drinking case study example

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CASE STUDY Juan (alcohol use disorder)

Case study details.

Juan is a 34-year old Mexican-American construction worker. He reports having to work in extreme heat during interstate road repair and notes that his use of alcohol is comparable to others at the work-site. During a typical 10-hour workday, he may drink up to 8 cold beers to deal with the heat. He does not believe that it affects his work productivity in any way but admits that he has experienced a couple of minor injuries while under the influence. When he began this work a few years back, he recalls not drinking as much. Over time, he has increased his alcohol use and even requires it when returning home. He reports being a family man and had never had alcohol around his family until that time. He explains that his job is tiring and he has no energy left to engage with his children or wife when at home. He also admits to not being able to remember much of his off days because of his drinking. Before this job, he states that he remembers spending time with his three little girls and sometimes finds himself missing those times. He says that when he tries to cut back drinking during special events or during Lent, he finds that he is irritable and craves alcohol. He eventually returns to drinking a similar amount or more. His wife and he argue about how much of his paycheck is going to buying beers instead of their credit card bills and how he is too drunk to spend time with her or the kids. He believes that if he wanted to he could probably cut back.

• Alcohol Use
• Irritability
• Loss of Interest
• Risky Behaviors
• Substance Abuse

Diagnoses and Related Treatments

2. substance and alcohol use disorders.

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Psychotherapy to Resolve Drinking Problems Case Study

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
• As a template for you assignment

Presenting Concern

Case conceptualization, diagnostic impressions, therapeutic approach, treatment goals, ethical considerations.

The client resorted to a counselor because he realized his drinking problems caused a chain of unpleasant situations in his life. More specifically, James identified having alcoholic inclinations caused by enormous stress associated with his work. James’ drinking problem took a toll on his family life since his wife threatened to leave with their two children. Additionally, the client specified that he is currently having a tense relationship with a leader of the firm due to his drinking episodes which make him skip working days.

The client is a Caucasian heterosexual male living in a family of four. His family might put a strain on his emotional health since he has to provide his wife and children with material goods. In addition, James is a religious person, which may be the factor contributing to his desire to be treated. He has an upper management position at a multinational biotechnology research and development firm. It means that his job puts much pressure on him and does not allow him to relax for too long. James resorted to alcohol to unwind the conversation with his boss and other leaders in the company. Finally, his personal life began to suffer since his wife wanted to split with him.

A clinician may use a guide titled “Helping patients who drink too much.” This assessment tool will be helpful in identifying the degree of severity of the condition. Furthermore, it is an excellent means of determining the proper treatment (Rabow et al., 2019). AUDIT Alcohol Screening Tool will be the following method of appraising James’ state. This screening will help identify a client’s drinking patterns and feelings when consuming alcohol and recognize if a patient is exposed to alcohol-related harms.

The provisional diagnosis for James is alcohol use disorder which is the cause of his mishaps. Alcohol intake violates the average balance of the activity of various body systems, causing a natural chain reaction. Alcoholic beverages are consumed in systematic intake of small doses or unsystematic intake of large quantities (Smith, 2017). The continuation of drunkenness leads to a gradual decrease in patients both socially and personally. The fact that James’ family and working relations are falling apart proves the previous statement.

The rationale for Diagnostic Impressions: Note: Use the DSM-5 to explain how the client’s symptoms are reflected in the diagnostic criteria for each diagnosis that you render.

As per the DSM-5, the criteria for alcohol use disorder in James’ case are the following:

• He wants to reduce alcohol consumption but cannot succeed.
• He continues drinking, disregarding the family and work problems.
• He has intoxication after drinking (KM, 2017).
• Sometimes, James consumes more alcohol than intended.
• He uses drinks as a means of mitigating communication (KM, 2017).

Psychotherapy is one of the most effective methods of treating alcoholism. Alcohol abuse is a systemic, multifactorial condition; therefore, psychotherapy of alcoholism should be systemic. The treatment of alcoholism with the help of psychotherapy involves the impact on patients in several directions (Smith, 2017). On the one hand, the etiological basis of addiction is being studied, and the counselor must understand why the patient’s life is reduced to alcohol consumption. On the other hand, the doctor programs the patient for a natural desire to stop drinking alcohol. It is usually suggested to an alcoholic that alcohol causes disgust or instills fear of alcohol consumption (Fitzgerald & Puttler, 2018). Psychotherapy of alcohol use disorder should be combined with drug therapy. Only a complex effect helps to cope with the disease successfully. Additional support for the patient is the understanding of family and loved ones. In general, psychotherapy in the treatment of chronic alcoholism works by changing the human psyche. This complex approach was chosen because James needs to get rid of this bad habit as well as preserve his family and maintain his working position.

The primary treatment goal would be investigating the causes of James’ alcohol abuse. The first step towards disposing of a problem is admitting it and identifying the roots because both the counselor and client must know where it stems from (Singer et al., 2019). The results will be measured during sessions – if James manages to recollect the events leading him to drink, the objective will be achieved.

The second treatment aim is to make James stop drinking alcohol. Throughout the course of psychotherapeutic sessions, James will fill out the screening paper, marking the days when he does not consume a bit of alcohol.

The third initial goal refers to defining the client’s future plans. This step is vital because the alcoholic should realize that they are in charge of their lives. In case James describes his further perspectives, the goal is attained.

Relapse Prevention and Continuum of Care: Describe relapse prevention needs and challenges for the client. Discuss the continuum of care plan and recommendations for the client.

If a relapse occurs, a patient needs to undergo medical treatment and detoxing procedures (Sliedrecht et al., 2019). Ideally, psychotherapy for alcoholism should last several years, with several sessions a month. A doctor should prescribe the intake of medical remedies.

The major challenge associated with treating alcohol use disorder is that the patient’s symptoms may worsen and lead to fatal outcomes. Additionally, the client may refuse to undergo some psychological interventions due to their disbelief.

Fitzgerald, H., & Puttler, L. (Eds.). (2018). Alcohol use disorders: A developmental science approach to etiology . Oxford University Press.

KM, L. (2017 ). Alcohol use disorder: Symptoms, treatment DSM-5 303 . Thriveworks.

Rabow, M. W., McPhee, S. J., & Papadakis, M. A. (2019). Current medical diagnosis and treatment 2020 . United States: McGraw-Hill Education.

Singer, V., Novalis, P. N., & Peele, R. (2019). Clinical manual of supportive psychotherapy . American Psychiatric Publishing.

Sliedrecht, W., de Waart, R., Witkiewitz, K., & Roozen, H. G. (2019). Alcohol use disorder relapse factors: A systematic review . Psychiatry research , 278 , 97–115.

Smith, D. (Ed.). (2017). Emerging adults and substance use disorder treatment: Developmental considerations and innovative approaches . Oxford University Press.

• The Facts About Alcoholism
• Health-Illness Continuum and Patient Experience
• Conceptualization of Health
• OCD: The Four D’s Diagnostic Indicators
• Services for Healthcare Providers of Critical Patients
• Postpartum Depression in African American Women
• The Depression Construct and Instrument Analysis
• Healthcare Workers' Stress Coping Strategies
• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2023, February 1). Psychotherapy to Resolve Drinking Problems. https://ivypanda.com/essays/psychotherapy-to-resolve-drinking-problems/

"Psychotherapy to Resolve Drinking Problems." IvyPanda , 1 Feb. 2023, ivypanda.com/essays/psychotherapy-to-resolve-drinking-problems/.

IvyPanda . (2023) 'Psychotherapy to Resolve Drinking Problems'. 1 February.

IvyPanda . 2023. "Psychotherapy to Resolve Drinking Problems." February 1, 2023. https://ivypanda.com/essays/psychotherapy-to-resolve-drinking-problems/.

1. IvyPanda . "Psychotherapy to Resolve Drinking Problems." February 1, 2023. https://ivypanda.com/essays/psychotherapy-to-resolve-drinking-problems/.

Bibliography

IvyPanda . "Psychotherapy to Resolve Drinking Problems." February 1, 2023. https://ivypanda.com/essays/psychotherapy-to-resolve-drinking-problems/.

Module 9: Substance-Related and Addictive Disorders

Case studies: substance-abuse disorders, learning objectives.

• Identify substance abuse disorders in case studies

Case Study: Benny

The following story comes from Benny, a 28-year-old living in the Metro Detroit area, USA. Read through the interview as he recounts his experiences dealing with addiction and recovery.

Q : How long have you been in recovery?

Benny : I have been in recovery for nine years. My sobriety date is April 21, 2010.

Q: What can you tell us about the last months/years of your drinking before you gave up?

Benny : To sum it up, it was a living hell. Every day I would wake up and promise myself I would not drink that day and by the evening I was intoxicated once again. I was a hardcore drug user and excessively taking ADHD medication such as Adderall, Vyvance, and Ritalin. I would abuse pills throughout the day and take sedatives at night, whether it was alcohol or a benzodiazepine. During the last month of my drinking, I was detached from reality, friends, and family, but also myself. I was isolated in my dark, cold, dorm room and suffered from extreme paranoia for weeks. I gave up going to school and the only person I was in contact with was my drug dealer.

Q : What was the final straw that led you to get sober?

Benny : I had been to drug rehab before and always relapsed afterwards. There were many situations that I can consider the final straw that led me to sobriety. However, the most notable was on an overcast, chilly October day. I was on an Adderall bender. I didn’t rest or sleep for five days. One morning I took a handful of Adderall in an effort to take the pain of addiction away. I knew it wouldn’t, but I was seeking any sort of relief. The damage this dosage caused to my brain led to a drug-induced psychosis. I was having small hallucinations here and there from the chemicals and a lack of sleep, but this time was different. I was in my own reality and my heart was racing. I had an awful reaction. The hallucinations got so real and my heart rate was beyond thumping. That day I ended up in the psych ward with very little recollection of how I ended up there. I had never been so afraid in my life. I could have died and that was enough for me to want to change.

Q : How was it for you in the early days? What was most difficult?

Benny : I had a different experience than most do in early sobriety. I was stuck in a drug-induced psychosis for the first four months of sobriety. My life was consumed by Alcoholics Anonymous meetings every day and sometimes two a day. I found guidance, friendship, and strength through these meetings. To say early sobriety was fun and easy would be a lie. However, I did learn it was possible to live a life without the use of drugs and alcohol. I also learned how to have fun once again. The most difficult part about early sobriety was dealing with my emotions. Since I started using drugs and alcohol that is what I used to deal with my emotions. If I was happy I used, if I was sad I used, if I was anxious I used, and if I couldn’t handle a situation I used. Now that the drinking and drugs were out of my life, I had to find new ways to cope with my emotions. It was also very hard leaving my old friends in the past.

Q : What reaction did you get from family and friends when you started getting sober?

Benny : My family and close friends were very supportive of me while getting sober. Everyone close to me knew I had a problem and were more than grateful when I started recovery. At first they were very skeptical because of my history of relapsing after treatment. But once they realized I was serious this time around, I received nothing but loving support from everyone close to me. My mother was especially helpful as she stopped enabling my behavior and sought help through Alcoholics Anonymous. I have amazing relationships with everyone close to me in my life today.

Q : Have you ever experienced a relapse?

Benny : I experienced many relapses before actually surrendering. I was constantly in trouble as a teenager and tried quitting many times on my own. This always resulted in me going back to the drugs or alcohol. My first experience with trying to become sober, I was 15 years old. I failed and did not get sober until I was 19. Each time I relapsed my addiction got worse and worse. Each time I gave away my sobriety, the alcohol refunded my misery.

Q : How long did it take for things to start to calm down for you emotionally and physically?

Benny : Getting over the physical pain was less of a challenge. It only lasted a few weeks. The emotional pain took a long time to heal from. It wasn’t until at least six months into my sobriety that my emotions calmed down. I was so used to being numb all the time that when I was confronted by my emotions, I often freaked out and didn’t know how to handle it. However, after working through the 12 steps of AA, I quickly learned how to deal with my emotions without the aid of drugs or alcohol.

Q : How hard was it getting used to socializing sober?

Benny : It was very hard in the beginning. I had very low self-esteem and had an extremely hard time looking anyone in the eyes. But after practice, building up my self-esteem and going to AA meetings, I quickly learned how to socialize. I have always been a social person, so after building some confidence I had no issue at all. I went back to school right after I left drug rehab and got a degree in communications. Upon taking many communication classes, I became very comfortable socializing in any situation.

Q : Was there anything surprising that you learned about yourself when you stopped drinking?

Benny : There are surprises all the time. At first it was simple things, such as the ability to make people smile. Simple gifts in life such as cracking a joke to make someone laugh when they are having a bad day. I was surprised at the fact that people actually liked me when I wasn’t intoxicated. I used to think people only liked being around me because I was the life of the party or someone they could go to and score drugs from. But after gaining experience in sobriety, I learned that people actually enjoyed my company and I wasn’t the “prick” I thought I was. The most surprising thing I learned about myself is that I can do anything as long as I am sober and I have sufficient reason to do it.

Q : How did your life change?

