0145-6008/02/2606-0936$03.00/0
ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH
Vol. 26, No. 6
June 2002
Promoting Self-Change With Alcohol Abusers: A
Community-Level Mail Intervention Based on Natural
Recovery Studies
Linda Carter Sobell, Mark B. Sobell, Gloria I. Leo, Sangeeta Agrawal, Lisa Johnson-Young, and John A. Cunningham
Background: By using a public health approach to the treatment of alcohol problems, this study analyzed
the efficacy and cost analysis of two versions of a community-level mail intervention to promote self-change
among alcohol abusers who had never sought help or treatment.
Methods: A total of 825 participants who responded to media solicitations were randomly assigned to
one of two interventions: (a) for bibliotherapy/drinking guidelines (n ⫽ 411), they were given two pamphlets
with information about the effects of alcohol and guidelines for low-risk drinking and self-monitoring, and
(b) for motivational enhancement/personalized feedback (n ⫽ 414), personalized advice/feedback was
provided on the basis of the participants’ assessment of their drinking and related behaviors.
Results: Although both groups exhibited significant reductions in drinking from 1 year before to 1 year
after intervention, there were no significant differences between the two interventions for any variable. This
suggests that the materials, irrespective of whether they were personalized, facilitated the reduction of
drinking. Cost analysis revealed that a brief mail intervention could reduce drinking at a very low cost per
participant (US$46 to US$97).
Conclusions: A brief community-level mail intervention for problem drinkers who had never sought
treatment resulted in sizable reductions in alcohol use over the year after the intervention compared with
the year before. Furthermore, many of those with poorer outcomes engaged in a natural stepped-care
process by seeking help. These results, coupled with the low cost to deliver the intervention, suggest that
public health campaigns could have a substantial effect on reducing alcohol problems and associated costs
as well as getting some individuals into treatment. Such an approach would represent a shift from the
alcohol field’s long-standing clinical focus to a broader public health perspective.
Key Words: Natural Recovery, Alcohol Abuse, Self-Change, Community, Public Health.
A
LTHOUGH THE STUDY of natural recoveries has
received increasing attention over the last 10 to 15
years (Klingemann et al., 2001; Sobell et al., 2000a), for
many years the topic of self-change was viewed as taboo
(Chiauzzi and Liljegren, 1993), was ignored (Sobell et al.,
2000a), or was given little credence (Klingemann et al.,
2001; Sobell et al., 1993). For example, Dupont (1993) has
claimed that “addiction is not self-curing,” and he and
others have argued that not to seek treatment is fatal
From the Center for Psychological Studies (LCS, MBS), Nova Southeastern University, Fort Lauderdale, Florida; the Center for Addiction and Mental
Health Services (GIL, JAC), Toronto, Ontario, Canada; the Department of
Psychology (JAC), University of Toronto, Toronto, Ontario, Canada; the
College of Nursing (SA), University of Nebraska Medical Center, Omaha,
Nebraska; and St. Joseph’s Health-Care Hospital (LJ-Y), Hamilton, Ontario,
Canada.
Received for publication March 6, 2002; accepted April 12, 2002.
Supported in part by NIAAA Grant AA08593.
Presented in part as an invited plenary lecture at the annual meeting of the
Research Society on Alcoholism, June, 2001, Montreal, Quebec, Canada.
Reprint requests: Linda C. Sobell, PhD, Nova Southeastern University,
Center for Psychological Studies, 3301 College Ave., Fort Lauderdale, FL
33314; Fax: 954-262-3895; E-mail: sobelll@nova.edu.
Copyright © 2002 by the Research Society on Alcoholism.
936
(Dupont, 1993; Johnson, 1973; Winick, 1962). Today, such
beliefs have been shown to lack an empirical basis. Furthermore, in the areas of mental health and health behaviors, self-change is a well recognized phenomenon. With
respect to mental health, Toro (1986) asserted that the
majority of “psychological” problems people experience
are never brought to mental health professionals or trained
paraprofessionals. Rather, they are often shared with “natural helpers” who possess no training. Commenting on
health behaviors, Davison et al. (2000, p. 205) found empirical support showing that “more Americans try to
change their health behaviors through self-help than
through all other forms of professionally designed programs.” They also reported that self-change populist approaches are often overlooked by professionals “because of
a bias toward professionalism on the one hand and a lack of
awareness on the other hand.”
Multiple and converging lines of evidence have led to the
recent recognition of self-change as an important pathway
to recovery from alcohol and drug problems (American
Psychiatric Association, 1994, 2000; Institute of Medicine,
1990; Klingemann et al., 2001; Sobell et al., 2000a). Research in this area has also led to the development of
Alcohol Clin Exp Res, Vol 26, No 6, 2002: pp 936–948
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PROMOTING SELF-CHANGE WITH ALCOHOL ABUSERS
alternative interventions for problem drinkers (Klingemann et al., 2001), including the large community intervention that is the focus of this article. Before describing that
study, it will be helpful to briefly review why research on
natural recoveries is important and the implications of this
research for public policy.
A particularly compelling reason for studying the process
of self-change from alcohol problems is that the field does
not have enduring effective treatments (Klingemann et al.,
2001; Sobell et al., 1993). Furthermore, the alcohol field
has failed to reach large numbers of individuals with less
severe problems (Klingemann et al., 2001; Sobell et al.,
1996b). In fact, for many years we have known that treated
alcohol abusers represent only a small proportion of those
who have alcohol problems (Cahalan, 1987; Erickson and
Alexander, 1989; Room, 1977). In this regard, Robins
(1993, p. 1051) has pointed out that “addiction looks very
different if you study it in a general population than if you
study it in treated cases.” If we examine only the tip of the
iceberg (i.e., treated cases), then our understanding of a
disorder is likely to be highly biased.
Brief Overview of the Literature
Because several comprehensive reviews of natural recoveries in the addictions field have recently been published
(Klingemann et al., 2001; Sobell et al., 2000a; Watson and
Sher, 1998), such a review will not be presented here.
Rather, what follows is a discussion of selected aspects of
the literature that relate to this study.
Two population surveys that examined the prevalence of
self-change from alcohol problems are noteworthy for two
reasons (Sobell et al., 1996a). First, they found that more
than three quarters of adults who had recovered from an
alcohol problem for one or more years did so without
treatment or help. Second, almost all (⬎90%) drinking
recoveries that involved a successful return to low-risk
drinking occurred through natural recovery. These two
Canadian surveys, along with other recent surveys (Dawson, 1996; Schutte et al., 2001), demonstrate that recovery
without treatment not only is a major route to recovery, but
is also associated with outcomes demonstrating a return to
low-risk drinking.
