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[Shanel Arrendell]

Heavydrinking is responsible for major health and social problems. Brief interventions have been shown to be effective, but there have been difficulties in reaching those who might benefit from them. Pilot studies have indicated that a Web-based intervention is likely to be acceptable to heavy drinkers and may produce some health benefits. However, there are few data on how many people might use such a program, the patterns of use, and potential benefits.

The aim was to examine the demographic characteristics of users of a free, Web-based, 6-week intervention for heavy drinkers and to describe the methods by which users identified the site, the pattern of site use and attrition, the characteristics associated with completing the program, and the self-reported impact on alcohol-related outcomes.

The records of 10000 users were analyzed. The mean age was 37.4 years, 51.1% were female, 37.5% were single, and 42.4% lived with children. The majority were White British, lived in the United Kingdom, and reported occupations from the higher socioeconomic strata. Over 70% connected to the Down Your Drink (Down Your Drink) site from another Internet-based resource, whereas only 5.8% heard about the site from a health or other professional. Much of the Web site use (40%) was outside normal working hours. Attrition from the program was high, with only 16.5% of registrants completing the whole 6 weeks. For those who completed the program, and the final outcome measures, measures of dependency, alcohol-related problems, and mental health symptoms were all reduced at week 6.

The Web-based intervention was highly used, and those who stayed with the program showed significant reductions in self-reported indicators of dependency, alcohol-related problems, and mental health symptoms; however, this association cannot be assumed to be causal. Programs of this type may have the potential to reach large numbers of heavy drinkers who might not otherwise seek help. There are significant methodological challenges and further research is needed to fully evaluate such interventions.

Excess alcohol consumption, and the harm caused by it, is a major public health concern throughout the developed world [1-3]. Regular heavy alcohol consumption and binge drinking are associated with physical problems, mental health problems, antisocial behavior, violence, accidents, suicide, injuries, road traffic accidents, unsafe sexual behavior, underperformance at school, and crime. In the United Kingdom, alcohol misuse accounts for over 30000 hospital admissions for alcohol dependence, up to 70% of all admissions to accident and emergency departments at peak times, and up to 22000 premature deaths. The total cost of alcohol misuse to the health service was calculated to be 1.7 billion per annum, which though substantial, is much less than the total annual cost of alcohol-related crime (7.4 billion) and lost productivity (6.4 billion) [3]. Similar costs are identified in the United States, with the overall economic cost of alcohol abuse estimated at $184.6 billion, most of which was attributed to lost productivity [1]. Alcohol dependence is not confined to adulthood: in 2000, nearly 14% of 16- to 19-year-olds in Great Britain were found to experience dependence on alcohol [3].

Brief interventions seek to change views of the personal acceptability of excessive drinking and to encourage self-directed behavior change. They can be delivered by practitioners or as self-help materials. There is a substantial body of evidence demonstrating that brief interventions for individuals at risk can have significant impact on reducing alcohol consumption and, in some cases, alcohol-related harm when delivered both in primary and secondary health care settings [4-8]. However, their impact on public health has been severely limited, due partly to the reluctance of at-risk individuals to seek help [9] and partly to a lack of health care resources and the unwillingness of health care professionals to undertake these interventions [10]. General practitioners, for example, who are in a key position to deliver such interventions, rarely do so because of both lack of skills and fear of potential adverse effects on relationships with their patients [10].

Until recently, self-help materials were almost exclusively paper-based. However, the Internet has triggered a growth in more interactive self-help materials. It is thought that this interactivity is likely to enhance the potential for behavior change [11]. In public health terms, the Internet has the considerable advantage that once the Web site has been developed, the marginal cost of delivering the intervention to unlimited numbers of people is minimal, in marked contrast to face-to-face interventions. Approximately 60% of individuals in the United Kingdom report using the Internet regularly [12], and a recent telephone survey in Canada showed that current drinkers are more likely to have access to the Internet than abstainers [13]. Heavy drinkers have been shown to benefit from a PC Windows-based behavioral treatment program [14,15]. Younger people, who are most at risk of binge drinking [3], use new information and communication technologies such as the Internet and mobile phones in preference to more traditional sources of health information or health promotion [16]. Pilot studies have shown that people with drinking problems are willing to use screening tools on the Internet [17,18]. One study asked Web site visitors to complete a questionnaire about their alcohol use and provided a brief intervention in the form of feedback and advice [19]. A recent review identified a number of Internet-based screening and assessment tools (but few treatment or intervention-based applications), which were mostly directed at college students and usually required users to attend special sessions in an office [20-22].