Benny : I could write a book to fully answer this question. My life is 100 times different than it was nine years ago. I went from being a lonely drug addict with virtually no goals, no aspirations, no friends, and no family to a productive member of society. When I was using drugs, I honestly didn’t think I would make it past the age of 21. Now, I am 28, working a dream job sharing my experience to inspire others, and constantly growing. Nine years ago I was a hopeless, miserable human being. Now, I consider myself an inspiration to others who are struggling with addiction.

Q : What are the main benefits that emerged for you from getting sober?

Benny : There are so many benefits of being sober. The most important one is the fact that no matter what happens, I am experiencing everything with a clear mind. I live every day to the fullest and understand that every day I am sober is a miracle. The benefits of sobriety are endless. People respect me today and can count on me today. I grew up in sobriety and learned a level of maturity that I would have never experienced while using. I don’t have to rely on anyone or anything to make me happy. One of the greatest benefits from sobriety is that I no longer live in fear.

Case Study: Lorrie

Figure 1. Lorrie.

Lorrie Wiley grew up in a neighborhood on the west side of Baltimore, surrounded by family and friends struggling with drug issues. She started using marijuana and “popping pills” at the age of 13, and within the following decade, someone introduced her to cocaine and heroin. She lived with family and occasional boyfriends, and as she puts it, “I had no real home or belongings of my own.”

Before the age of 30, she was trying to survive as a heroin addict. She roamed from job to job, using whatever money she made to buy drugs. She occasionally tried support groups, but they did not work for her. By the time she was in her mid-forties, she was severely depressed and felt trapped and hopeless. “I was really tired.” About that time, she fell in love with a man who also struggled with drugs.

They both knew they needed help, but weren’t sure what to do. Her boyfriend was a military veteran so he courageously sought help with the VA. It was a stroke of luck that then connected Lorrie to friends who showed her an ad in the city paper, highlighting a research study at the National Institute of Drug Abuse (NIDA), part of the National Institutes of Health (NIH.) Lorrie made the call, visited the treatment intake center adjacent to the Johns Hopkins Bayview Medical Center, and qualified for the study.

“On the first day, they gave me some medication. I went home and did what addicts do—I tried to find a bag of heroin. I took it, but felt no effect.” The medication had stopped her from feeling it. “I thought—well that was a waste of money.” Lorrie says she has never taken another drug since. Drug treatment, of course is not quite that simple, but for Lorrie, the medication helped her resist drugs during a nine-month treatment cycle that included weekly counseling as well as small cash incentives for clean urine samples.

To help with heroin cravings, every day Lorrie was given the medication buprenorphine in addition to a new drug. The experimental part of the study was to test if a medication called clonidine, sometimes prescribed to help withdrawal symptoms, would also help prevent stress-induced relapse. Half of the patients received daily buprenorphine plus daily clonidine, and half received daily buprenorphine plus a daily placebo. To this day, Lorrie does not know which one she received, but she is deeply grateful that her involvement in the study worked for her.

The study results? Clonidine worked as the NIDA investigators had hoped.

“Before I was clean, I was so uncertain of myself and I was always depressed about things. Now I am confident in life, I speak my opinion, and I am productive. I cry tears of joy, not tears of sadness,” she says. Lorrie is now eight years drug free. And her boyfriend? His treatment at the VA was also effective, and they are now married. “I now feel joy at little things, like spending time with my husband or my niece, or I look around and see that I have my own apartment, my own car, even my own pots and pans. Sounds silly, but I never thought that would be possible. I feel so happy and so blessed, thanks to the wonderful research team at NIDA.”

• Liquor store. Authored by : Fletcher6. Located at : https://commons.wikimedia.org/wiki/File:The_Bunghole_Liquor_Store.jpg . License : CC BY-SA: Attribution-ShareAlike
• Benny Story. Provided by : Living Sober. Located at : https://livingsober.org.nz/sober-story-benny/ . License : CC BY: Attribution
• One patientu2019s story: NIDA clinical trials bring a new life to a woman struggling with opioid addiction. Provided by : NIH. Located at : https://www.drugabuse.gov/drug-topics/treatment/one-patients-story-nida-clinical-trials-bring-new-life-to-woman-struggling-opioid-addiction . License : Public Domain: No Known Copyright

Misinformation & Fake News

• Getting Started

Practice: Case Studies

Widely shared fake news stories from 2020-23, widely shared fake news stories from 2016-18, fake news exercise.

• Types of Misinformation
• Legitimate News Sources
• Books & Articles
• Video Resources
• Other Resources
• Case Study 1
• Case Study 1 - Explained
• Case Study 2
• Case Study 2 - Explained

On August 20, 2022, a TikTok video was posted, claiming that Disney World was going to lower the drinking age to 18. It was stated that Disney World was battling the Florida government in court to get a resort exemption, which would allow anyone 18 and older to drink on property. The TikTok video acquired millions of views in just a couple days. This story was also posted on facebook, instagram, and Twitter. Shortly after, the story made it on ABC 10 News.

The video originated from an article posted on a blog called Mouse Trap News. Small segment of the original article below. Full article can be found here: "Drinking Age at Disney World May be Lowered to 18".

The Claim: Walt Disney Company was seeking a resort exemption to lower the drinking age to 18 years old, in Disney World, Florida.

To find the truth about this story, we will use Michael Caufield's  Four Moves and a Habit. 

1. Check for previous work: For this case, we looked up this claim on  Snopes ( fact checking resource ). They published an article on the story and labeled it as fake news satire. It was also aired on ABC 10 News, on their fact or fiction  segment, where it was determined to be fiction. The news segment can be viewed  here .

2. Go upstream to the source:  The TikTok video originally came from an article published by the same TikTok user, @mousetrapnews. They have their own webpage dedicated to news stories about disneyland parks.  The original article claimed that Disney was battling Florida in the courts over the minimum drinking age, but no evidence such as sources or court filings are mentioned.

3. Read laterally: Upon further exploration of the site itself, their  About  page actually bluntly admits that they only write fake stories about Disney Parks (see picture below).

4. Circle back: If we go back to the main article explaining the story, it reads in the description an explanation of the National Minimum Drinking Age Act passed by congress and signed into law by President Reagan. The article then asks the reader a question "Didn’t think you would get a history lesson from us, did you?" and "Now that we have set up the act, we have some Disney news to go with it.", these playful comments already makes the story a little suspicious. We can also check another form of social media the user has. They also had an Instagram account, where they state "Real Disney News That is 100% Fake" and "The Onion Of Disney News".

 Interestingly enough, many of the Mouse Trap News fake news stories have been featured on different news websites and shows, such as The Associated Press, USA Today, and on The Tonight Show with Jimmy Fallon .

The Conclusion: The Walt Disney Company did not seek a resort exemption to lower the drinking age to 18 years old, in Disney World, Florida.

In October 2020, posts on social media and articles were published claiming that a new CDC study found the Majority of those infected with COVID-19 ‘always’ wore Masks (examples of the articles below). This claim was further elevated on October 15, 2020, a town hall broadcast by NBC, interviewed U.S. President Donald Trump. During this interview Trump stated, " But just the other day, they came out with a statement that 85% of the people that wear masks catch it." Trump's source for this claim was the new study published by the CDC. Full transcription of this interview can be found  here.  This information was ultimately, misinterpreted. Below is the CDC's tweet addressing the misinformation.

The Claim: CDC reported that the majority of those infected with COVID-19 ‘always’ wore masks.

• Check for previous work:  For this case, we looked up this claim on  Snopes and FactCheck.org ( fake news fact checker ). Both resources claim the information as false and misleading.
• Go upstream to the source:  The claim originated from a study published by the CDC titled,  Community and Close Contact Exposures Associated with COVID-19 Among Symptomatic Adults ≥18 Years in 11 Outpatient Health Care Facilities.   This study examined how SARS-CoV-2, the virus that causes COVID-19, may be transmitted both within communities and between close contacts. While Trump used the correct percentage from the study, the data was misinterpreted. The study reported that 85 percent had reported wearing masks always or often. The study also found that for those in the group who had tested negative, 89 percent had reported wearing masks with the same frequency. The CDC pointed out that "People w/ and w/o COVID19 had high levels of mask use in public. Even for those who always wear a mask, there are activities where masks can’t be worn, like eating or drinking. People w/ COVID-19 were more likely to have eaten in a restaurant." The study noted, "Exposures and activities where mask use and social distancing are difficult to maintain, including going to locations that offer on-site eating and drinking, might be important risk factors for SARS-CoV-2 infection."
• Read laterally: The claim is challenging the notion that wearing a mask is not effective at preventing the spread of COVID-19. We have to take in consideration that this study was investigating mask wearing in community activities. CDC's website provides Science Briefs  which is a summary of the scientific evidence used to inform specific CDC guidance and recommendations. In one  brief , they state, "individual prevention benefit increases with increasing numbers of people using masks consistently and correctly." So, the people from the original study might have not been using their masks effectively if repeatedly taking them off in social settings. Other medical experts such as Dr. Anthony Fauci, states "Masks aren't perfect. They help, but they're not a guarantee that you're not going to get Covid if you wear a mask”.  
• Circle back:  If you find yourself getting overwhelmed by other sources on the claim, circle back to the claim and investigate the background of that source. Using the  AllSides Media Bias Chart , we can see that  The Federalist  is listed on the very, far right side of the chart. The author of that article, Jordan Boyd, has her twitter page linked to her name and we can see that her posts are on the far right of the political spectrum. The  California Globe  is listed as a conservative leaning publication on  Snopes,  many of their other posts written by the author lean to the right of the political spectrum. You can also circle back to the original study the claims were based on and question the accurateness. One issue with the study is the data was self-reported through phone surveys. So, people could have inaccurately reported mask use since there was no video monitoring to confirm. 

Check Your Emotions:  The use of masks and its effectiveness against COVID-19 was a highly politicized topic when the pandemic started. By downplaying the severity of the virus (despite all the losses recorded by the CDC), President Trump's attitude about the pandemic and the use of masks contributed the view that the COVID-19 public health crisis should be viewed as a political issue.

Conclusion: The CDC did not report that the majority of those infected with COVID-19 ‘always’ wore masks.

For more examples on COVID-19 myths and using Michael Caufield's  Four Moves and a Habit to fact check them, visit our   COVID Vaccines Libguide.

• Jan. 6 Capitol Riot
• COVID-19 and Vit. C
• Adrenochrome Shipment
• RNA in Chicken Feed

The Claim: The U.S. Capitol police gave the protesters an "okay" to enter the Capitol.

• Check for previous work: For this claim, we looked up this claim on Factcheck.org  (fake news fact checker). Factcheck.org debunks the story here.
• Go upstream to the source: this claim originated from a video clip that was posted all over social media. This video clip was posted by a group of Trump supporters who attacked the United States Capitol Building in Washington, D.C., after U.S. President Donald Trump did not win the 2020 presidential election, on January 6, 2021. They uploaded a video where shows a police officer “appears to tell” the group that they wouldn't stop them from entering the building. However, nowhere in the video does the police make that claim. A fake news website called, The Gateway Pundit, reported the same claim on Facebook and Instagram. Even a radio show in Texas called “Walton & Johnson,” ran a similar headline.
• Read laterally: the next step would be to see what others are saying about this claim. In this case we should look at what the police officers in this video clip said about the incident. US Capitol police officers said in an email statement to factcheck.org , that the officers were blocking the whole way and attempting to de-escalate the situation by telling the crowd to not attack or assault and to remain calm. The Justice Department reported that about 140 police officers were assaulted that day.
• Circle back: If you find yourself, getting overwhelmed by other sources on the claim, circle back and investigate the background of that source. If we look back to the actual incident on January 6, 2021, we know from ample public evidence released by the FBI showed Trump supporters violently assaulting officers at the Capitol. Other shown footage included Trump supporters breaking through a metal barrier outside the capital and breaking windows of the building to enter.

Conclusion: The U.S. Capitol police never gave protestors permission to enter the Capitol.

The Claim: High doses of vitamin C can cure COVID-19.

• Check for previous work: Throughout the year 2020, many websites and social media posts were claiming how high doses of vitamin C could cure and/or be an effective treatment for COVID-19. For this case, we looked up this claim on Snopes (fact checkering source) which they claim the information as false and misleading.
• Go upstream to the source: These claims stemmed from multiple studies detailing how vitamin C can help support the bodies immune system. According to Harvard Health Publishing , vitamin C has some marginal benefits for the common cold, such as reducing the duration of symptoms, if it is taken before catching a cold. Those benefits can be achieved with a diet that includes 200 milligrams of vitamin C, which is easily obtainable with a daily diet that includes fruits and vegetables .
• Read laterally: To gain additional background on this claim, we can read multiple sources and this this case see if it has been tested in trials. The CDC ultimately reported that there was insufficient evidence for the panel to recommend either for or against vitamin C for the treatment of COVID-19 and non-hospitalized patients. Most of the trials had a limitation such as small sample sizes, study designs that had different doses or formulations of vitamin C and different outcome measures.
• Circle back: If you find yourself, getting overwhelmed by other sources on the claim, circle back to the claim, and investigate the background of that source. In this particular claim, there is some truth and vitamin C is good for your immunity. However, some of the hype around these claims came from unpublished sources, fake news, personal websites, and from "influencers" on social media. We can refer to the CDC website and peer review published articles about the relationship between COVID-19 and vitamin C. Clinical trials can be found on the ClinicalTrials.gov website.