Intervening With Problem Drinkers
Most individuals who recover from alcohol problems
without treatment are problem drinkers. Many studies
show that large numbers of problem drinkers resist being
called “alcoholic” and do not enter treatment (Cunningham et al., 1993b, 1994a; Klingemann et al., 2001; Sobell et
al., 1992). The fact that the stigma of being labeled “alcoholic” is probably the biggest single factor that prevents
problem drinkers from seeking treatment or delaying their
entry into treatment raises two critical issues when designing an intervention. The first is that labels must be avoided,
because they elicit resistance (Miller and Rollnick, 1991;
Substance Abuse and Mental Health Administration,
1999). Problem drinkers do not see themselves fitting the
“alcoholic” stereotype that is ingrained in the public’s mind
(Cunningham et al., 1993a, 1994b). To the contrary, “problem drinkers” are not down and out, they are not severely
dependent on alcohol, and they often have a high level of
social stability (Institute of Medicine, 1990; Kahan, 1996;
Sobell and Sobell, 1993a,b). Thus, solicitations to such
individuals need to be presented in a nonconfrontational
and nonthreatening manner. The second critical issue is
how to capture the attention of this large, elusive group
that seldom crosses traditional clinical thresholds. In this
regard, it makes sense to use public appeals, because problem drinkers are not using existing treatment services.
In the study described in this article, we created an
empirically based advertisement that we hoped would appeal to problem drinkers who had not previously sought
formal help or treatment. The advertisement had three
explicit messages. (a) “Thinking of changing your drinking?” was chosen because we wanted a message that would
not evoke resistance and would encourage people to think
about their drinking and because it might heighten the
motivation of those already thinking about changing; (b)
“Do you know that 75% of people change their drinking on
their own?” was chosen because, despite the fact that a
sizable percentage of individuals change their drinking
without help or treatment, research has shown that the
general public does not believe that problem drinkers can
change on their own; and (c) “Call us for free materials that
can be completed at home” was chosen because one of the
major reasons that people give for not entering treatment is
that they want to change their drinking on their own. As
discussed later, advertisements were run containing these
three messages for approximately 1 year in newspapers and
other audiovisual mediums (e.g., cable television, radio,
and flyers).
Brief Interventions
Since the seminal publication of a brief intervention by
Orford et al. (1976) a quarter of a century ago, numerous
studies have been published that show that brief interventions are effective in getting alcohol abusers to significantly
reduce their alcohol use, whether the intervention is as
short as 5 min with a physician (e.g., Fleming and Manwell,
1999; Rollnick et al., 1997), a few cognitive/behavioral outpatient sessions (e.g., Breslin et al., 1999; Sobell and Sobell,
1993a, 1998), a correspondence intervention with a selfhelp manual (e.g., Kavanagh et al., 1999; Sitharthan et al.,
1996), or bibliotherapy (Miller and Baca, 1983; Miller and
Taylor, 1980). The effectiveness of brief interventions suggests
that their major function is motivational (i.e., they catalyze a
person’s own resources to bring about self-change).
Unfortunately, because the majority of brief interventions have used small samples, it could be argued, as in the
smoking field (Becoña and Vazquez, 2001; Law and Tang,
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SOBELL ET AL.
1995), that the cost of using scarce health care resources
and expert help for each success is too large for these
approaches to have a major effect in reducing alcohol
problems (Fingarette, 1988; Kreitman, 1986; Rose, 1985;
Skog, 1999; Wallace et al., 1988). Put differently, although
brief interventions have had an impressive record of accomplishment, they can reach only a small proportion of
problem drinkers. As suggested in Rose’s (1985) prevention paradox, if an intervention can affect enough people,
even small per capita gains can translate into large benefits
for society. Examples of population approaches are plentiful in the smoking arena (Curry, 1993; Curry et al., 1992;
Lichtenstein et al., 1996; Orleans et al., 1991), in which
brief interventions have been converted into effective selfadministered formats (Orleans et al., 1991). In the alcohol
field, however, similar extensions of brief interventions are
lacking.
Set against this background, this study was designed to
promote self-change among problem drinkers who were
unwilling, not ready, or otherwise unmotivated to access
the formal health care system to change their drinking. The
intervention took the treatment to the individuals via a mail
intervention that was free, offered anonymity, and was not
part of any formal program. This project, Promoting SelfChange, was a community-level intervention derived from
research examining natural recovery processes with alcohol
abusers and clinical trials by using a Guided Self-Change
model of treatment with problem drinkers (Sobell et al.,
1996b; Sobell and Sobell, 1998).
METHODS
Participant Recruitment
The Promoting Self-Change project was conducted as a communitylevel mail intervention that did not require participants to come to a
treatment program. Participants voluntarily responded to advertisements
(i.e., newspapers, cable television, radio, postal flyers, and posters in
subways stations) in the greater metropolitan area of Toronto, Ontario
(Canada). Participants who responded to the advertisements were
screened by telephone; they received and mailed back assessment materials to a numbered, unnamed postal box. Advertisements were run for
nearly a year with the three messages described previously. Most participants were recruited through newspaper advertisements. The study was
approved by a joint Addiction Research Foundation/University of Toronto Institutional Review Board.
Participants were screened by telephone with the Quick Drinking
Screen (QDS), a reliable drinking screening instrument (Sobell et al.,
1999), to determine eligibility. Inclusion criteria included reported consumption of, on average, more than 12 drinks (1 drink ⫽ 13.6 g of absolute
alcohol) per week or consuming 5 or more drinks on 5 or more days in the
past year. The reason specific drinking levels were used as study inclusion
criteria was that epidemiological studies suggest an increased risk of social
and health problems associated with weekly consumption of more than 12
drinks. Other brief interventions have also used drinking entry criteria
(Fleming et al., 2002; Freund and Butters, 1982; Israel et al., 1996; Wallace
et al., 1988). All participants had to be of legal drinking age, which was 19
years old in Ontario, Canada. Because of the brevity of the two interventions in this study, it was decided to limit this trial to individuals who had
never had formal help or treatment for an alcohol problem. Excluding
people with a history of treatment was intended to ensure that more
severely dependent alcohol abusers were not part of this brief intervention
(Heather, 1989; Sobell et al., 1992, 1996a).
The definition of formal treatment was similar to that used in a study
of natural recovery with alcohol abusers (Sobell et al., 1992, 1993). Treatment included any intervention by formally recognized programs or individuals whose main goal was to treat people who had alcohol problems, or
any other treatment specifically addressing alcohol problems (e.g., alcohol
treatment rehabilitation centers; outpatient, inpatient, public, and private
alcohol treatment facilities or programs providing services for alcohol
abusers; use of antialcohol drugs such as disulfiram or calcium carbimide;
no more than two Alcoholic Anonymous meetings or similar self-help
groups when attended by participants to deal with their own drinking
problem; professional counseling for alcohol problems; and treatmentoriented drinking driver courses). Participation in alcohol-related treatment of any duration, even one session, was considered treatment because
of the growing number of studies showing that brief interventions are
effective (Academy for Health Services Research and Health Policy, 2000;
Bien et al., 1993; Fleming and Manwell, 1999; Fleming et al., 2000;
VanBeurden et al., 2000). Some types of warnings or advice were not
considered as formal help or treatment, including nondiagnostic warnings
or interventions by friends, relatives, and ministers; diagnostic warnings by
physicians; and detoxification for alcohol withdrawal with no concurrent
or subsequent treatment or counseling.
