervention (Brief et al., 2013). The lack of efficacy persisted regardless

Conclusion

This review revealed a dearth of studies published in this area, particularly in serving military populations. Studies included in this review and meta-analysis used various alcohol measures, but using the comparable measure of AWDs, brief alcohol interventions in military and veteran populations were not efficacious. This study finds limited evidence that longer, more intensive interventions may be more helpful. Future research investigating the most suitable normative feedback for delivery of

Source role of funding

Nothing declared.

Contributors

LG and AD contributed to the conception and design of this study, AD, CM and LG conducted the data extraction, LG conducted the statistical analysis, AD and LG revised and drafted the article and all authors contributed to and approved the final draft.

Conflict of interest

None.

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