Conclusion: doses of vitamin C are not a proven as an effective cure for COVID-19.

Claim: Putin intercepts adrenochrome shipment

1. Check for previous work: In this case if we looked for "adrenochrome putin shipment" to check for previous work, we would find that politifact.com already did a fact check on this story.

2. Go upstream to the source: This example is from Real Raw News . This website is known for fabricating stories; if that's information you knew coming into this evaluation, you would know this is an automatic red flag and we could stop here. However, if you didn't know that, you could make a few judgements about what other stories are on the page to get a sense of the angle and political bias for this news source. If you research Andrei Zakharov, whose name was used as a source of information, you'll find that he is a Russian journalist that works for the BBC Russian Service, not as Russian FSB Agent. As a story featuring adrenochrome and blood harvesting with a history of conspiracy theories behind it, you should already be skeptical. Looking up some of the facts in the story help us determine more about its truthiness.

3. Read laterally: Given what we've learned from steps 1 and 2, at this point in the evaluation we could stop our search, dismiss the story, and move on with our lives. However, if we aren't satisfied with what we found, out next step is to look for other stories about this issue. Are other reports of this story coming from reputable sources? Is the story reported elsewhere with the same facts? Are there discrepancies in what's being reported? This is the step where we need to be paying extra attention to who's publishing the story that corroborates this narrative. On the internet you can find pretty much anything you look for, but "anything" isn't always an accurate story to trust.

4. Circle back: There's plenty of facts within this story for us to investigate and check. However, we eventually want to come to a conclusion and circling back will bring us to the question of whether this story has any truth. Given what we've learned: no, this is not factual.

Check your Emotions: The habit we're practicing throughout is about checking our emotions. Do I want this story to be true? Does this story sound too outrageous to be true? Am I attached to what the truth about this story is one way or another?

The Claim: chickens are not laying eggs, because RNA is being added to commercial chicken feed.

• Check for previous work: For this case, we looked up this claim on politifact.com. This resource debunks it here.
• Go upstream to the source: The claim originated from a published research article titled, " Messenger RNA sequencing and pathway analysis provide novel insights into the biological basis of chickens’ feed efficiency. " This study aimed to characterize the biological basis of differences between chickens with low and high feed efficiency, with a long-term goal of improving the ability to select for feed efficiency. Nowhere in the article did it mention adding RNA to chicken feed. RNA sequencing was being used to see how differences in feed efficiency can be explained by what levels of RNA are produced by the chickens' cells.
• Read laterally: The next step would be to see what others are saying about this claim based on the article. PolitiFact actually did many email interviews with experts in the field, to talk about the claim. Multiple experts said commercial feed manufactures were not adding RNA to chicken feed, and that this claim was a misinterpretation of the data. The FDA also confirmed that RNA is not on its own, a feed additive. The articles cited from the original TikTok video are not relevant to the argument made in the video. The FDA also stated that there are many ways why a chicken's egg-laying behavior and quantity could change. They recommended consulting a licensed veterinarian, who can examine the animal and take a detailed medical and diet history.
• Circle back: If you find yourself, getting overwhelmed by other sources on the claim, circle back to the claim, and investigate the background of that source. The first thing one should question is how RNA is being referred to in the post. RNA stands for ribonucleic acid, which is a naturally occurring nucleic acid found in all living cells. So, the claim of adding synthetic RNA into commercial feed does not make any sense. Furthermore, a search can be done to confirm what common factors are affecting chicken egg laying. Common reasons listed were management practices, improper nutrition, parasite infection, disease, lighting, and stress.

Conclusion: RNA is not being added to commercial chicken feed.

• Trump Bills Michelle Obama
• "Pizzagate"
• Donald Trump Wins the Popular Vote
• Hillary's Health
• Muslims Demanding Handouts
• Burning Tipis at Standing Rock
• Student Desecrates Constitution

This example is from Before It's News; it's also featured on at least one other similarly fake website. The amounts supposedly owed by the Obamas are pretty unbelievable. Even if the presidential couple had indeed bought everything the article claims they did, the total would not come anywhere close to $11 billion, a figure equal to the GDP of a small country. It also includes some grammatical issues, and "eleventy" isn't a word.

It's also worth looking at the Before It's News site itself:

A few points:

• "Alternative," "Spirituality," and "Unexplained" are terms that one doesn't find among the tabs on any legitimate news site.
• No professional news organization lets just anyone "upload news."
• The presence of advertising, and the nature or quality of the products being advertised, is not a sound indicator of the site's reliability. Ads for Duracell batteries and Mapquest could quite conceivably show up in the margins of The Seattle Times ' website , for example. Newspapers, in both their print and online versions, generally cannot survive without ad revenue.
• This site deals heavily in sensationalist headlines (the ones underlined are just some of the most outrageous).

Among the most notorious fake news stories of 2016 was one alleging that Hillary Clinton was running a child-prostitution ring out of a Washington, D.C., pizzeria. This had real-world consequences for the employees of that pizzeria when an armed man decided to "self-investigate" the rumors, as described in  "Dissecting the #PizzaGate Conspiracy Theories,"  by Gregor Aisch, Jon Huang, and Cecilia Kang.

During the 2016 election, another persistent fake news story was that Donald Trump won both the popular vote and the electoral college vote. That Trump won the electoral college by a clear margin is undisputed. While the federal government did not release the official results of the popular vote until mid-2017, a great number of sources, ranging from the more conservative  The Wall Street Journal  to the more liberal  The New York Times reported Hillary Clinton winning the popular vote by margins ranging from approximately a million votes (on Nov. 9, 2016) to three million (NYT estimate as of Feb. 10, 2017).

During the 2016 presidential campaign, fake news sites circulated several stories alleging that Hillary Clinton was in poor health, the implication being that she was not fit enough for the rigors of the presidency. Fake news site 70News dedicated an entire section to these rumors, most of which were bolstered by photos or video clips showing Clinton in moments of apparent frailty or disorientation. This illustrates a common fake news tactic: the use of tidbits of truthful imagery to support exaggerated or unsubstantiated claims. Laura Mallonee writes about this phenomenon in " How Photos Fuel the Spread of Fake News ."

Not all fake news is geared toward a conservative audience; liberals may be just as quick to believe falsehoods that seem to confirm their hopes and fears. A February 2017 story run by Alternative Media Syndicate claimed that police forces arrayed against the pipeline protesters at the Standing Rock Indian Reservation raided and burned a protester camp, offering graphic imagery of flaming tipis as proof. This story is completely false; the image was taken from a 2007 HBO film, Bury My Heart At Wounded Knee . Snopes.com debunks the story here .

In February 2018, after surviving a shooting in which 17 of her schoolmates died, Florida teenager Emma Gonzalez became an outspoken proponent of gun control legislation. Not long after, imagery of her apparently tearing up a copy of the U.S. constitution went viral on right-wing websites. This imagery was doctored ; the originals came from a Teen Vogue photo shoot in which Gonzalez symbolically tore up a target sign. Photo manipulation is a time-honored propaganda tactic, but is now easier than ever thanks to Photoshop and other editing tools.

• Robert Amnor story

Work in groups of 3-5. Using any methods you can think of, try to determine whether the story is (a) false, (b) true, or (c) a mix of truth and falsehood. Go back to the home page of this guide if you need some direction on what to look for.

Discuss which (if any) of the fake news hallmarks from the first page of this guide are evident in this story.

• << Previous: Getting Started
• Next: Types of Misinformation >>
• Last Updated: Apr 16, 2024 12:19 PM
• URL: https://libguides.lib.cwu.edu/fakenews

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Alcohol Addiction Case Study: Steven's Story

Meet Steven. He is a 30-year-old junior marketing executive, he’s single and he shares an apartment with his brother. He seems to be living a good life. However, Steven was in denial about his drinking problem .

He had a very active social life and could be found at a bar, club or restaurant every night of the week. He enjoyed his social life but alcohol is always present whenever he goes out. He joked that he looks like an alcoholic because he’s holding a drink in every photo of himself. In reality, it’s no laughing matter.

Steven met a woman that he liked. She also thinks he’s sweet and they had been seeing each other for a couple of months. She notices that every time she calls him he is drinking but thinks nothing of it. After all, maybe this man just enjoys a couple of drinks when he’s out with friends or colleagues. She doesn’t think that drinking every night makes him an alcoholic. She may also be wrong.

Warning signs of an alcohol problem

In fact, she thinks Steven is a really nice guy and they have spent time together, spoken on the phone scores of times and have grown closer.

A couple of months after they meet they decide to go out together for a night. She drops over to his place beforehand and while they share a bottle of wine Steven tells her his mother has asked him to promise not to drink. They laugh about how parents often refuse to view their children as adults. She still does not think he has a problem.

She’s not alone in not recognising the signs of someone with an unhealthy relationship with alcohol. It’s not always easy. High functioning alcoholics may hold professional jobs, work at the highest levels and not appear as chaotic or drunk. However, there does come a point when even the hardest drinker has too much. Steven may already be there.

Things go well for Steven that the night and his new love interest agrees to another date. A week later he picks her up and they start swapping stories on the way to their date. He starts to tell her some quite concerning tales. He woke up one morning after a big night of drinking and found his shirt was covered in blood. He doesn’t know how the blood got there, or what he did, he says with a laugh.

On another occasion, he was at a nightclub and a young woman knocked into him, spilling his drink. Enraged in the moment, he pushed her back and the woman careered across the room. This is when Steven admitted that – back then – he didn’t know what his alcohol limit was. Now, his new lady is becoming a little worried.

Why is it hard to stop drinking?

It’s important to note that Steven used the past tense in this conversation. Since this happened, a year ago, he had changed his drinking habits, he said. Right then, Steven pulls two bottles of strong alcohol out of his pocket. He offers them to his date but she is happy with the drink she has, and feels worried about his drinking tonight. He drinks the small bottle that he brought for himself – and the one for her.

Two hours later the couple were in a nightclub and Steven seemed to be holding his alcohol well. He was enjoying his night and had already had two beers and was ready for a shot of tequila. This was where things went downhill.

After drinking the powerful shot of alcohol he began to alienate the woman he arrived with. He spilt salt all over the bar, then began dancing sloppily and said insulting things. His behaviour is awful and embarrassing and the woman he likes leaves, saying she never wants to see him again. Despite his behaviour, Steven can’t understand why. She never calls him again.

Help for alcohol problems

Steven needed some help. He was in a state of denial about his drinking problem and there are a host of signs and symptoms of his alcohol dependence . Signs that his life is moving out of control could include:

• An inability to stop drinking
• An inability to see how drinking creates personal conflict
• Spending so much money on alcohol that he is putting himself in a financially difficult position
• Allowing his drinking, and his behaviour while drinking to, to jeopardise existing relationships and potential future relationships
• A lack of understanding on Steven’s part so he doesn’t see the connection between his poor decisions and bad situations.
• Not understanding why people around him are worried about him.

People were worried about him but Steven continues to drink excessively on an almost daily basis. He still argues that he doesn’t have a problem. That means he doesn’t need to seek help. He is wrong. he needs to have an alcohol detox first.

The terms “alcohol abuse” and “alcoholism” are used interchangeably in modern culture but there’s a clear and important difference. Alcoholism is an addiction or dependence to drink alcohol – it’s a compulsion that cannot be ignored. It is destructive.

Alcohol abuse is where someone drinks excessively despite knowing it’s not a positive force in their life. Both of these types of behaviour can be destructive. We don’t know where Steven sits on this spectrum.

Long-term effects

The barrier here is that Steven doesn’t think he has a problem. In the long term, he will never be able to find a more secure job position as his behaviour and health will become increasingly erratic. He may also struggle to enjoy a serious romantic relationship.

Meanwhile, his inability to stop drinking will eventually permanently affect the way his body works. His liver and kidneys are particularly at risk. When his health deteriorates the burden of his care will put financial pressure on him, his family and society.

Steven could also suffer from problems in his brain. Alcohol interferes with the brain’s connections and he may eventually find his mood and behaviour suffers. That’s damage he’s sustained thanks to his lifestyle. This makes it harder to think clearly and move with coordination.

His heart is also at risk. He may have developed an irregular heartbeat, is at increased risk of having a stroke and may suffer high blood pressure. His chance of developing several cancers is also increased.

Steven’s story shows that there’s no concrete way to recognise drug and alcohol problems. You might be friends with, working with, or dating someone with an alcohol problem and not even know it. Alcoholism and drug problems, much like other chronic illnesses, can’t be diagnosed by just looking at someone, or even casually getting to know them. However, if you pay attention there are probably warning signs.

When to get help for drinking

If somebody has to drink in the morning, or has to sneak away often during the day (even while at work) to drink secretly, then they may be alcohol-dependent. They will rather hide and down a few drinks than go through the withdrawal symptoms. This isn’t a life you can can sustain forever.

There will almost certainly come a point when Steven realises that he wants, or needs, to stop drinking. However, that’s not an easy task. Unsupervised attempts to detox from alcohol can be life-threatening. Alcohol withdrawal can cause brain damage, seizures, heart palpitations, and other side effects which can leave you in need of serious medical attention.