Over 12 months, 2434 people responded to advertisements, of which
678 (27.9%) were initially determined to be ineligible. The majority of the
initially ineligible participants (90.4%; 613 of 678) reported having received prior treatment or having participated in a self-help group, 6.9% (n
⫽ 47) reported drinking below the inclusion criteria, 2.2% (n ⫽ 15) were
excluded for other reasons, and 0.4% (n ⫽ 3) were underage. No materials, guidance, or referrals were given to respondents who were not
eligible for the study. All of the 1756 people who met the initial screening
criteria were sent assessment questionnaires. Of these, 42.3% (743 of
1756) did not return their questionnaires. Of the 1013 who returned their
questionnaires, 18.6% (n ⫽ 188) did not participate in the study for a
variety of reasons [e.g., 78 (40.8%) had been in treatment; 76 (40.3%) did
not want to participate further].
Intervention Groups
The final sample consisted of 825 alcohol abusers who signed an
informed consent to participate. Eligible participants were sent an assessment package that included several questionnaires that they were asked to
complete and return in a stamped self-addressed envelope. The mean
(SD) number of days between when the participants responded to advertisements and when we received their assessment forms was 18.2 (21.8).
After the assessment materials were completed and returned by mail,
participants were randomly assigned to one of two interventions: motivational enhancement/personalized feedback (MEPF; n ⫽ 414) or bibliotherapy/drinking guidelines (BDG; n ⫽ 411). On the basis of their assessment materials, individuals in the MEPF condition received advice
feedback describing their drinking levels, high-risk situations, and motivation for change. The advice feedback materials were designed to inform
participants where their drinking fit in with respect to national norms and
associated health risks. These materials were reprinted in the appendix to
a previous article describing the study design (Sobell et al., 1996b) and
have been part of the Guided Self-Change intervention model of treatment (Sobell et al., 1996b; Sobell and Sobell, 1993a, 1998; Substance
Abuse and Mental Health Administration, 1999).
Personalized advice/feedback materials were used for three reasons: (a)
motivational interventions suggest that such materials can be used to
increase motivation and commitment to change (DiClemente et al., 2001;
Substance Abuse and Mental Health Administration, 1999); (b) personalized feedback is supported by research on efficacy enhancement (Bandura and Cervone, 1983; Bandura and Schunk, 1981) and intrinsic motivation (Curry et al., 1990); and (c) because many problem drinkers do not
view their drinking as serious enough to warrant changing, these materials
were intended to promote self-change by getting problem drinkers to
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PROMOTING SELF-CHANGE WITH ALCOHOL ABUSERS
compare their drinking with that of other drinkers (Sobell and Sobell,
1993b, 1998; Sobell and Sobell, 2000b).
Participants assigned to the BDG condition completed the same questionnaires as the MEPF group. However, instead of the personalized
feedback, they were sent two alcohol informational pamphlets that were
available in the public domain and contained information about the effects
of alcohol (e.g., tolerance and standard drinks) and provided information
on low-risk drinking guidelines (e.g., identify risky drinking conditions, use
self-monitoring logs). None of the materials sent to participants in the
BDG group contained personalized feedback.
Assessment Measures
Because this was a mail intervention, the assessment materials were
mailed to participants who returned them in a self-addressed stamped
envelope. Participants also were asked to sign and return an informed
consent that explained that they would be contacted by mail after 1 year
to evaluate whether the materials had helped them change their drinking
and what their drinking was like during the follow-up year.
In addition to providing background and drinking history information,
all participants were asked to reconstruct their daily drinking over the past
year by using a 360-day alcohol timeline follow-back (TLFB) calendar
(Sobell and Sobell, 1992, 2000a). They also completed the Alcohol Use
Disorders Identification Test (AUDIT)—a brief measure of alcohol problems (Allen and Columbus, 1995)—and several measures of motivation
and self-efficacy (e.g., How seriously would you like to reduce or quit
drinking? In terms of the severity of your drinking problem, which of the
following best describes your drinking during the past year? At this
moment, how confident are you that you will change your current drinking?). Questions such as these have been used to assess motivation and
self-efficacy in previous studies of addictive behaviors (Curry, 1993; DiClemente et al., 1991; Richmond et al., 1993; Sobell and Sobell, 1993a;
Sobell et al., 1995).
For all demographic and alcohol-related variables, there were no significant differences between groups before treatment (p ⬎ 0.05; t tests for
parametric variables; ␹2 tests for nonparametric variables). Thus, in Table
1, all participants’ pretreatment data were combined for ease of presentation. As can be seen, participants were on average 48 years old, one third
were women, and they were generally socially stable. Almost two thirds
(61%) were married; 83% had completed high school, with close to a third
having some college education; 60% were employed full-time; and a
similar percentage worked in white-collar jobs. Although participants
reported having had a drinking problem for a mean of 11.5 years, very few
reported any alcohol-related arrests or hospitalizations. On a scale from 0
to 40, where 8 or more is suggestive of an alcohol problem, participants’
mean AUDIT score was 20 (Allen et al., 1997; Conigrave et al., 1995). In
terms of drinking in the year preceding the intervention, participants
reported drinking on more than three quarters of all days, and they
reported consuming approximately six drinks on average on days when
they drank. Participants in this study were similar to problem drinkers who
have participated in brief interventions (Bien et al., 1993; Heather, 1994;
Sobell and Sobell, 1998; Sobell et al., 1992).
RESULTS
Follow-Up
All participants were scheduled to be followed up by mail
(except for those randomly selected for an in-person interview) 1 year from the date that the advice/feedback materials (MEPF group) or informational pamphlets (BDG
group) were sent to them. To minimize attrition and remind them of their 1-year follow-up, all participants were
sent reminder letters at 4 and 8 months from the date when
the feedback materials or pamphlets were sent out. For the
12-month follow-up, participants were mailed question-
Table 1. Characteristics of 825 Participants at Assessmenta
Variable
Sex (female)
Employed (self-employed or full-time)
White collarb
Age (years)
Married
Completed university
Ethnicity (white)
Described alcohol problem as major/very major
Definitely/probably intending to quit in next 2 weeks
Never in alcohol treatment/self-help groups (e.g., AA)
Days drinking in the past year
AUDIT scorec
Past quit attempts [median]
Years with a drinking problem
Alcohol-related arrests
Alcohol-related hospitalizations
Alcohol-related consequencesd
Days drinking/week in past year
Drinks/drinking day/past yeare
Drinks/week/past yeare
Days drinking five or more drinks in the past yeare
Greatest number of drinks in 1 day in the past yeare
% or Mean
(SD)
33.1%
60.4%
62.3%
47.5 (11.8)
60.6%
30.7%
94.4%
48.5%
73.3%
100.0%
77.7%
20.2 (6.2)
17.2 (64.2) [5.0]
11.4 (9.2)
0.5 (1.5)
0.1 (1.3)
4.1 (2.0)
5.4 (1.7)
5.9 (2.8)
31.9 (18.5)
164.4 (117.0)
12.1 (6.4)
a
Because participants in the two intervention groups—motivational enhancement/personalized feedback (n ⫽ 414) and bibliotherapy/drinking guidelines (n ⫽
411)— did not differ significantly (p ⬎ 0.05) on any of the variables, data were
combined for all participants.