One exception is the Alcohol Help Centre, which provided online personal feedback to users of an online eHealth service [23]. A modified version of this Internet-based tool was piloted in Finland. In a relatively small cohort study (n = 343), at 3-month follow-up, users had reduced their drinking compared to baseline [24].

The aims of the present study were to describe the patterns of use and self-reported effectiveness among users of Down Your Drink. The study set out to describe the demographic characteristics of users, the methods employed to identify and access Down Your Drink, the patterns of use, the demographic and clinical characteristics associated with completing the 6-week program, and self-reported changes in alcohol-related outcomes associated with use of Down Your Drink.

Down Your Drink was developed with support from the Alcohol Education and Research Council as a Web-based interactive program of brief interventions to reduce alcohol consumption in heavy drinkers and is hosted on a single dedicated Web site [25].

The animated home page invited visitors to assess their level of drinking by taking the Fast Alcohol Screening Test (FAST) [26]. Feedback was presented numerically and visually. The home page (Figure 1) also contained links to frequently asked questions (FAQs) about heavy drinking, information about the 6-week program, its authors, the research study, and the organizations sponsoring the site (The National Health Service, Alcohol Concern, Alcohol Education and Research Council, and the Royal Free and University College London Medical School ).

An off-line advertising campaign was run in September 2001 to coincide with the launch of the Web site and the early part of the pilot study. All off-line advertising ceased at the end of 2001 (Multimedia Appendix 2). The site was also registered with the Yahoo search engine and was listed in the information pages of a number of UK-based health-related periodicals. By the time this study started (September 2003), there had been no off-line advertising for this Web site for over 18 months. All visitors to the Down Your Drink site were invited to complete an initial assessment using the FAST [26]. The maximum score for the FAST is 16, and the cutoff point for risky drinking is 3. Those who scored 3 or above were advised that they were at risk from their drinking behavior and were directed to the free 6-week program. Those with lower FAST scores were also able to use the program. Visitors who wished to participate in the 6-week program were required to complete an online consent form (Multimedia Appendix 3) and provide registration data prior to accessing the site. Following this, they could enter the first week of the program.

In order to participate, users were invited to read the policy on confidentiality, complete the consent procedure, and then choose a username and password. Those who agreed to register were required to submit information about their age, gender, marital status, family composition, ethnicity, occupation, country of residence, and how they had learned about the site.

The primary outcome measure was the 14-item Short Alcohol Dependency Questionnaire (SADD), which measures dependency on alcohol [31]. This was selected in preference to a measure of alcohol consumption as, at that time, there was no direct measure of alcohol use validated for use on the Internet. Secondary outcome measures included an abbreviated (35-item) version of the Alcohol Problems Questionnaire (APQ), which assesses harm associated with heavy drinking [32], and the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM), a 34-item measure of mental health symptoms [33]. For all these questionnaires, higher scores indicate greater levels of harm. All measures were completed online at the end of weeks 1 and 6. Respondents were able to review and check their responses by the using the back button on their browser. Respondents were not required to complete all the items in each questionnaire, thus allowing the possibility of differential response rates on each questionnaire.

All the data for the study were collected automatically on a live database located on a secure dedicated Web site. Access to this database was by password only and was restricted to members of the research team. This database was initially launched simultaneously with the Down Your Drink Web site in October 2001, but was withdrawn at the end of the pilot phase for re-development. The upgraded database was subsequently re-launched in September 2003, and the data presented here are from the first 10000 users after the launch of the revised database.

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