We’re sharing Steven’s story in the hope that it might help you or someone you know get in to a alcohol rehab. If you see your situation in this story then please talk to someone that can help you. You only need to ask. Help is out there. Like Steven, after a string of wrong choices, make the right one with serenity was so important.

Attending Alcohol Rehab

Steven completed a 4 week programme and with the in-depth inner work we done with him. He is 7 years clean and sober with loving family all back and running his own new successful business.

He often pops in to say hi to the team and has a chat with some of the clients showing there’s hope going into alcohol rehab. The smile we see on his face every time he comes says it all.

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To drink alcohol or not to drink it

• A young believer struggles to apply his personal convictions against drinking alcohol in a cross-cultural social setting in France.
• The protagonist's past experiences and personal background influence his stance on alcohol, with his alcoholic father and cautionary tales of missionaries contributing to his abstinence position.
• When believers find themselves in cross-cultural situations where their convictions conflict with societal norms, they may be tempted to set aside personal convictions in order to build relationships.

Case study of a young believer in France

Worldview collision: Use this case study to hone your critical thinking and ethical decision-making skills.

Use this case study to shape your answer to the question: what should i do in those situations where my convictions are in direct opposition to other people's expectations.

It had been a long evening for John. What had started out as a privilege had turned into a disaster.

John seemed to have already insulted and upset the Professor by refusing an aperitif and then some wine. As they sat in the living room after the meal, Professor Piaget set a glass in front of John, ready to pour some of his prized Brittany cider. John wondered if it was right for him to continue on a course of action that seemed to be alienating his host. Or would it be all right just this once to forget all that teaching in Bible College, forget his alcoholic father, and forget even what the Smiths would think and say? Would it be all right to drink a little cider (which did not contain much alcohol anyway)?

Earlier, John had spent two summers in France. Now, in obedience to what he felt to be the will of God, John had returned to that country and had entered the beginning French course at the University of Nantes. He was living in a dormitory where he hoped to develop relationships with French students. He also made friends with the Smiths, an American missionary family who were starting a church in Nantes.

John had just graduated from a conservative religious college in the U.S. that took a strong stand against drinking alcoholic beverages. That total abstinence stand was OK with John. Because John's father was an alcoholic, he knew firsthand the suffering that alcoholism could bring. In his conversations with the Smiths, John was sad to learn about some missionaries who had started drinking wine to be hospitable to the French and who had wound up as alcoholics.

One day, John, along with three other foreign students, received an invitation from his professor. Professor Piaget was graciously opening his home to them for dinner. John had heard that it was a real privilege for students to be invited to a professor's home in France.

When the night arrived for the dinner, John's missionary friends, the Smiths, loaned him their car so that he could pick up his Japanese friend, Isao. As they arrived at the Piagets' house, the students were excited. Little did John suspect that this dinner would turn out to be a problematic experience.

Dr. and Mrs. Piaget were very cordial. John spoke less French than anyone there, but everyone was patient with him. After all the students arrived, Professor Piaget offered everyone an aperitif (a type of cocktail). Wanting to be a good witness for his Lord, John refused the alcoholic drink. John thought the professor seemed ill at ease because, for a moment, Dr. Piaget appeared not to know what to do. After an uneasy silence, the professor offered John a lemon drink. As the awkwardness of the moment passed, John breathed a sigh of relief.

When dinner was served, John partook heartily. But when Dr. Piaget began filling the guests' glasses with the customary wine, John politely refused his share. This time, the professor appeared to feel awkward and even somewhat angry at this young foreigner for refusing his hospitality. Though the professor offered John a Coke as a substitute drink, the atmosphere had changed. Due to the length of French meals and people's thirst, the host had to go get more wine. Again, John was the only one to refuse it.

When dinner was finished, everyone sat around the table talking. Mrs. Piaget cleared the remains of dessert and coffee off the table. It had been a great time for everyone except for John and perhaps his host.

John began asking himself several questions:

• Is the Lord pleased with the way the evening has gone?
• Will I ever be able to share my faith in Christ with Dr. Piaget?
• Is it really so bad to drink a little wine?
• Which is worse: drinking a little alcohol or erecting a barrier between myself and someone who does not know the Lord?

These questions and more had run through John's mind throughout the meal, particularly now, when everyone else was enjoying the relaxing conversation.

Eventually, Professor Piaget excused himself. After a few minutes, he reappeared carrying a tray. On it was a large flask surrounded by a neat circle of glasses. The professor began to tell his guests how good Brittany cider was. Then, he noted, especially for John's benefit, that the cider contained only a little alcohol. The professor set glasses in front of everyone and began to pour.

As his professor moved closer to him, John became anxious.

• Should he refuse again, even though the professor had pointed out for John's sake that the cider contained just a little alcohol?
• Should he refuse again and risk building an even higher barrier between his teacher and himself?
• On the other hand, did he dare ignore the teachings and warnings of both the Bible College and the Smiths?

Holding a glass, Professor Piaget paused in front of John. At that moment, John . . .

Some discussion questions:

• What should John do or say now?
• What should have happened differently for the evening to have gone better?
• Should the Smiths have been more proactive in helping John?
• What principles should we follow when interacting with people whose position on a particular lifestyle issue differs from ours?
• Can you think of examples of similar situations which involve different lifestyle issues?

Seven steps to effective case study discussion

This case study is a revised version of one by Dennis Teague in Case Studies in Missions, edited by Paul and Frances Hiebert, Baker Book House. It may be reproduced only upon payment of a 35-cent royalty per copy to Baker Book House, P.O. Box 6787, Grand Rapids, MI 49516 USA

Professor Culbertson's experience

Afterword: Some Background Material

Refusing alcoholic beverages in cross-cultural situations can sometimes be challenging due to cultural norms and expectations. However, there are several polite and respectful courses of action for someone committed to a no-alcohol lifestyle:

• Be Direct but Polite: Simply say, "No, thank you" or "I don't drink alcohol, but I appreciate the offer."
• Provide a Brief Explanation: If you feel comfortable, you can briefly explain your reasons for not drinking alcohol. For example, you might say, "I've made a personal choice to abstain from alcohol" or "I prefer to stay sober for health reasons."
• Use Cultural Sensitivity: In some cultures, refusing an offer of alcohol directly may be considered impolite. In such cases, you can still politely decline but offer an alternative, such as, "I'd prefer water or juice, thank you."
• Offer a Toast with a Non-Alcoholic Beverage: If there's a toast involved, raise your glass with a non-alcoholic beverage like water or a soft drink.
• Shift the Focus: Redirect the conversation away from your refusal by asking about the cultural significance of the beverage or by engaging in another topic of conversation.
• Plan Ahead: If you know you'll be in a situation where alcohol might be offered, plan your response in advance to feel more confident in your refusal.
• Stay Firm but Friendly: Remember that it's okay to decline an offer of alcohol, and you don't owe anyone a detailed explanation. Stay firm in your decision while remaining polite and respectful.

By employing strategies like these, you can navigate cross-cultural situations gracefully while maintaining your commitment to a no-alcohol lifestyle.

Related articles

• John Wesley's self-examination questions
• Defining sin
• Contextualization
• Other case studies

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Ethical considerations in investigating youth alcohol norms and behaviours: a case for mature minor consent

Affiliations.

• 1 Collaboration for Evidence, Research and Impact in Public Health (CERIPH), Curtin University, Perth, WA 6845, Australia.
• 2 School of Public Health, Curtin University, Perth, WA 6845, Australia.
• PMID: 26411327
• DOI: 10.1071/HE14101

Mature minor consent only became available in Australia in 2007. There is neither an explicitly defined protocol, nor a clear definition evident in the literature relating to use of the mature minor concept in health research. Due to difficulties in defining fixed age ranges to varying levels of maturity and vulnerability, there is a lack of clarity surrounding when it might be reasonable and ethical to apply for or grant a waiver for parental consent. This paper describes the challenges faced and solutions created when gaining approval for use of mature minor consent in a respondent-driven sampling (RDS) study to explore the social norms and alcohol consumption among 14-17-year-old adolescents (n = 1012) in the community. The University's Human Research Ethics Committee granted mature minor consent for this study, and the techniques applied enabled recruitment of adolescents from community-based settings through use of RDS to achieve the required sample. This paper has relevance for research that requires a waiver for parental consent; it presents a case study for assessing mature minors and makes recommendations on how ethical guidelines can be improved to assist human research ethics application processes.

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Drinking Problems

• 1.0 Overview
• 2.0 Case Study
• 3.0 Conversation Questions

Engaging in conversation practice related to case studies about problems such as alcohol addiction can help learners to develop their communication skills, expand their vocabulary, and improve their grammar and pronunciation in the context of a specific topic.

Students can learn how to express themselves more clearly, listen actively, and respond appropriately to various scenarios involving alcohol addiction. They can also learn how to use relevant terminology, idiomatic expressions, and phrasal verbs in discussing alcohol addiction.

Steven’s Story

Steven is a 43-year-old man who has been struggling with alcohol addiction for several years. He started drinking in his early 20s as a way to socialize with his friends and alleviate stress from work. Initially, he would only drink on weekends or during special occasions, but over time, his drinking gradually increased in frequency and quantity.

After the birth of his child, Steven started drinking more heavily as a way to cope with the stress and demands of parenthood. He found it challenging to balance the responsibilities of being a new father with his job and other commitments, and he often turned to alcohol as a way to escape from his problems.

Steven’s alcohol consumption has caused significant problems in his personal and professional life. He has lost his job twice due to showing up to work drunk and has strained his relationships with his family and friends. Despite these issues, Steven has found it challenging to quit drinking. He has tried going to AA meetings, detox programs, and therapy sessions, but none of these attempts have been successful.

As Steven’s drinking continued to escalate, his relationship with his wife began to suffer. She became increasingly concerned about his behavior and the impact it was having on their family. They argued frequently, and his wife threatened to leave him if he didn’t quit drinking.

If Steven fails to quit drinking, it is likely that his relationship with his wife will deteriorate further. She may lose patience with his behavior and decide to leave him, which would have significant emotional and financial consequences for their family. Steven knows that he needs to quit drinking for the sake of his marriage and his family, but he is struggling to find the strength and support he needs to overcome his addiction.

Conversation Questions

• How do you think Steve's alcohol addiction started?
• What different methods has Steve tried to quit drinking, and why do you think they were unsuccessful?
• How do you think Steve's relationship with his wife has been affected by his alcohol addiction?
• What advice would you give to Steve to help him overcome his addiction?
• What steps can society take to better support individuals struggling with alcohol addiction?
• How can we raise awareness about the dangers of alcohol addiction and the importance of seeking help?
• In your opinion, is it possible for someone with an alcohol addiction to fully recover and live a sober life? Why or why not?
• What role do you think family and friends can play in supporting someone struggling with alcohol addiction?
• In your opinion, what are some common misconceptions people have about alcohol addiction?
• What are some ways to prevent alcohol addiction from becoming a problem in the first place?

Keep The Conversation Going!

Gregory is a qualified TEFL teacher who has been teaching English as a Foreign Language (ESL) for over a decade. He has taught in-person classes in Spain and to English learners around the world online.

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Drink Case Studies Samples For Students

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While studying in college, you will certainly have to compose a lot of Case Studies on Drink. Lucky you if linking words together and organizing them into relevant content comes easy to you; if it's not the case, you can save the day by finding an already written Drink Case Study example and using it as a model to follow.

This is when you will certainly find WowEssays' free samples database extremely helpful as it includes numerous professionally written works on most various Drink Case Studies topics. Ideally, you should be able to find a piece that meets your criteria and use it as a template to develop your own Case Study. Alternatively, our competent essay writers can deliver you an original Drink Case Study model crafted from scratch according to your personal instructions.

Free Red Bull: Building Brand Equity In Non-Traditional Ways Case Study Sample

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The Association Between Antidepressant Use and Drug-Induced Liver Injury: A Nationwide, Population-Based Case–Control Study in Taiwan

• Original Research Article
• Open access
• Published: 05 June 2024

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• Ching-Ya Huang 1 , 2 ,
• Ying-Shu You   ORCID: orcid.org/0009-0001-7802-6097 3 , 4 ,
• Jian-Ming Lai 3 ,
• Cheng-Li Lin 5 ,
• Hsing-Yu Hsu   ORCID: orcid.org/0000-0003-4424-9476 3 &
• Yow-Wen Hsieh   ORCID: orcid.org/0000-0002-0523-3482 2 , 3  

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Background and Objective

The complex risk factors of liver injury have prevented the establishment of causal relationships. This study aimed to explore the effects of antidepressant class, cumulative days of medication exposure, presence of comorbidities, and the use of confounding drugs on the risk of antidepressant-induced liver injury.

The population-based case–control study sample included individuals registered on the Taiwan National Health Insurance Database between 2000 and 2018. Hospitalized patients with suspected drug-induced liver injury were considered as cases, while control subjects were matched 1:1 by age, gender, and index date (the first observed diagnosis of liver injury). Multivariable regression models were performed to evaluate the association between antidepressants and liver injury.