b
Hollingshead scale (Hollingshead and Redlich, 1958).
c
AUDIT scores can range from 0 to 40.
d
Maximum number of consequences was 8.
e
One drink ⫽ 13.6 g of absolute alcohol.
naires to complete at their residence, including the alcohol
TLFB covering the period of time from their initial screening through their 12-month follow-up.
Of the original 825 participants, 657 (79.6%: MEPF, 321;
BDG, 336) were located for follow-up, a rate similar to that
of other large brief intervention and clinical trials (Babor et
al., 1996; Edwards and Rollnick, 1997; Fleming et al., 2002;
Grant et al., 1997; Project MATCH Research Group,
1998); 5 (0.6%) were reported as deceased (n ⫽ 4) or
incapacitated (n ⫽ 1); 102 (12.4%) refused or withdrew
from the follow-up; 59 (7.2%) were lost to follow-up; and 2
(0.2%; BDG) were excluded from the study because they
reported having never received the study materials. Across
the two intervention groups, there was no significant (Fisher’s exact test; p ⫽ 0.201) differential attrition/dropout as a
function of the intervention group assignment.
To address possible bias introduced by the characteristics
of participants available and not available for follow-up, the
characteristics of participants unavailable for study or lost
to follow-up were compared with those found on the same
22 pretreatment variables in Table 1. The two groups differed significantly (p ⬍ 0.05; t tests for parametric variables;
␹2 tests for nonparametric variables) on only 3 of the 22
pretreatment variables, none of which were demographic
characteristics. Participants not followed up had significantly greater AUDIT scores and more alcohol-related
consequences, and they reported consuming more drinks
per week than participants who were followed up. These
results are similar to those of studies that have performed
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SOBELL ET AL.
Table 2. Statistics for 1 Year Before and After Intervention Drinking and Related Variables by Intervention Group and Percentage Reduction/Increase by Group
Motivational enhancement/personalized feedback
(n ⫽ 321)
Variable
Mean (SD) days drinking per week, past yeara
% Days drinking, past year
% Change
Mean (SD) drinks per drinking day, past yearb
% Change
Mean (SD) drinks per week, past yearb
% Change
Mean (SD) days drinking five or more drinks,
past yearb
% Change
Mean (SD) alcohol consequences, past yearc
% Change
% Used alcohol treatment/self-help, past year
% Change
Preintervention
Postintervention
5.5 (1.6)
4.6 (2.2)
78.6
65.7
16.4% reduction 1 year pre to post
5.9 (3.2)
4.7 (2.7)
20.3% reduction 1 year pre to post
31.7 (19.6)
22.0 (17.1)
28.7% reduction 1 year pre to post
159.8 (115.5)
102.8 (115.4)
35.7% reduction 1 year pre to post
4.0 (2.0)
1.7 (1.8)
57.5% reduction 1 year pre to post
Not applicabled
24.3
24.3% increase 1 year pre to post
Bibliotherapy/drinking guidelines
(n ⫽ 336)
Preintervention
Postintervention
5.4 (1.6)
4.6 (2.1)
77.1
65.7
14.5% reduction 1 year pre to post
5.9 (2.8)
4.7 (2.5)
20.3% reduction 1 year pre to post
30.8 (16.3)
22.2 (16.4)
27.9% reduction 1 year pre to post
161.1 (112.9)
111.5 (115.3)
30.8% reduction 1 year pre to post
3.9 (1.9)
1.6 (1.8)
59.0% reduction 1 year pre to post
Not applicabled
24.4
24.4% increase 1 year pre to post
a
Determined by taking the variable mean days drinking per week in past year, multiplying by 51.43, and dividing by 360 days.
One drink ⫽ 13.6 g of absolute ethanol.
c
Maximum number of consequences was 8.
d
To be eligible for the study, participants could not have received any formal help or treatment.
b
such analyses; that is, participants not followed up seem to
have more alcohol problems on some variables and not on
other characteristics (Edwards and Rollnick, 1997).
Because of the time demands of the mailed-out postintervention assessment (i. e., approximately 2 hr), some participants initially said they did not have time to complete all
the forms. In an effort to collect at least minimal follow-up
data, it was decided to ask participants who were unwilling
or unable to complete a full follow-up interview if they
would be willing to take a few minutes to answer some brief
questions about their drinking and related behaviors. Such
a procedure was used successfully by Project MATCH to
collect follow-up on individuals who would not complete a
full follow-up interview (Miller and Del Boca, 1994). Because participants in this study had provided reliable drinking data on the QDS as compared with their preintervention 360-day TLFB (Sobell et al., 1999), it was decided to
use the QDS questions and a few brief questions about
consequences and treatment use for participants who did
not want to complete the full follow-up interview. This
procedure allowed limited follow-up data to be collected
for an additional 23.0% (190 of 825) of all participants. Of
the 657 participants followed up, 467 (71.1%) completed
the full follow-up battery, including the year-long TLFB
calendar. Drinking data were obtained for the remaining
190 participants by using the QDS; 24.2% (46 of 190) of
them provided complete follow-up data with the exception
of the TLFB, and the remainder (144 of 190) provided very
limited follow-up data beyond the QDS data. The mode of
follow-up data collection (i.e., QDS versus TLFB) did not
vary as a function of the intervention group assignment
[␹2(1) ⫽ 0.17, p ⬎ 0.05].
Because some participants used the TLFB (n ⫽ 467) to
report their posttreatment drinking, whereas others used
the QDS (n ⫽ 190), participants’ 1-year posttreatment
drinking reports were compared by using the first four
drinking variables listed in Table 2. There were no signifi-
cant differences (p ⬎ 0.05) between the two modes of
reporting drinking behavior for any of the four drinking
variables.
Data Integrity and Manipulation Checks:
Pre- and Postintervention
A QDS with five drinking questions was used to screen
participants when they first responded to advertisements.
An earlier report that used data from these participants
(Sobell et al., 1999) found that drinking data from the QDS
(participants were interviewed by telephone) were very
similar to the daily drinking data from the 360-day preintervention TLFB calendar (self-administered and returned
by mail). This suggests that at the assessment, the 825
participants provided very reliable drinking data at an aggregate level.
