One in every ten patients reported to have a risky alcohol consumption. Male gender, young age and living alone were associated with this. Despite the fact that an overwhelming majority reported to find it completely acceptable to be questioned about their alcohol and smoking habits, the proportion that had been asked about their drinking habits (44 %) was lower than the proportion that had been asked about their smoking habits (62 %). In addition, a lower proportion of those who had a risky alcohol use had been recommended to reduce their intake and/or quit when compared to the smokers – 10 % versus 29 %.
Compared to a German study of incidence rates in medical wards, in which 20 % had an AUDIT score above the recommended threshold value, our study found a lower proportion with a risky alcohol consumption (9.3 %)
(17). A mapping study of patients in Western Norway determined that 3.5 % of them had a harmful consumption of alcohol (18). This is higher than our findings (1.3 %).
The participants in the study from Western Norway, which also included patients from surgical wards, were five years younger on average (60 years). One of the reasons for the lower incidence in our study could be the relatively high average age in our sample, since the proportion that has a risky alcohol consumption is lower in older than in younger age groups
(19). Nor did our study include patients who had been admitted during weekends or patients admitted only to the emergency ward. As expected, we found a higher proportion of risky consumption among men and in the younger age groups. This is known from other studies as well (18).
The proportion of alcohol users was three times higher than the proportion of smokers (61 % versus 20 %). The findings in this study nevertheless indicate that assessment of alcohol use is less frequent than assessment of smoking. In light of the fact that the use of alcohol may be directly related to the cause of admission and may have implications for prognosis development and health in general, there should be good reason to pay equally close attention to identifying alcohol use.
One can imagine a number of reasons why questions about alcohol fail to be asked – for example that health personnel consider questions about alcohol use to be more sensitive than enquiries about smoking. We could also see that patients over 67 years were asked about drinking habits less frequently than were the younger age groups. One may speculate that health personnel believe that patients above a certain age cannot have a problematic consumption of alcohol, and refrain from asking. The findings show that one in every four of those who had a risky alcohol consumption was ≥ 67 years. Patient records and recording of case histories can thus not be based on such inferences; asking the patient is in fact necessary.
The HUNT studies found that the proportion of older people (> 60 years) who had a problematic consumption of alcohol increased from HUNT2 (1995 – 97) to HUNT3 (2006 – 08). The proportion among older people in the age group 70 – 79 years increased from less than 0.5 % in HUNT2 to 4.5 % in HUNT3, and in the age group 60 – 69 years it increased from 4.4 % to 7.3 %
(20). It has been estimated that the number of elderly people will increase by 50 % by 2030, meaning that the number of elderly people with a problematic consumption of alcohol will increase even if the estimates are extrapolated only on the basis of the HUNT3 findings (20).
Those who had a risky alcohol consumption received less counselling than the smokers. Others have made similar findings. A study among gynaecologists revealed a very high rate of counselling for smokers (79 %), while the counselling rate for those with a risky alcohol consumption amounted to only 36 %
(21). The most relevant obstacles were stated to be that doctors had little time and also little training in providing advice about alcohol use, and they therefore coped less well with this than with providing advice about smoking (21). They also had less faith in the usefulness of providing advice on alcohol use.
One may ask whether the hectic everyday life of a somatic hospital ward provides room for giving advice and initiating measures with regard to the patients’ use of alcohol. The disease picture associated with alcohol is undeniably more complex than the disease picture for smoking, and implementing advisory services as part of standard practice has proven difficult
The effect of brief counselling interventions in hospital wards has been documented, however
(8). Serious illness and hospitalisation can be regarded as a «window of opportunity» to motivate for change, especially if health consequences of the alcohol consumption can be identified (8). A precondition, which is also an underlying premise in this article, is that the assessment should focus on the patients’ alcohol use to the same extent as on their smoking habits. When such assessments are described in a case history, it will also be easier for the patient’s regular general practitioner to follow up this topic at a later stage (24).
The strength of the study lies in its comprehensive data material. However, there was a significant proportion that was not included (46 %). Most of these patients were defined as non-includable for administrative reasons or because they were deemed too ill to answer any questions. Altogether 13 % did not want to participate, and a selection bias can thus not be excluded. One may imagine that those who did not want to participate included a larger proportion of patients with risky alcohol consumption. If the weekend patients and those who had been admitted to the emergency ward had also been included, we cannot exclude the possibility that we might have found a higher incidence of risky alcohol consumption.
The accuracy of identification of risky alcohol consumption depends on the use of recognised tools. The short version of AUDIT used here has been validated
(14) and was considered to fit well with the objective of the study. AUDIT-4 captures average consumption over the last year, and we held it to be essential to supplement this with questions on actual consumption during the week preceding admission. We cannot exclude the possibility that those who were captured with the aid of this question, but not by AUDIT, were discovered exactly because of their consumption during the week in question. The question about recent consumption addresses the here-and-now and easier to recall more precisely from memory. We believe that this could constitute an alternative approach to counselling, cf. the threshold values to risky and harmful consumption referred to above, and questions about actual consumption during the last week may thus be a supplement to AUDIT.
Whether self-reported alcohol consumption can be trusted is another matter. Estimates indicate that underreporting in questionnaire-based surveys may be close to 50 % when compared to biological markers
(25). However, there are no reliable markers of a relatively low-frequency consumption (26). One therefore needs to rely on available self-reported data, while keeping in mind that these may be minimum figures (18).
The patients were asked whether they could recall having been asked about smoking and alcohol use. The responses do not necessarily reveal whether they were in fact asked – some reservations are necessary regarding the patients’ memory. However, there is little reason to assume that the patients would have forgotten questions about alcohol to a greater extent than questions about smoking, so we may assume that the comparison is valid.