The findings showed that antidepressant users exhibited a higher risk of liver injury (adjusted odds ratio [aOR] 1.16, 95% confidence interval [CI] 1.12–1.20), particularly those prescribed non-selective serotonin reuptake inhibitors (NSRIs; aOR 1.05; 95% CI 1.01–1.10), selective serotonin reuptake inhibitors (SSRIs; aOR 1.22; 95% CI 1.16–1.29), serotonin-norepinephrine reuptake inhibitors (SNRIs; aOR 1.18; 95% CI 1.13–1.24), and others (aOR 1.27; 95% CI 1.14–1.42). Moreover, cases exhibited a more significant proportion of antidepressant usage and longer durations of treatment compared with controls. The risk of liver injury was higher in the first 30 days of use across all classes of antidepressants (aOR 1.24; 95% CI 1.18–1.29).

SSRIs or SNRIs are commonly used to treat depression and other psychological disorders, and consideration of their potential effects on the liver is essential.

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1 Introduction

Drug-induced liver injury (DILI) is a relatively rare occurrence, with an incidence rate ranging from 1 per 10,000 to 100,000 individuals [ 1 ]. A recent study in France reported that DILI had an incidence rate of approximately 14 per 100,000 person-years, of whom 12% required hospitalization and 6% died [ 2 ]. Despite this, there is limited evidence extrapolating the overall incidence of DILI to Taiwan. Prospective studies conducted in Taiwan reported an incidence of 768 cases per 100,000 person-years for statin-induced DILI [ 3 ], as well as an incidence of 31.6 cases per 10,000 persons for antifungal agent-induced DILI, exemplified by fluconazole [ 4 ]. Given the high prevalence of hepatitis in Taiwan and the clinical presentation similarities with DILI, accurate diagnosis is often complicated, suggesting that reported incidence rates might underestimate the true prevalence.

The risk factors for DILI include age, gender, presence of comorbidities, drug interactions, and drug dosage [ 5 ]. Evidence suggests that age can increase sensitivity to and limit the metabolism of hepatotoxic drugs in humans [ 6 ], with drug efficacy and metabolism rates significantly differing in children and elderly individuals compared with adults [ 7 ]. One study found that females exhibited a higher risk of adverse drug reactions, potentially due to differences in metabolism rates and medication dosage between genders [ 6 ], although this was contradicted by another study that reported observing the opposite results [ 8 ]. Drug interactions and the presence of comorbidities can also increase the risk of DILI, with Bell and Chalasani demonstrating that patients diagnosed with hepatitis types B and C and human immunodeficiency virus (HIV) exhibited an increased risk of being diagnosed with DILI [ 9 ]. Concurrent use of other hepatotoxic drugs was also identified as a risk factor for DILI [ 10 ].

In Japan, 60% of DILI occurs within 30 days of commencing medication usage, while 80% occurs within 90 days of commencing usage [ 11 ]. Several other studies have also shown that acute DILI may develop within 1–3 months of commencing medication usage [ 12 , 13 , 14 ]. Some studies have shown that approximately 1.28–4 patients per 100,000 patient-years require hospitalization for antidepressant-induced liver injury (AILI). In particular, the incidence rates of AILI associated with nefazodone and tricyclic/tetracyclic antidepressant usage are approximately 28.96 and 4 patients per 100,000 patient-years, respectively [ 15 , 16 , 17 , 18 ]. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have also been shown to lead to asymptomatic mildly abnormal liver function in approximately 0.5–1% of patients, while monoamine oxidase inhibitors (MAOIs) usage resulted in AILI in approximately 3% of patients [ 17 ]. However, diagnosis of AILI is challenging as it is primarily based on exclusion, suggesting that the incidence rates may be underestimated [ 18 ].

DILI primarily has two pathophysiological types, as follows: (1) idiosyncratic: dose-independent, unpredictable, occurs as a consequence of either immune-mediated liver damage (immuno-allergic idiosyncratic DILI) or direct cellular injury (metabolic idiosyncratic DILI); and (2) intrinsic: dose-dependent, predictable, occurs as a consequence of drug accumulation [ 17 ]. Most pathophysiological types of AILI are either immune-allergic or metabolic idiosyncratic DILI, with the majority being of the hepatocellular type and fewer being the cholestatic or mixed types. Moreover, acute hepatocellular injury and jaundice have a mortality rate of approximately 10% [ 17 ]. Although there are reports of hepatotoxicity linked to adverse reactions from antidepressants, extensive studies conducted in Taiwan exclusively centered around the occurrence of liver cancer, reporting a low incidence and mortality rate [ 19 , 20 ]. This contrasts with other research exploring the mechanisms of liver injury, revealing a notable research gap concerning the impact of diverse antidepressant drug treatments and their dose–response relationships on the risk of hepatotoxicity.

Therefore, this nationwide population-based study aims to assess the risk of AILI associated with different pharmacological classifications and the duration of antidepressant use. The investigation relies on data from the Taiwan National Health Insurance Database from 2000 to 2018.

2.1 Data Sources

This population-based, case–control study used the Taiwan National Health Insurance (NHI) database, which was established in 1995 and covers more than 99.6% of the Taiwanese population. The National Health Insurance Research Database (NHIRD) contains claims data (e.g., registry of beneficiaries, clinical and hospital care records, drug prescriptions, and other medical service records) from the NHI database and is reviewed annually. Additionally, data from the Longitudinal Generation Tracking Database (LGTD 2005), which contains approximately two million individuals randomly selected from the NHIRD, was also used. The clinics and hospitals recorded diagnoses using the International Classification of Diseases, Ninth and Tenth Revision, and Clinical Modification (ICD-9-CM and ICD-10-CM). Patient confidentiality was protected through data pseudonymization (wherein all original identification numbers were replaced with encoded serial numbers to enable linkage to claims data) implemented by the Taiwanese government prior to the release of data for research.

2.2 Study Population

The study population included individuals aged 20 years or over who did not have any history of relevant code from ICD-9-CM [ 21 ] of malignant neoplasms (140–239); viral hepatitis A, B, or C infections, other viral hepatitis infections (070.0–070.9), or carriers of the hepatitis virus (V026.1–V026.9); infectious mononucleosis and cytomegalovirus and coxsackie virus infections (573.1–573.2); cholelithiasis (574.0–574.9); chronic liver disease; cirrhosis; alcoholic liver disease; liver abscess; portal pyemia; hepatic coma; portal hypertension; hepatorenal syndrome; chronic passive congestion of the liver (571.0–573.0); and liver disorders during pregnancy (646.7) between January 1, 2000 and December 31, 2018.

Cases were patients hospitalized with the diagnosis code of suspected DILI during the study period based on the ICD-9-CM, ICD-10-CM, and the previous study, including disorders of bilirubin excretion, acute and subacute necrosis of liver, liver cirrhosis, chronic liver disease (nonalcoholic), hepatic coma, hepatitis (non-viral), other disorders of the liver, and other specified disorders of the biliary tract [ 3 , 4 , 21 ]. A control individual free from liver injury was randomly selected for each case, matching (1:1) on age, gender, and the index date (the first observed diagnosis of liver injury in the case).

2.3 Exposure to Antidepressants

The antidepressants included in this study were monoamine oxidase A inhibitors (MAO-AIs), non-selective serotonin reuptake inhibitors (NSRIs), SSRIs, and SNRIs. Medications not included in the aforementioned classes were classified as other antidepressants (i.e., trazodone hydrochloride, oxitriptan, mirtazapine, and agomelatine, etc.). The cumulative exposure to antidepressants was defined as the total number of days before the index date that the patient was prescribed antidepressants. Patients were categorized into groups (i.e., 1–30 days, 31–90 days, and 91+ days) based on their cumulative exposure to antidepressants to allow examination of the association with the risk of liver injury. Non-users were those who had never used antidepressants before the index date.

2.4 Covariates

Factors such as the use of other medications and a history of comorbidities have been shown to be related to liver injury and, therefore, were considered confounders in the current analysis (Table 1 ). Medications causing liver damage were prescribed for >90 days a year before the index date, including anti-tuberculosis agents, statins (or fibrates), antibiotics, antifungals, anti-epileptics, non-steroidal anti-inflammatory drugs (NSAIDs), and other potential hepatotoxic agents (i.e., acetaminophen, amiodarone, and methotrexate) [ 22 ]. Comorbidities were defined as the presence of chronic renal failure, hyperthyroidism, diabetes mellitus, malnutrition, hyperlipidemia, heart failure, hypertension, ischemic heart disease, arrhythmia, chronic kidney disease, and renal failure.

2.5 Statistical Analyses

Descriptive statistics were compared between the cases and controls using the Student’s t -test or Mann–Whitney U test for continuous variables and the Chi-square test for categorical variables, respectively. Crude and multivariate logistic regressions were used to compare the risk of liver injury between antidepressant users and non-users, and the findings were reported as odds ratios (ORs) and 95% confidence intervals (CIs). The multivariate models adjusted for age, gender, history of comorbidities, and use of liver damage-related drugs prior to the index date of 1 year. All data analyses were carried out using SAS 9.4 (SAS Institute, Cary, NC, USA), and a two-tailed p value of <0.05 was considered statistically significant.

The study sample included 59,989 cases hospitalized with a primary diagnosis of liver injury and 59,989 controls matched by age, gender, and index date. Approximately half of the cases exhibited hepatitis (49%), and were statistically significantly more likely than controls to have a higher prevalence of antidepressant usage (20.3% vs 13.9%), longer durations of antidepressant exposure (33 days vs 30 days), and use of other liver damage-related medications for >90 days (i.e., statins, antifungals, anti-tuberculosis agents, antibiotics, anti-epileptics, NSAIDs, acetaminophen, amiodarone, and methotrexate). Moreover, a greater proportion of cases were likely to have a history of comorbidities, including hypertension (33.2% vs 24.4%), diabetes mellitus (17.7% vs 10.1%), ischemic heart disease (17.0% vs 11.6%), arrhythmia (7.0% vs 4.6%), heart failure (4.8% vs 2.8%), hyperlipidemia (29.5% vs 15.6%), chronic kidney disease and renal failure (5.8% vs 2.7%), hyperthyroidism (2.6% vs 1.4%), and fasting or malnutrition (0.6% vs 0.2%) than controls (Table 1 ).

Table 2 presents the distribution and odds of antidepressant users among the study population. Compared with the controls, cases had a significantly higher proportion of patients using any classes of antidepressants, which was associated with an increased risk of liver injury across all durations of use (the range of crude ORs was 1.44–2.35). After adjusting for covariates, antidepressant users exhibited a significantly higher risk of liver injury (adjusted OR [aOR] 1.16, 95% CI 1.12–1.20). This risk was particularly elevated when individuals were prescribed NSRIs (aOR 1.05; 95% CI 1.01–1.10), SSRIs (aOR 1.22; 95% CI 1.16–1.29), SNRIs (aOR 1.18; 95% CI 1.13–1.24), or other types of antidepressants including trazodone hydrochloride, oxitriptan, mirtazapine, and agomelatine (aOR 1.27; 95% CI 1.14–1.42). However, all MAO-AIs users had no significant result compared with non-users.

Subgroup analyses presented in Table 2 , stratified based on days of drug usage, revealed that individuals using any class of antidepressants faced a higher risk of developing liver injury within the initial 1–30 days compared with non-users (aOR 1.24; 95% CI 1.03–1.54). Furthermore, these findings remained consistent across all classes, including MAO-AI (aOR 1.26; 95% CI 1.03–1.54), NSRI (aOR 1.14; 95% CI 1.08–1.20), SSRI (aOR 1.34; 95% CI 1.24–1.45), and SNRI (aOR 1.21; 95% CI 1.14–1.30) users. Notably, there was a discernible declining trend in risk with longer durations of usage, especially among patients using NSRIs for >90 days, who exhibited a significantly reduced risk when compared with individuals who had not utilized any form of NSRI (aOR 0.86; 95% CI 0.79–0.94).

4 Discussion

To the best of our knowledge, this is the first Asian population-based study to illustrate the association between antidepressant use and the risk of DILI in the general population. The current study first demonstrates the nationwide risk of AILI in Taiwan over 18 years. Systematically, the study collected data encompassing the risk of liver injury linked to all classes of antidepressants, analyzing the cumulative days of exposure. The findings of the current study showed an association between antidepressant usage and risk of liver injury, with a significantly larger proportion of patients with liver injury using antidepressants compared with those without liver injury. Additionally, the median duration of antidepressant use was significantly longer in patients with liver injury compared with those without liver injury. Noteworthy is the observation that nearly 50% of suspected AILI patients presented with non-viral hepatitis. Furthermore, a higher prevalence of AILI was observed in patients with comorbidities, including cardiovascular disease, diabetes, renal disease, and others.

The risk of AILI in this study is lower than in the previous research, which may be due to differences in drug category distribution and other demographics [ 23 ]. Further analysis showed that certain pharmaceutical classes of antidepressants (e.g., SSRIs and other classes of antidepressants) were associated with an overall higher risk of liver injury compared with other classes, except for MAOIs. In addition, certain antidepressants may carry an increased risk of liver injury, particularly in the first 30 days of use, as suggested by research findings [ 23 ]. Patients using these medications should exercise caution, and healthcare providers should monitor for potential liver-related adverse effects during the initial month of treatment.