At follow-up, of those willing to participate in a full
follow-up interview (n ⫽ 657), 70 participants were randomly selected to be interviewed in person, paid US$100,
given a breath test, and asked to provide the name of a
collateral (i.e., significant other—friend or family member)
to be interviewed to confirm the participant’s postintervention self-reports. Data comparing participants’ and collaterals’ self-reports of the participants’ postintervention
drinking and related behavior for five variables are shown
in Table 3. For all variables, participants’ and collaterals’
self-reports did not differ significantly (p ⬎ 0.05) and were
significantly correlated (p ⬍ 0.01). The collateral interviews
provided support for the validity of the participants’
postintervention self-reports. In addition, all 70 participants had a zero blood alcohol level at their follow-up
interview.
Participants who completed the follow-up questionnaire
(n ⫽ 515) were asked whether they had ever read the
intervention materials. Of the 509 who responded to this
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PROMOTING SELF-CHANGE WITH ALCOHOL ABUSERS
Table 3. Agreement Between Participants and Collaterals for Postintervention Drinking and Related Variablesa
Variable
Reliability
correlationb
Respondents,
mean (SD)
Collaterals,
mean (SD)
t Value
(two-tailed)
0.54
0.56
0.48
0.54
0.53
9.60 (8.7)
10.7 (8.8)
9.9 (9.7)
1.8 (1.7)
NAf
8.7 (9.7)
8.9 (9.4)
12.5 (11.1)
1.9 (2.0)
NAf
0.79, NSc
1.48, NSc
1.78, NSc
0.35, NSc
85.7%g
No. Days abstinent (n ⫽ 56)
No. Days drinking one to three drinks (n ⫽ 56)d
No. Days drinking four or more drinks (n ⫽ 56)d
No. Alcohol consequences (n ⫽ 64)e
% Used alcohol treatment/help in
postintervention year (n ⫽ 70)
a
The interval over which drinking data were compared for participants and their collaterals was 30 days before the follow-up interview.
Pearson correlations except for the variable % used alcohol treatment/help, which was a ␬ coefficient; all p values were ⬍0.01.
c
NS, not significant, p ⬎0.05.
d
One drink ⫽ 13.6 g of absolute ethanol.
e
Maximum number of consequences was 8.
f
NA, not applicable; these were nonparametric data.
g
Percentage agreement (i.e., yes/yes and no/no) between participants and collaterals.
b
Table 4. Multivariate and Univariate Analysis of Variance F Ratios for Intervention Group ⫻ Time
ANOVA
Variable
Time (T)
Intervention Group (IG)
T ⫻ IG
MANOVA
Drinking days
per week
Drinks per
drinking daya
Drinks per
weeka
Days five or
more drinksa
Total
consequencesb
F(6,651)
F(1,655)
F(1,655)
F(1,655)
F(1,655)
F(1,655)
185.69*
0.75
0.38
172.49*
0.28
1.41
122.13*
.04
0.02
193.58*
0.06
0.65
155.13*
0.41
0.75
860.31*
0.55
0.01
F ratios are Wilks’s approximation of F values.
MANOVA, multivariate analysis of variance; ANOVA, univariate analysis of variance.
a
One drink ⫽ 13.6 g of absolute alcohol.
b
Maximum number of consequences was 8.
* p ⬍ 0.001.
question, only 4 (2 in each group) reported that they had
not read the materials.
Data Analysis
Results were analyzed with multivariate analysis of variance (MANOVA) for repeated measures (time: 1 year
before intervention and 1 year after intervention; multivariate analyses of covariance were not used because the
assumptions of heterogeneity of variance were not met).
Dependent variables were (a) frequency of drinking (mean
percentage of days drinking); (b) drinking intensity (mean
number of drinks per drinking day; one drink ⫽ 13.6 g of
absolute ethanol); (c) mean weekly drinking quantity
(mean number drinks per week); (d) mean frequency of
heavy or binge drinking (mean percentage of drinking days
when five or more drinks were consumed); and (e) mean
consequences (mean number of consequences; the total
number of consequences ranged from 0 to 8). Intervention
conditions (MEPF, BDG) were a between-subjects factor.
Time (1 year before intervention and 1 year after intervention) was a within-subject factor.
Table 2 shows the drinking data for both groups of
participants at 1 year before and after intervention. In
addition, the percentages of reductions or increases from 1
year before to 1 year after intervention for each group are
shown. Although there were no significant differences (p ⬎
0.05) between the two groups for any of the variables in
Table 2, participants in both interventions showed large
and significant changes on all drinking and related measures from 1 year before to 1 year after intervention.
Table 4 displays multivariate and univariate ANOVA F
ratios for intervention group ⫻ time. As shown in Table 4,
for drinking outcomes, the only significant (p ⬍ 0.05) effects obtained were for time, with significant findings for all
dependent variables.
The effect of sex was also explored by adding sex as a
factor in the analyses. As would be expected, there were
main effects for sex for all variables, indicating that women
drank less than men, but there were no significant interactions involving sex. These analyses are not presented.
The results in Table 4 suggest that the materials, regardless of whether they were personalized, facilitated the reduction of participants’ drinking and related consequences;
that completing the assessment materials or just seeing the
advertisement had a reactive effect; or some combination
of these. For subsequent analyses, the two intervention
conditions were pooled because there were no significant
group differences at preintervention or postintervention.
At the 1-year follow-up, participants in each group who
completed the follow-up questionnaire (n ⫽ 515) were asked
how helpful the intervention materials they received had been
to them. Of the 509 who responded to this question, 4 were
excluded because they reported never having read the materials. The percentage of participants in the two groups who
said the materials were not helpful did not differ significantly
[MEPF, n ⫽ 238, 32.7%; BDG, n ⫽ 267, 34.1%; ␹2(1) ⫽ 0.10;
942
SOBELL ET AL.