The prevalence of liver injury was also relatively high among those who had used anti-tuberculosis agents, statins (or fibrates), antibiotics, antifungals, anti-epileptics, NSAIDs, and other potential hepatotoxic agents (i.e., acetaminophen, amiodarone, and methotrexate) [ 22 ] for >90 days compared with those who had not, consistent with previous studies [ 12 ]. This could be attributed to the independent association of these drugs with the risk of liver injury. When combined with antidepressants, they may collectively contribute to an increased burden on the liver, potentially leading to damage.

The mechanism for AILI is not yet fully understood. Studies suggest that DILI may be related to allergic reactions, oxidative stress, lipid peroxidation, cytochrome-P450 enzyme ( CYP450 ) metabolites, or immune-mediated reactions [ 17 , 24 ]. SSRIs and SNRIs are metabolized in the liver, especially through the CYP450 enzyme pathway, which includes CYP2C19 , CYP2C9 , and CYP2D6 [ 25 ]. In elderly patients or CYP2C19 poor metabolizers, the oral clearance rate is diminished, leading to a higher likelihood of adverse reactions and hepatotoxicity due to dose accumulation [ 26 ]. In clinical management, the dosage or medication regimen may be altered when an elevation in the patient’s liver indices is detected. This could explain the slight reduction in the observed risk of liver injury after a treatment duration exceeding 30 days.

MAO-AIs inhibit monoamine oxidase in the liver, reducing the breakdown of neurotransmitters and increasing their concentration in the synaptic cleft. In this study, the overall risk of DILI in users of MAO-AIs was not significantly higher than that in non-users, perhaps due to the known liver toxicity of these drugs, leading clinicians to avoid prescribing them to high-risk patients. However, MAO-AIs demonstrate multiple interactions with other medications, food, or overdose, leading to an elevated risk of hepatotoxicity [ 27 ]. A significantly higher risk observed within the first 30 days with MAO-AI use in this study may be attributed to the potential omission of these interaction factors during the initial administration period.

On the other hand, using NSRIs involves liver metabolism, either through a direct toxic effect or a hypersensitivity reaction, and is influenced by other drugs that induce or inhibit microsomal enzymes [ 24 ]. Long-term NSRI users typically administer low doses. Hence, the risk of hepatotoxicity is less obvious. In particular, our findings revealed that patients using NSRIs (e.g., tricyclic antidepressants [TCAs] like imipramine or amitriptyline) for more than 90 days had a significantly reduced risk compared with non-users. This can be explained by the fact that most prescriptions for NSRIs with a low dose and long duration are given to nocturia sufferers. Nocturia is often managed by addressing underlying causes or conditions that contribute to increased nighttime urination, such as age, diabetes, and cardiovascular-related conditions [ 28 , 29 ]. NSRIs, with their anticholinergic effects that can affect bladder function, have been used off-label for managing nocturia. Overall, it is important to note that there may be residual confounding from long-term antidepressant usage in mitigating the risk of certain adverse outcomes.

Antidepressants, particularly SSRIs and SNRIs, are commonly used to treat depression and other psychological disorders, and awareness of their potential effects on the liver is essential. Clinicians should evaluate the patient’s condition when considering the risks and benefits of prescribing antidepressants and take appropriate measures where necessary.

5 Strengths and Limitations

The current study had several strengths, including a large sample size and longitudinal follow-up, which facilitated robust investigation of rare events such as liver injury. The effects of the duration of and cumulative exposure to antidepressant use were also examined to supplement existing evidence on the association between long-term antidepressant use and liver injury. Strict statistical analysis, including subgroup comparisons, was carried out to reduce the risk of bias.

This study also had several limitations. Firstly, this nationwide case–control study lacked detailed laboratory information such as hepatic fibrosis stage, baseline liver biochemical tests (e.g., alanine aminotransferase [ALT], alkaline phosphatase [ALP], total bilirubin [TB]), and lipid profile (e.g., triglycerides, low density lipoprotein cholesterol). Secondly, lack of access to medical records prevented use of a standardized definition for liver damage (e.g., Roussel Uclaf Causality Assessment Method [RUCAM]). Therefore, the lack of a validation study specifically conducted for the diagnosis code of liver injury in the NHIRD and the inclusion of only patients hospitalized with a primary diagnosis of liver injury (defined using ICD codes) may have led to selection bias. Thirdly, the NHIRD did not include information on the patients’ body index (e.g., height and weight), behavioral factors (e.g., alcohol consumption and smoking), and use of alternative medications (e.g., over-the-counter products and herbal products). These limitations were addressed by imposing strict criteria to exclude non-DILI patients.

6 Conclusion

This population-based study adds to existing evidence by exploring the association between antidepressant use and the risk of liver injury. Overall, the findings showed that antidepressant usage was consistently associated with an increased risk of liver injury, and this was particularly applicable to SSRI and SNRI users as well as those using antidepressants for 1–30 days.

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Department of Pharmacy, Asia University Hospital, Taichung, Taiwan

Ching-Ya Huang

School of Pharmacy, China Medical University, Taichung, Taiwan

Ching-Ya Huang & Yow-Wen Hsieh

Department of Pharmacy, China Medical University Hospital, 2 Yuh-Der Road, Taichung, 404327, Taiwan

Ying-Shu You, Jian-Ming Lai, Hsing-Yu Hsu & Yow-Wen Hsieh

Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan

Ying-Shu You

Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan

Cheng-Li Lin

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This study was partly supported by the Taiwan Ministry of Health and Welfare Clinical Trial Center (MOHW112-TDU-B-212-144004), China Medical University Hospital (DMR-111-105; DMR-112-087;DMR-113-009). We express our gratitude to the Health Data Science Center, China Medical University Hospital for providing administrative, technical, and funding support.

Ethics Approval

This study involving human participants was reviewed and approved by Institutional Review Board of China Medical University Hospital Research Ethics Committee [CMUH109-REC2-031(CR-4)] on February 04, 2024. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

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The original contributions presented in the study are included in the article materials. The dataset used in this study is held by the Taiwan Ministry of Health and Welfare (MOHW). The Ministry of Health and Welfare must approve our application to access this data. Any researcher interested in accessing this dataset can submit an application form to the Ministry of Health and Welfare requesting access. Please contact the staff of MOHW (Email: wt.vog.whom@uwloracts) for further assistance. Taiwan Ministry of Health and Welfare Address: No.488, Sec. 6, Zhongxiao E. Rd., Nangang Dist., Taipei City 115, Taiwan (R.O.C.). Phone: +886-2-8590-6848.

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CYH and YWH contributed to the conception of the study and design. YSY took responsibility for the material preparation and methodology. YSY, CML, CLL, and HYH conducted the data collection, analysis, and interpretation. All authors drafted the manuscript, and CYH and YWH critically reviewed the article’s intellectual content. All authors read and approved the final version.

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Huang, CY., You, YS., Lai, JM. et al. The Association Between Antidepressant Use and Drug-Induced Liver Injury: A Nationwide, Population-Based Case–Control Study in Taiwan. Drugs - Real World Outcomes (2024). https://doi.org/10.1007/s40801-024-00419-0

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DOI : https://doi.org/10.1007/s40801-024-00419-0

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AI on Trial: Legal Models Hallucinate in 1 out of 6 (or More) Benchmarking Queries

A new study reveals the need for benchmarking and public evaluations of AI tools in law.

Artificial intelligence (AI) tools are rapidly transforming the practice of law. Nearly  three quarters of lawyers plan on using generative AI for their work, from sifting through mountains of case law to drafting contracts to reviewing documents to writing legal memoranda. But are these tools reliable enough for real-world use?

Large language models have a documented tendency to “hallucinate,” or make up false information. In one highly-publicized case, a New York lawyer  faced sanctions for citing ChatGPT-invented fictional cases in a legal brief;  many similar cases have since been reported. And our  previous study of general-purpose chatbots found that they hallucinated between 58% and 82% of the time on legal queries, highlighting the risks of incorporating AI into legal practice. In his  2023 annual report on the judiciary , Chief Justice Roberts took note and warned lawyers of hallucinations. 

Across all areas of industry, retrieval-augmented generation (RAG) is seen and promoted as the solution for reducing hallucinations in domain-specific contexts. Relying on RAG, leading legal research services have released AI-powered legal research products that they claim  “avoid” hallucinations and guarantee  “hallucination-free” legal citations. RAG systems promise to deliver more accurate and trustworthy legal information by integrating a language model with a database of legal documents. Yet providers have not provided hard evidence for such claims or even precisely defined “hallucination,” making it difficult to assess their real-world reliability.

AI-Driven Legal Research Tools Still Hallucinate

In a new  preprint study by  Stanford RegLab and  HAI researchers, we put the claims of two providers, LexisNexis (creator of Lexis+ AI) and Thomson Reuters (creator of Westlaw AI-Assisted Research and Ask Practical Law AI)), to the test. We show that their tools do reduce errors compared to general-purpose AI models like GPT-4. That is a substantial improvement and we document instances where these tools provide sound and detailed legal research. But even these bespoke legal AI tools still hallucinate an alarming amount of the time: the Lexis+ AI and Ask Practical Law AI systems produced incorrect information more than 17% of the time, while Westlaw’s AI-Assisted Research hallucinated more than 34% of the time.

Read the full study, Hallucination-Free? Assessing the Reliability of Leading AI Legal Research Tools

To conduct our study, we manually constructed a pre-registered dataset of over 200 open-ended legal queries, which we designed to probe various aspects of these systems’ performance.

Broadly, we investigated (1) general research questions (questions about doctrine, case holdings, or the bar exam); (2) jurisdiction or time-specific questions (questions about circuit splits and recent changes in the law); (3) false premise questions (questions that mimic a user having a mistaken understanding of the law); and (4) factual recall questions (questions about simple, objective facts that require no legal interpretation). These questions are designed to reflect a wide range of query types and to constitute a challenging real-world dataset of exactly the kinds of queries where legal research may be needed the most.

Figure 1: Comparison of hallucinated (red) and incomplete (yellow) answers across generative legal research tools.

These systems can hallucinate in one of two ways. First, a response from an AI tool might just be  incorrect —it describes the law incorrectly or makes a factual error. Second, a response might be  misgrounded —the AI tool describes the law correctly, but cites a source which does not in fact support its claims.

Given the critical importance of authoritative sources in legal research and writing, the second type of hallucination may be even more pernicious than the outright invention of legal cases. A citation might be “hallucination-free” in the narrowest sense that the citation  exists , but that is not the only thing that matters. The core promise of legal AI is that it can streamline the time-consuming process of identifying relevant legal sources. If a tool provides sources that  seem authoritative but are in reality irrelevant or contradictory, users could be misled. They may place undue trust in the tool's output, potentially leading to erroneous legal judgments and conclusions.

Figure 2:  Top left: Example of a hallucinated response by Westlaw's AI-Assisted Research product. The system makes up a statement in the Federal Rules of Bankruptcy Procedure that does not exist (and Kontrick v. Ryan, 540 U.S. 443 (2004) held that a closely related bankruptcy deadline provision was not jurisdictional). Top right: Example of a hallucinated response by LexisNexis's Lexis+ AI. Casey and its undue burden standard were overruled by the Supreme Court in Dobbs v. Jackson Women's Health Organization, 597 U.S. 215 (2022); the correct answer is rational basis review. Bottom left: Example of a hallucinated response by Thomson Reuters's Ask Practical Law AI. The system fails to correct the user’s mistaken premise—in reality, Justice Ginsburg joined the Court's landmark decision legalizing same-sex marriage—and instead provides additional false information about the case. Bottom right: Example of a hallucinated response from GPT-4, which generates a statutory provision that has not been codified.

RAG Is Not a Panacea

Figure 3: An overview of the retrieval-augmentation generation (RAG) process. Given a user query (left), the typical process consists of two steps: (1) retrieval (middle), where the query is embedded with natural language processing and a retrieval system takes embeddings and retrieves the relevant documents (e.g., Supreme Court cases); and (2) generation (right), where the retrieved texts are fed to the language model to generate the response to the user query. Any of the subsidiary steps may introduce error and hallucinations into the generated response. (Icons are courtesy of FlatIcon.)

Under the hood, these new legal AI tools use retrieval-augmented generation (RAG) to produce their results, a method that many tout as a potential solution to the hallucination problem. In theory, RAG allows a system to first  retrieve the relevant source material and then use it to  generate the correct response. In practice, however, we show that even RAG systems are not hallucination-free. 

We identify several challenges that are particularly unique to RAG-based legal AI systems, causing hallucinations. 

First, legal retrieval is hard. As any lawyer knows, finding the appropriate (or best) authority can be no easy task. Unlike other domains, the law is not entirely composed of verifiable  facts —instead, law is built up over time by judges writing  opinions . This makes identifying the set of documents that definitively answer a query difficult, and sometimes hallucinations occur for the simple reason that the system’s retrieval mechanism fails.

Second, even when retrieval occurs, the document that is retrieved can be an inapplicable authority. In the American legal system, rules and precedents differ across jurisdictions and time periods; documents that might be relevant on their face due to semantic similarity to a query may actually be inapposite for idiosyncratic reasons that are unique to the law. Thus, we also observe hallucinations occurring when these RAG systems fail to identify the truly binding authority. This is particularly problematic as areas where the law is in flux is precisely where legal research matters the most. One system, for instance, incorrectly recited the “undue burden” standard for abortion restrictions as good law, which was overturned in  Dobbs (see Figure 2). 

Third, sycophancy—the tendency of AI to agree with the user's incorrect assumptions—also poses unique risks in legal settings. One system, for instance, naively agreed with the question’s premise that Justice Ginsburg dissented in  Obergefell , the case establishing a right to same-sex marriage, and answered that she did so based on her views on international copyright. (Justice Ginsburg did not dissent in  Obergefell and, no, the case had nothing to do with copyright.) Notwithstanding that answer, here there are optimistic results. Our tests showed that both systems generally navigated queries based on false premises effectively. But when these systems do agree with erroneous user assertions, the implications can be severe—particularly for those hoping to use these tools to increase access to justice among  pro se and under-resourced litigants.

Responsible Integration of AI Into Law Requires Transparency

Ultimately, our results highlight the need for rigorous and transparent benchmarking of legal AI tools. Unlike other domains, the use of AI in law remains alarmingly opaque: the tools we study provide no systematic access, publish few details about their models, and report no evaluation results at all.

This opacity makes it exceedingly challenging for lawyers to procure and acquire AI products. The large law firm  Paul Weiss spent nearly a year and a half testing a product, and did not develop “hard metrics” because checking the AI system was so involved that it “makes any efficiency gains difficult to measure.” The absence of rigorous evaluation metrics makes responsible adoption difficult, especially for practitioners that are less resourced than Paul Weiss. 

The lack of transparency also threatens lawyers’ ability to comply with ethical and professional responsibility requirements. The bar associations of  California ,  New York , and  Florida have all recently released guidance on lawyers’ duty of supervision over work products created with AI tools. And as of May 2024,  more than 25 federal judges have issued standing orders instructing attorneys to disclose or monitor the use of AI in their courtrooms.

Without access to evaluations of the specific tools and transparency around their design, lawyers may find it impossible to comply with these responsibilities. Alternatively, given the high rate of hallucinations, lawyers may find themselves having to verify each and every proposition and citation provided by these tools, undercutting the stated efficiency gains that legal AI tools are supposed to provide.

Our study is meant in no way to single out LexisNexis and Thomson Reuters. Their products are far from the only legal AI tools that stand in need of transparency—a slew of startups offer similar products and have  made   similar   claims , but they are available on even more restricted bases, making it even more difficult to assess how they function. 

Based on what we know, legal hallucinations have not been solved.The legal profession should turn to public benchmarking and rigorous evaluations of AI tools. 

This story was updated on Thursday, May 30, 2024, to include analysis of a third AI tool, Westlaw’s AI-Assisted Research.

Paper authors: Varun Magesh is a research fellow at Stanford RegLab. Faiz Surani is a research fellow at Stanford RegLab. Matthew Dahl is a joint JD/PhD student in political science at Yale University and graduate student affiliate of Stanford RegLab. Mirac Suzgun is a joint JD/PhD student in computer science at Stanford University and a graduate student fellow at Stanford RegLab. Christopher D. Manning is Thomas M. Siebel Professor of Machine Learning, Professor of Linguistics and Computer Science, and Senior Fellow at HAI. Daniel E. Ho is the William Benjamin Scott and Luna M. Scott Professor of Law, Professor of Political Science, Professor of Computer Science (by courtesy), Senior Fellow at HAI, Senior Fellow at SIEPR, and Director of the RegLab at Stanford University. 

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Bird Flu (H5N1) Explained: Bird Flu Has Killed Dozens Of Dairy Cows In Multiple States, Report Says

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Here’s the latest news about a global outbreak of H5N1 bird flu that started in 2020, and recently spread among cattle in U.S. states and marine mammals across the world, which has health officials closely monitoring it and experts concerned the virus could mutate and eventually spread to humans, where it has proven rare but deadly.

A sign warns of a outbreak of bird flu.

June 6 Dozens of cows infected with bird flu have either died or been slaughtered in Colorado, Ohio, Michigan, South Carolina and Texas, which is unusual since—unlike poultry—cows cost more to slaughter and around 90% usually make a full recovery, Reuters reported .

June 5 A new study examining the 2023 bird flu outbreak in South America that killed around 17,400 elephant seal pups and 24,000 sea lions found the disease spread between the animals in several countries, the first known case of transnational virus mammal-to-mammal bird flu transmission.

May 30 Another human case of bird flu has been detected in a dairy farm worker in Michigan—though the cases aren’t connected—and this is the first person in the U.S. to report respiratory symptoms connected to bird flu, though their symptoms are “resolving,” according to the Centers for Disease Control and Prevention.

May 23 A new study with mice suggests that drinking infected milk can spread the disease—and that a certain type of pasteurization may not always be effective in killing the virus.

May 22 Michigan reported bird flu in a farmworker—the second U.S. human case tied to transmission from dairy cows—though the worker had a mild infection and has since recovered.

May 21 Australia reported its first human case of bird flu after a child became infected in March after traveling to India, though the child has since recovered after suffering from a “severe infection,” according to the Victorian Department of Health.

May 16 The USDA conducted a study, and discovered that after high levels of the virus was injected into beef, no trace was left after the meat was cooked medium to well done, though the virus was found in meat cooked to lower temperatures.

May 14 The Centers for Disease Control and Prevention released influenza A waste water data for the weeks ending in April 27 and May 4, and found several states like Alaska, California, Florida, Illinois and Kansas had unusually high levels, though the agency isn’t sure if the virus came from humans or animals, and isn’t able to differentiate between influenza A subtypes, meaning the H5N1 virus or other subtypes may have been detected.

May 10 The Food and Drug Administration announced it will commit an additional $8 million to ensure the commercial milk supply is safe, while the Department of Agriculture said it will pay up to $28,000 per farm to help mitigate the spread of the disease, totaling around $98 million in funds.

May 9 Some 70 people in Colorado are being monitored for bird flu due to potential exposure, and will be tested for the virus if they show any symptoms, the Colorado Department of Public Health told Forbes—it was not immediately clear how or when the people were potentially exposed.

May 1 The Department of Agriculture said it tested 30 grocery store ground beef products for bird flu and they all came back negative, reaffirming the meat supply is safe.

May 1 The Food and Drug Administration confirmed dairy products are still safe to consume, announcing it tested grocery store samples of products like infant formula, toddler milk, sour cream and cottage cheese, and no live traces of the bird flu virus were found, although some dead remnants were found in some of the food—though none in the baby products.

April 30 Wenqing Zhang, head of the World Health Organization's Global Influenza Programme, said during a news briefing "there is a risk for cows in other countries to be getting infected," with the bird flu virus, since it’s commonly spread through the movement of migratory birds.

April 29 The Department of Agriculture told Forbes it will begin testing ground beef samples from grocery stores in states with cow outbreaks, and test ground beef cooked at different temperatures and infected with the virus to determine if it's safe to eat.

April 24 The USDA said cow-to-cow transmission may be occurring due to the cows coming into contact with raw milk—and warned against humans and other animals, including pets, consuming unpasteurized milk to prevent potential infection.

April 18 Jeremy Farrar, chief scientist for the World Health Organization, said during a press conference the threat of bird flu spreading between humans was a “great concern,” since it’s evolved and has increasingly been infecting mammals (on land and sea), which means it could possibly spread to humans.

April 1 The CDC reported the second U.S. human case of bird flu in a Texas dairy farmer who became infected after contracting the virus from infected dairy cows, but said the person was already recovering.

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Can Bird Flu Spread Between Humans?

Bird flu doesn’t “transmit easily from person-to-person,” according to the World Health Organization. Bird flu rarely affects humans, and most previous cases came from close contact with infected poultry, according to the CDC. Because human-to-human spread of bird flu poses “pandemic potential,” each human case is investigated to rule out this type of infection. Though none have been confirmed, there are a few global cases—none in the U.S.—where human-to-human transmission of bird flu was thought to be “probable,” including in China , Thailand , Indonesia and Pakistan .

Is Bird Flu Fatal To Humans?

It is very deadly. Between January 2003 and March 28, 2024 there have been 888 human cases of bird flu infection in humans, according to a report by the World Health Organization. Of those 888 cases, 463 (52%) died. To date, only two people in the U.S. have contracted H5N1 bird flu, and they both were infected after coming into contact with sick animals. The most recent case was a dairy worker in Texas who became ill in March after interacting with sick dairy cows, though he only experienced pink eye. The first incident happened in 2022 when a person in Colorado contracted the disease from infected poultry, and fully recovered.

Is It Safe To Drink Milk Infected With Bird Flu?

Raw, unpasteurized milk is unsafe to drink, but pasteurized milk is fine, according to the FDA. Bird flu has been detected in both unpasteurized and pasteurized milk, but the FDA recommends manufacturers against making and selling unpasteurized milk since there’s a possibility consuming it may cause bird flu infection. However, the virus remnants in pasteurized milk have been deactivated by the heat during the pasteurization process , so this type of milk is still believed safe to consume.

Is It Safe To Consume Meat Infected With Bird Flu?

The CDC warns against eating raw meat or eggs from animals “confirmed or suspected” of having bird flu because of the possibility of transmission. However, no human has ever been infected with bird flu from eating properly prepared and cooked meat, according to the agency. The possibility of infected meat entering the food supply is “extremely low” due to rigorous inspection, so properly handled and cooked meat is safe to eat, according to the USDA. To know when meat is properly cooked, whole beef cuts must be cooked to an internal temperature of 145 degrees Fahrenheit, ground meat must be 160 degrees and poultry must be cooked to 165 degrees. Rare and medium rare steaks fall below this temperature. Properly cooked eggs with an internal temperature of 165 degrees Fahrenheit kills bacteria and viruses including bird flu, according to the CDC. “It doesn’t matter if they may or may not have [avian] influenza… runny eggs and rare pieces of meat” are never recommended, Francisco Diez-Gonzalez, director and professor for the Center for Food Safety at the University of Georgia, told Forbes. To “play it safe,” consumers should only eat fully cooked eggs and make sure “the yolks are firm with no runny parts,” Daisy May, veterinary surgeon with U.K.-based company Medivet, said .

What Are Bird Flu Symptoms In Humans?

Symptoms of bird flu include a fever, cough, headache, chills, shortness of breath or difficulty breathing, runny nose, congestion, sore throat, nausea or vomiting, diarrhea, pink eye, muscle aches and headache. However, the CDC advises it can’t be diagnosed based on symptoms alone, and laboratory testing is needed. This typically includes swabbing the nose or throat (the upper respiratory tract), or the lower respiratory tract for critically ill patients.

How Is Bird Flu Affecting Egg Prices?

This year’s egg prices have increased as production decreased due to bird flu outbreaks among poultry, according to the USDA. A dozen large, grade A eggs in the U.S. costed around $2.99 in March, up almost a dollar from the fall. However, this price is down from a record $4.82 in January 2023, which was also spiked by bird flu outbreaks . Earlier this month, Cal-Maine Foods—the country’s largest egg producer—temporarily halted egg production after over one million egg-laying hens and chickens were killed after being infected with bird flu.

Why Do Poultry Farmers Kill Chickens With Bird Flu?

Once chickens have been infected with bird flu, farmers quickly kill them to help control the spread of the virus, since bird flu is highly contagious and fatal in poultry. The USDA pays farmers for all birds and eggs that have to be killed because of bird flu, as an incentive to responsibly try and curb the spread of the disease. The USDA has spent over $1 billion in bird flu compensation for farmers since 2022, according to the nonprofit Food & Environment Reporting Network.

Is There A Vaccine For The Bird Flu (h5n1)?

The FDA has approved a few bird flu vaccines for humans. The U.S. has a stockpile of vaccines for H5N1 bird flu, but it wouldn’t be enough to vaccinate all Americans if an outbreak were to happen among humans. If a human outbreak does occur, the government plans to mass produce vaccines, which can take at least six months to make enough for the entire population. CSL Seqirus, the maker of one of the approved vaccines, expects to have 150 million vaccines ready within six months of an announcement of a human bird flu pandemic. Although there are approved vaccines for other variants designed for birds, there are none for the H5N1 variant circulating. However, the USDA began trials on H5N1 animal-specific vaccines in 2023.

Key Background

As of May 30, more than 92 million poultry (primarily chickens) in 48 states have been euthanized because of bird flu since 2022, and 57 dairy cow herds across nine states have tested positive, according to data from the CDC (unlike chickens, cows appear to recover from the virus). The USDA believes wild migratory birds are the original source of the cow outbreaks that recently has experts concerned it may mutate and spread more easily in humans, though the CDC said its risk to the public remains low . Farrar called the cattle infections in the U.S. a “huge concern,” urging public health officials to continue closely monitoring the situation “because it may evolve into transmitting in different ways.” The increased number of mammal bird flu infections since 2022 “could indicate that the virus is looking for new hosts, and of course, moving closer to people,” Andrea Garcia, vice president of science, medicine and public health for the American Medical Association, said . The first report of a walrus dying from bird flu was detected in April on one of Norway’s Arctic Islands, and the first U.S. dolphin infected with bird flu died back in 2022, according to a report published April 18. More than 10 human bird flu cases were reported to the World Health Organization in 2023, and all but one survived. Bird flu has devastated bird populations, and 67 countries reported the deaths of 131 million poultry in 2022 alone. Although bird flu typically infects wild birds and poultry, it’s spread to other animals during the outbreak, and at least 10 countries have reported outbreaks in mammals since 2022. Around 17,400 elephant seal pups died from bird flu in Argentina in 2023, and at least 24,000 sea lions died in South America the same year. Besides cattle, bird flu has been detected in over 200 other mammals—like seals, raccoons and bears—in the U.S. since 2022. Although rare, even domestic pets like dogs and cats are susceptible to the virus, and the FDA warns against giving unpasteurized milk to cats to avoid possible transmission.