Table 5. One-year Pre- and Postintervention Statistics for Drinking Variables, Consequences, and Treatment Use By Participants’ Subjective Ratings of Problem
Severity and Motivation at the Assessmenta
Seriousness of changing
Variable
Drinking days/week
Before
After
Drinks/drinking daya
Before
After
Drinks/weeka
Before
After
No. Days five or
more drinksa
Before
After
Total
consequencesd
Before
After
Posttreatment use
% No use
% Used
Intent to change
Subjective problem severity
Confidence of changing
Very/fairly serious
(n ⫽ 376)
Not very/not at all
serious (n ⫽ 281)
Yesb
(n ⫽ 475)
Noc
(n ⫽ 182)
Very major/major
(n ⫽ 310)
Minor/very minor/
not a problem
(n ⫽ 347)
5.4 (1.7)
4.2 (2.2)
5.5 (1.6)
5.0 (2.0)
5.3 (1.7)
4.3 (2.2)
5.9 (1.5)
5.3 (1.9)
5.3 (1.7)
4.4 (2.2)
5.6 (1.6)
4.7 (2.1)
5.4 (1.7)
4.4 (2.2)
5.5 (1.6)
4.8 (2.1)
6.2 (3.3)
4.7 (2.6)
5.5 (2.6)
4.8 (2.6)
6.0 (3.2)
4.6 (2.6)
5.7 (2.5)
5.0 (2.7)
6.5 (3.0)
5.1 (2.8)
5.4 (2.9)
4.4 (2.4)
5.9 (3.1)
4.4 (2.4)
5.9 (2.9)
5.0 (2.8)
32.5 (19.9)
25.0 (15.9)
29.5 (15.0)
24.3 (17.7)
30.6 (18.4)
20.2 (15.3)
33.0 (16.8)
27.1 (19.4)
33.1 (17.3)
23.1 (17.6)
29.6 (18.5)
21.2 (16.0)
30.9 (18.9)
19.7 (14.4)
31.6 (16.9)
24.9 (18.8)
168.7 (114.0)
99.3 (110.9)
149.4 (113.6)
117.9 (120.5)
155.1 (111.7)
96.1 (108.8)
174.5 (119.4)
136.5 (126.7)
173.3 (112.2)
117.3 (119.9)
149.0 (114.8)
98.3 (110.6)
156.8 (111.9)
93.2 (107.2)
164.6 (116.6)
123.2 (122.2)
4.2 (1.9)
1.8 (1.9)
3.7 (1.9)
1.5 (1.6)
4.0 (2.0)
1.7 (1.7)
3.8 (1.9)
1.8 (1.8)
4.9 (1.6)
2.2 (2.0)
3.2 (1.9)
1.3 (1.5)
3.9 (2.0)
1.6 (1.8)
4.0 (1.9)
1.8 (1.9)
41.1
16.1
34.6
8.2
54.5
17.8
21.2
6.5
31.1
16.1
44.6
8.2
75% or
more
(n ⫽ 349)
39.9
13.2
Less than 75%
(n ⫽ 308)
35.8
11.1
Data are presented as mean (SD) unless otherwise noted.
a
One drink ⫽ 13.6 g of absolute ethanol.
b
Yes ⫽ definitely/probably yes.
c
No ⫽ definitely/probably no.
d
Maximum number of consequences was 8.
p ⬎ 0.05]. Thus, although participants in each group were
given very different intervention materials, both groups found
the materials similarly helpful.
To better understand the factors related to changes in
drinking, the relationships of five predictor variables to
changes in drinking were explored. The predictor variables
included four preintervention subjective ratings and
whether participants used treatment after the intervention.
The four rating/motivational variables were seriousness of
desire to change, intent to change, self-perception of severity of drinking problem, and confidence in changing.
MANOVA for repeated measures were used with time as
the repeated factor (preintervention and postintervention
drinking). Four dependent variables were entered into each
analysis: drinking frequency (mean percentage of days
drinking), mean number of drinks per week, drinking intensity (mean number of drinks per drinking day), and
mean frequency of heavy drinking (mean percentage of
days when five or more drinks were consumed). Means and
SDs for these analyses appear in Table 5. Corresponding
MANOVA and ANOVA F ratios are shown in Table 6.
The MANOVA found significant main effects for time for
all variables, significant main effects for each rating/motivational variable (but not for treatment use), and significant interactions for all variables but treatment use.
The analysis for seriousness of desire to change was
based on the question “How seriously would you like to
reduce or quit drinking altogether?” (two levels: very seriously/fairly seriously versus not very seriously/not at all
seriously). The analyses found a significant main effect for
time (p ⬍ 0.001) for all variables and a significant (p ⬍
0.001) interaction between seriousness of desire to change
and time for all dependent variables. As shown by the
patterning of means in Table 5, for all dependent variables,
participants who stated they were serious about changing
their drinking showed a greater decline in drinking than
other participants.
Intent to change was evaluated as a two-level variable
based on the question “Do you intend to reduce or quit
drinking in the next two weeks?” (two levels: definitely
no/probably no versus definitely yes/probably yes). As for
the variable seriousness of desire to change, the analysis for
intent to change revealed a significant main effect for time
(p ⬍ 0.001) for all variables and revealed significant (p ⬍
0.05) interactions between drinking and intent to change
for all dependent variables. As shown in Table 5, as for
seriousness of desire to change, those participants who
stated they intended to change showed a greater decline in
drinking than the other participants.
Preintervention self-perception of the severity of one’s
drinking problem was assessed by the question “What best
describes your drinking during the past year?” (two levels:
very major/major problem versus very minor/minor problem/
not a problem). As for the previous variables, a significant
main effect for time (p ⬍ 0.001) was found for all variables.
However, unlike seriousness of desire to change and intent to
change, no significant (p ⬎ 0.05) interaction was found between drinking and preintervention problem severity.
Finally, confidence in changing one’s drinking was assessed by responses to the question “How confident are you
943
PROMOTING SELF-CHANGE WITH ALCOHOL ABUSERS
Table 6. Multivariate and Univariate Analysis of Variance F Ratios for Preintervention Variables and Treatment Use ⫻ Drinking Variables and Consequences
ANOVA
Variable
Time ⫻ seriousness of changing
Time (T)
Seriousness (S)
T⫻S
Time ⫻ intent to change
Time
Intent (I)
T⫻I
Time ⫻ problem severity
Time
Problem (P)
T⫻P
Time ⫻ confidence in changing
Time
Confidence (C)
T⫻C
Time ⫻ treatment use
Time
Treatment use (TU)
T ⫻ TU
MANOVA
Drinking days
per week
Drinks per
drinking daya
Drinks per
weeka
Days five or
more drinksa
Total
consequencesb
F(6,651)
F(1,655)
F(1,655)
F(1,655)
F(1,655)
F(1,655)
188.66***
4.81***
6.89***
178.69***
12.66***
25.01***
124.70***
2.50
13.82***
201.63***
0.14
27.93***
159.63***
0.00
19.79***
864.06***
10.11**
2.87
187.50***
6.08***
2.65***
173.92***
28.38***
6.88**
123.68***
0.19
8.11**
196.10***
12.48***
9.21**
156.10***
11.76**
4.85*
864.75***
0.43
3.39
192.25***
28.39***
5.59***
172.13***
4.95*
0.07
122.61***
22.60***
2.65
193.78***
5.12*
1.33
155.05***
7.62**
0.40
894.83***
135.53***
26.29***
186.60***
1.82
2.43*
173.44***
4.68*
5.03*
123.78***
1.97
8.91**
196.86***
6.04*
11.76***
156.54***
5.78*
6.72**
861.49***
1.45
0.91
185.69***
0.75
0.38
172.49***
0.28
0.24
122.13***
0.04
0.89
193.58***
0.06
0.65
155.13***
0.41
0.75
860.31***
0.56
0.91
F ratios are Wilks’s approximation of F values.
MANOVA, multivariate analysis of variance; ANOVA, univariate analysis of variance.
a
One drink ⫽ 13.6 g of absolute ethanol.
b
Maximum number of consequences was 8.
* p ⬍ 0.05; ** p ⬍ 0.01; *** p ⬍ 0.001.
that you will change your current drinking?” (two levels:
75% or more confidence versus less than 75% confidence).
As for the other variables, the analysis revealed a significant main effect for time (p ⬍ 0.001) for all variables. Like
for seriousness of desire to change and intent to change,
significant (p ⬍ 0.05) interactions between drinking and
participants’ confidence that they would change their
drinking behavior were found for all dependent variables.
As for seriousness of desire to change and intent to change,
those participants who expressed more confidence in
changing demonstrated a greater amount of change than
other participants. The analysis for treatment use showed
only a main effect for time.
The results for the four preintervention rating/motivational
variables in Table 5 suggest that commitment to changing was
related to the change process. Specifically, participants who at
the preintervention assessment reported that they were highly
to very serious about changing, were more intent on changing,
and were more confident of changing were those who
achieved more change over the course of the 1-year follow-up.
These results suggest that it might be helpful to devote attention to increasing the commitment to changing (i.e., motivation) for participants who initially have or express lower levels
of commitment or confidence. Similarly, because poor outcome expectations might characterize individuals with low
self-confidence, providing more assistance in changing for
such individuals might be beneficial (e.g., encouraging them to
seek treatment or to use self-help resources rather than continuing to pursue self-change).
To be eligible for the study, participants could not have
used treatment or self-help groups; however, during the
postintervention follow-up year, 24.4% (n ⫽ 160) reported
using some type of help or treatment. As shown in Table 2,
there was no significant difference in terms of the percentage of participants in each intervention group who used
some form of help after the intervention. To further explore differences between participants who did and did not
seek additional help, data from the groups were combined,
and a MANOVA for repeated measures was performed
with time (1 year before intervention and 1 year after
intervention) as a within-subject variable and use of treatment (yes or no) as a between-subjects variable; dependent
variables were the mean number of drinking days per week,
the mean number of drinks per drinking day, the mean
number of drinks per week, the number of days five or
more drinks were consumed, and the total number of
alcohol-related consequences reported.
The MANOVA found a main effect for time [F(6,655) ⫽
52.89; p ⬍ 0.001] and a significant main effect for treatment
use [F(6,655) ⫽ 2.46; p ⬍ 0.05], but no significant treatment
use ⫻ time interaction. Consistent with the pattern found
for other analyses, univariate analyses found that participants in both groups showed significant declines from preintervention to postintervention for all dependent variables. However, univariate tests found a significant
treatment use effect [F(1,561) ⫽ 6.57; p ⬍ 0.05] only for the
variable of mean number of drinks per week, and they
found a significant univariate interaction for that variable
[F(1,561) ⫽ 5.38; p ⬍ 0.05]. Inspection of group means
(SD) [preintervention used treatment ⫽ 5.3 (1.7) drinks per
week; postintervention used treatment ⫽ 4.2 (2.3) drinks
per week; preintervention did not use treatment ⫽ 5.5 (1.6)
944
SOBELL ET AL.
drinks per week; postintervention did not use treatment ⫽
4.7 (2. 1) drinks per week] suggested that participants who
used treatment showed a slightly greater decline in the
mean number of drinks per week than those who did not
use treatment, although those who did not use treatment
drank somewhat more drinks per week at both time points.
However, because the interaction term in the MANOVA
was not significant and a significant univariate interaction
effect was found for only one of five variables, it is unlikely
that this interaction is reliable.
Cost Analysis
Unlike cost-analysis studies that involve detailed and
idiosyncratic cost estimates (Fleming et al., 2000, 2002), the
cost analysis for this project was easy to calculate because
the project was funded entirely by a grant. Factors used in
calculating the cost per participant included 1 year’s salary
and fringe benefits for a research assistant; 1 year’s charges
for a telephone line; materials preparation costs for the
initial mailout (to 1756 participants); and the mailed-out
feedback materials (825 individuals), associated postage
costs, and costs for composing and placing the advertisements. On this basis, the participant cost for each of the 825
participants who returned their completed assessment materials was US$96.98. This first calculation assumes that the
only people affected by the project were the 825 participants who returned their completed assessment materials.
However, it is possible that seeing and responding to the
advertisements, receiving the assessment materials, completing the assessment materials (although not mailing
them back), or a combination of these might affect drinking
practices (not determinable from this project); thus, a second per-participant cost analysis was calculated. If merely
responding to the advertisements affected drinking, it is
possible that the number of participants affected could be
as high as the 1756 who met the initial screening criteria
and were sent the assessment materials. In this regard, this
would reduce the cost per participant to US$45.56. In
reality, the number of individuals whose drinking was affected by participating in the project probably lies somewhere between these two figures.
DISCUSSION
Problem drinkers who participated in the Promoting
Self-Change project reported a significant decrease in highrisk drinking and related consequences 1 year after the
intervention compared with 1 year before. The MEPF
package, however, did not add value to the intervention
beyond that provided by the informational advice pamphlets. A testable alternative explanation is that participating in the assessment affected participants such that neither
intervention had an appreciable added effect. Another possible explanation is that the act of responding to the advertisements precipitated change by the participants. Finally, it
is possible that the lack of differences between conditions
relates to the fact that the BDG group received explicit
general guidelines for low-risk drinking. In contrast, the
MDPF group received implicit direction in that they were
told where their drinking stood in comparison to national
norms, but they were not given targets for low-risk drinking. Regardless of how the changes in drinking were
achieved or why no significant difference was found between conditions, it is clear that a large-scale intervention
can produce substantial benefits with little cost.
It is possible that the MEPF intervention will have an
advantage with participants who are less desirous of changing (e.g., patients in primary care centers versus volunteers
who respond to advertisements). Our findings suggest that
those individuals who before the intervention reported a
stronger desire to change, expressed a greater intent to
change, and had greater confidence in their ability to
change showed larger changes in drinking than other participants. Other studies with alcohol abusers have similarly
found pretreatment self-confidence or motivation to be a
significant predictor of outcomes (Breslin et al., 1997; DiClemente et al., 1995; Kavanagh et al., 1996, 1999; McKay
et al., 1993; Sitharthan and Kavanagh, 1990; Sobell et al.,
1995, 2000b).
The finding that participants in both interventions experienced significant reductions in their drinking and alcoholrelated consequences from 1 year before intervention to 1
year after intervention suggests that the materials, irrespective of whether they were personalized, facilitated the reduction of participants’ drinking. Whether the change was
mainly due to the materials, to completing the assessment
materials, or to participants’ responding to the media announcements is an important consideration, but from a
practical standpoint, because one would ethically need to
respond in some way to individuals who responded to
advertisements, the BDG intervention would seem to be a
feasible large-scale community intervention.
It was possible to compare the percentage reduction in
drinking for two variables (drinks per week and bingedrinking days) with the results from two other brief interventions (Fleming et al., 1997; Sitharthan et al., 1996). Data
for all participants in each study were used to calculate the
following reductions in drinking from 1 year before to 1
year after intervention: (a) percentage reduction in drinks
per week: 27.4% (Fleming et al., 1997), 22.4% (Sitharthan
et al., 1996), and 28.3% (this study); and (b) percentage
reduction in heavy/binge drinking days: 24.2% (Fleming et
al., 1997) and 33.2% (this study). As can be seen, the
overall reductions in drinks per week and heavy/binge
drinking days were similar to or slightly greater for participants in this study compared with those in two other brief
interventions. Although the reductions in drinking were
substantial and would be expected to considerably lessen
the risk of problems, many participants were still drinking
at levels above those recommended as low risk (“Nutrition
and Your Health,” 1990). Further, although the risk of
problems was not assessed in this study, from a public
PROMOTING SELF-CHANGE WITH ALCOHOL ABUSERS
health perspective, it can be expected that decreases in
alcohol consumption to the extent that occurred in this
study would have potential health benefits, such as decreasing blood pressure and decreasing the risk of cardiovascular
diseases (Bondy et al., 1999; Klatsky, 1999; Theobald et al.,
2000).
This community-level mail intervention is consistent with
an efficient approach to improving public health; individuals are first provided with an intervention that is minimally
intrusive on their lifestyle, yet has a reasonable chance of
success (Sobell and Sobell, 2000b). Not only can such interventions reach large numbers of individuals who are
otherwise unwilling, not ready, or not motivated to access
the formal health care system, but, if widely used, they
could generate enormous health and related benefits. It
also seems that intervention materials need not be personalized, which would greatly reduce the intervention costs.
Given the positive results for both groups, it is reasonable to speculate that the change in participants’ behavior
occurred earlier than would have occurred without the
intervention and, therefore, that the anticipated costs of
these participants’ alcohol problems to society were reduced. For those for whom the intervention does not work,
the level of care can be stepped up (i.e., more treatment or
an alternative treatment). In this regard, close to a quarter
of the participants found for 1-year follow-up reported that
they had their first help-seeking experience during the
follow-up year. This suggests that individuals whose problems were not resolved through the mail interventions and
who felt that they needed more than the mail intervention
offered engaged in their own stepped care by seeking help
rather than letting their problem worsen.
In terms of the calculated participant cost, whatever
figure (i.e., US$46 or US$97) is used, the cost of delivering
this intervention is 25–50% of that reported in a recent
intervention (i.e., US$205 total cost per patient) that used
brief physician advice to reduce alcohol abusers’ drinking
(Fleming et al., 2002), and it is comparable to the costs (i.e.,
US$22 to US$144 per quitter) of delivering self-help interventions to smokers [reviewed in Curry (1993)]. Moreover,
although the cost of delivering the mail intervention was
low, the intervention was conducted as a time-limited research project. Thus, little use was made of free public
service announcements, and there was no attempt to combine project efforts with other public outreach projects
(e.g., National Alcohol Screening Day). Likewise, if mail
materials were produced en masse, costs could be further
reduced. Similarly, the one full-time staff member for 1
year could obviously produce materials for many more than
825 participants per year. If the intervention were to be
made available over the Internet (Cunningham et al., 2000;
Humphreys and Klaw, 2001), the costs could become miniscule because there would be no postage or printing costs
and minimal advertising costs. In other words, procedures
similar to those used in this project could be implemented
on a large-scale basis at a fraction of the cost. Furthermore,
945
because this is a mail intervention, dissemination could be
done from any location, thus eliminating geographical barriers to help seeking.
Although several aspects of this intervention are likely to
be attractive to problem drinkers (e.g., no forced goal,
anonymity, confidentiality, no travel time to a clinic, little
time, no cost), because almost all participants were white,
generalizability to other racial/cultural groups awaits further study, as does the extension of such an intervention to
problem drinkers who have had previous treatment or selfhelp. In this regard, although it had been anticipated that
most of the participants would have minor alcohol problems, participants’ mean score of 20.2 on the AUDIT suggests that many had serious drinking problems even though
they had never been in treatment. This further suggests that
interventions such as the one reported here have promise
for reaching individuals with serious problems either by
helping them reduce or stop their drinking or by serving as
a bridge to facilitate treatment entry.
Finally, the brief intervention used in this study was
unlike traditional alcohol treatment in two major and significant ways. First, it used an empirically crafted message
to attract individuals who previously had not addressed
their alcohol problem. It seems that the message was successful, considering that close to 2500 people responded to
the advertisements. The second way this study differed is
that it was a confidential mail intervention that took the
treatment to the people. In so doing, it resulted in significant pre-post decreases in drinking and alcohol-related
consequences, for very little cost and very little effort. The
promise of further research along this line is supported by
two studies that found that both problem drinkers (Cunningham et al., 1999; Koski-Jännes and Cunningham, 2001)
and non–problem drinkers (Werch, 1990) have reported an
interest in receiving self-help materials to help them reduce
their drinking or to learn to drink more moderately.
The public health implications of interventions like the
one reported in this article have been succinctly articulated
in a recent editorial by Humphreys and Tucker (2002), who
called for more responsive and effective intervention systems for alcohol-related problems. In arguing that “[a]lcohol intervention systems are often unresponsive to the full
range of problems, resources, treatment preferences, goals,
motivations and behavior-change pathways with the affected population” (p. 127), they assert that “systems
should enhance the accessibility, appeal and diversity of
services” (p. 128). Finally, they suggest four avenues by
which this can be accomplished: (a) not only should interventions be targeted at drinkers with less serious alcohol
problems, but they should also be disseminated more
broadly, including nonspecialty health care and community
settings; (b) although untested, teleheath services could
reach a large percentage of problem drinkers who have not
accessed the formal health care system (American Psychological Association, 2000; Jerome et al., 2000); (c) rather
than waiting for individuals to cross the clinical threshold,
946
SOBELL ET AL.
wider, more active, and novel approaches for getting individuals to consider looking at their alcohol use are needed;
and (d) receipt of services should be more rapid, address
the person’s concerns, be more flexible (e.g., goal choice),
and meet people where they are on the readiness-to-change
continuum. This radical shift in thinking, that is, viewing
alcohol problems as a public health problem, although new
to many in the alcohol field, was advocated by the Institute
of Medicine (1990) more than a decade ago. Our findings
strongly suggest that such an approach is feasible.
In conclusion, it is time for the alcohol field to respond to
the full range of alcohol problems by offering multiple and
varied behavior-change pathways.
ACKNOWLEDGMENT
The authors thank Dr. J. Scott Tonigan for his statistical advice
and comments on an earlier draft of this paper.
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