On June 5, WHO confirmed the first human death of a strain of bird flu that’s never before been seen in humans and is separate from H5N1. A 59-year-old man in Mexico contracted H5N2, and died on April 24 after being hospitalized and developing a fever, diarrhea, nausea, shortness of breath and general discomfort. Cases of H5N2 have been reported in poultry in Mexico, but the man had no history with poultry or animals, WHO said. It’s unclear how he became infected. He was bedridden for weeks prior to the infection, and suffered from several other health conditions.

Further Reading

Another Bird Flu Variant Reaches Humans: What To Know About H5N2—After First-Ever Confirmed Death

WHO Warns Threat Of Bird Flu Spreading To Humans Is ‘Great Concern’ (Forbes)

One In Five Milk Samples From Across US Had Traces Of Bird Flu Virus, FDA Says (Forbes)

Can Pets Get Bird Flu? Here’s What To Know (Forbes)

Avian H5N1 (Bird) Flu: Why Experts Are Worried—And What You Should Know (Forbes)

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Our Current Understanding of the Human Health and Environmental Risks of PFAS

What epa is doing.

Learn what EPA is doing to address PFAS.

Per- and Polyfluoroalkyl Substances (PFAS) Are a Group of Manufactured Chemicals

PFAS are a group of manufactured chemicals that have been used in industry and consumer products since the 1940s because of their useful properties. There are thousands of different PFAS, some of which have been more widely used and studied than others.

Perfluorooctanoic Acid (PFOA) and Perfluorooctane Sulfonate (PFOS), for example, are two of the most widely used and studied chemicals in the PFAS group. PFOA and PFOS have been replaced in the United States with other PFAS in recent years.

One common characteristic of concern of PFAS is that many break down very slowly and can build up in people, animals, and the environment over time.

PFAS Can Be Found in Many Places

PFAS can be present in our water, soil, air, and food as well as in materials found in our homes or workplaces, including:

• Drinking water – in public drinking water systems and private drinking water wells.
• Soil and water at or near waste sites - at landfills, disposal sites, and hazardous waste sites such as those that fall under the federal Superfund and Resource Conservation and Recovery Act programs.
• Fire extinguishing foam - in aqueous film-forming foams (or AFFFs) used to extinguish flammable liquid-based fires.  Such foams are used in training and emergency response events at airports, shipyards, military bases, firefighting training facilities, chemical plants, and refineries.
• Manufacturing or chemical production facilities that produce or use PFAS – for example at chrome plating, electronics, and certain textile and paper manufacturers.
• Food – for example in fish caught from water contaminated by PFAS and dairy products from livestock exposed to PFAS.
• Food packaging – for example in grease-resistant paper, fast food containers/wrappers, microwave popcorn bags, pizza boxes, and candy wrappers.
• Household products and dust – for example in stain and water-repellent used on carpets, upholstery, clothing, and other fabrics; cleaning products; non-stick cookware; paints, varnishes, and sealants.
• Personal care products – for example in certain shampoo, dental floss, and cosmetics.
• Biosolids – for example fertilizer from wastewater treatment plants that is used on agricultural lands can affect ground and surface water and animals that graze on the land.

People Can Be Exposed to PFAS in a Variety of Ways

Due to their widespread production and use, as well as their ability to move and persist in the environment, surveys conducted by the Centers for Disease Control and Prevention (CDC) show that most people in the United States have been exposed to some PFAS. Most known exposures are relatively low, but some can be high, particularly when people are exposed to a concentrated source over long periods of time. Some PFAS chemicals can accumulate in the body over time.

Current research has shown that people can be exposed to PFAS by:

• Working in occupations such as firefighting or chemicals manufacturing and processing.
• Drinking water contaminated with PFAS.
• Eating certain foods that may contain PFAS, including fish.
• Swallowing contaminated soil or dust.
• Breathing air containing PFAS.
• Using products made with PFAS or that are packaged in materials containing PFAS.

Exposure to PFAS May be Harmful to Human Health

Current scientific research suggests that exposure to certain PFAS may lead to adverse health outcomes. However, research is still ongoing to determine how different levels of exposure to different PFAS can lead to a variety of health effects. Research is also underway to better understand the health effects associated with low levels of exposure to PFAS over long periods of time, especially in children.

What We Know about Health Effects

Current peer-reviewed scientific studies have shown that exposure to certain levels of PFAS may lead to:

• Reproductive effects such as decreased fertility or increased high blood pressure in pregnant women.
• Developmental effects or delays in children, including low birth weight, accelerated puberty, bone variations, or behavioral changes.
• Increased risk of some cancers, including prostate, kidney, and testicular cancers.
• Reduced ability of the body’s immune system to fight infections, including reduced vaccine response.
• Interference with the body’s natural hormones.
• Increased cholesterol levels and/or risk of obesity.

Additional Health Effects are Difficult to Determine

Scientists at EPA, in other federal agencies, and in academia and industry are continuing to conduct and review the growing body of research about PFAS. However, health effects associated with exposure to PFAS are difficult to specify for many reasons, such as:

• There are thousands of PFAS with potentially varying effects and toxicity levels, yet most studies focus on a limited number of better known PFAS compounds.
• People can be exposed to PFAS in different ways and at different stages of their life.
• The types and uses of PFAS change over time, which makes it challenging to track and assess how exposure to these chemicals occurs and how they will affect human health. 

Certain Adults and Children May Have Higher Exposure to PFAS

Some people have higher exposures to PFAS than others because of their occupations or where they live. For example:

• Industrial workers who are involved in making or processing PFAS or PFAS-containing materials, or people who live or recreate near PFAS-producing facilities, may have greater exposure to PFAS.
• Pregnant and lactating women tend to drink more water per pound of body weight than the average person and as a result they may have higher PFAS exposure compared to other people if it is present in their drinking water.

Because children are still developing, they may be more sensitive to the harmful effects of chemicals such as PFAS. They can also be exposed more than adults because:

• Children drink more water, eat more food, and breathe more air per pound of body weight than adults, which can increase their exposure to PFAS.
• Young children crawl on floors and put things in their mouths which leads to a higher risk of exposure to PFAS in carpets, household dust, toys, and cleaning products.

Breast milk from mothers with PFAS in their blood and formula made with water containing PFAS can expose infants to PFAS, and it may also be possible for children to be exposed in utero during pregnancy.  Scientists continue to do research in this area. Based on current science, the benefits of breastfeeding appear to outweigh the risks for infants exposed to PFAS in breast milk . To weigh the risks and benefits of breastfeeding, mothers should contact their doctors.

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Information on How to Provide Input on Proposed Government Actions

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Regulations are mandatory requirements that can apply to individuals, businesses, state or local governments, non-profits, and others.

Federal agencies are required to provide an opportunity for public comment when proposing a new regulation and must consider the comments in revising the proposal and issuing a final rule.  In carrying out our mission to protect human health and the environment, EPA develops regulations to prevent or to clean up hazardous chemicals released into our air, land, and water, some of which relate to PFAS. 

Commenting on a proposed regulation is an important opportunity to make your voice heard. It is a way for you to provide decisionmakers with key information on any or all aspects of the proposed action, including:

• Pointing out key issues in the proposed regulation that you or your community are concerned about,
• Offering additional data and scientific evidence that may not have been considered,
• Identifying factual errors, and
• Proposing alternative solutions.  

EPA’s regulations will always be announced in the Federal Register and can be found at the following government websites: https://www.federalregister.gov/ , and https://www.regulations.gov/ .

For some rules, EPA holds a public hearing where you can provide comments in person or remotely. The agency always accepts comments in writing. All comments – whether in person or written – get the same level of consideration. Below are additional resources to help you comment on EPA’s proposed regulations related to PFAS.

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• Watch a webinar on “Techniques and Skills for Providing Effective Input in the EPA Rulemaking Process.”
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• v.40(5-6); 2020 Jun

Original quantitative research - Drinking patterns, alcohol-related harm and views on policies: results from a pilot of the International Alcohol Control Study in Canada

Mark van der maas.

1 School of Social Work, Rutgers University, New Brunswick, New Jersey, United States of America

Norman Giesbrecht

2 Centre for Addiction and Mental Health, Toronto, Ontario, Canada

Gina Stoduto

Heather orpana.

4 School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada

Robert Geneau

3 Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ontario, Canada

Robert Mann

Introduction:.

We conducted a pilot assessment of the feasibility of implementing the International Alcohol Control (IAC) Study in Ontario, Canada, to allow for future comparisons on the impacts of alcohol control policies with a number of countries.

The IAC Study questionnaire was adapted for use in the province of Ontario, and a split-sample approach was used to collect data. Data were collected by computerassisted telephone interviewing of 500 participants, with half the sample each answering a subset of the adapted IAC Study survey.

Just over half of the sample (53.6%) reported high frequency drinking (once a week or more frequently), while 6.5% reported heavy typical occasion drinking (8 drinks or more per session). Self-reported rates of alcohol-related harms from one’s own and others’ drinking were relatively low. Attitudes towards alcohol control varied. A substantial majority supported more police spot checks to detect drinking and driving, while restrictions on the number of alcohol outlets and increases in the price of alcohol were generally opposed.

Conclusion:

This pilot study demonstrated that the IAC Study survey can be implemented in Canada with some modifications. Future research should assess how to improve participation rates and the feasibility of implementing the longitudinal aspect of the IAC Study. This survey provides additional insight into alcohol-related behaviours and attitudes towards alcohol control policies, which can be used to develop appropriate public health responses in the Canadian context.

• The estimates of average drinks per months from the International Alcohol Control (IAC) Study were significantly higher than those from the Centre for Addiction and Mental Health (CAMH) Monitor (26.3 vs. 19.4).
• The typical drinking session at a public special event or while camping or staying at a cabin/cottage approximated a binge-drinking session (5+ for men, 4+ for women).
• Only 8.3% of respondents were in favour of a policy of increasing the price of alcohol.
• Those who had purchased alcohol in the past six months from a grocery store showed significantly higher rates of over-drinking (53.5% vs. 40.54%) as compared to those who had not.

Introduction

The majority of adults in Canada consume alcohol, 1 and the production and distribution of alcohol creates thousands of jobs, while governments derive significant tax revenues from alcohol production and sales.

At the same time, alcohol causes or contributes to a large number of conditions, diseases and injuries. 2 According to the Global Burden of Disease Study, in 2016, alcohol was responsible for approximately 350 000 disability-adjusted life year (DALYs) and 3.9% of all-cause DALYs in Canada. 3 In the same year, alcohol was the third leading behavioural contributor to the burden of disease globally, and the second leading behavioural contributor in Canada. 3 Alcohol is the largest single contributor to motor vehicle fatalities and was associated with one-third of motor vehicle collision fatalities in 2012, exceeding the number of deaths from assault. 4 In the United States, about one-third of those who die by suicide have been shown to be alcohol positive at the time of death. 5 Excessive use of alcohol causes secondary harm to others, 6 including substantial problems in families 7 and in the workplace, 8 and frequently involves aggression and violence. 9 , 10 Aggression is related to both overall consumption and frequency of intoxication. 11 , 12

In Canada, burden related to alcohol in terms of costs that include health care, law enforcement and lost productivity has been estimated to be approximately $14.7 billion annually. 13 In most Canadian provinces, estimates of these burdens exceed revenues collected by governments. 14

An effective prevention strategy requires a combination of population-level interventions and more focused interventions. The World Health Organization has identified three “best buys” for cost-effective alcohol policy interventions: tax increases, restricted access to retailed alcohol and bans on alcohol advertising. 15 Other population- level strategies include national/ provincial/territorial alcohol strategies, alcohol pricing and type of alcohol control and retailing system. 16

A population-level perspective is essential as the major burden of morbidity and mortality from alcohol is attributable not to the small proportion of the population that exhibit dependence on alcohol, but to the large portion of the population considered to be “moderate” drinkers. 17 , 18 Population-level interventions tend to avoid victim blaming and stigmatization of those who are alcohol dependent or regularly engage in high-risk drinking. 19 Other common interventions designed to promote population health include drinking and driving countermeasures, server interventions, and screening and brief interventions.

While there is substantial evidence supporting the effectiveness of populationlevel policies and interventions (e.g. studies by Babor et al. 20 and Anderson et al. 21 ), more information is needed on the causal effects of policy on behaviour change. 18 The International Alcohol Control (IAC) Study was designed to address this gap. The IAC Study measures the impact of policy on behaviours such as purchasing and response to marketing to better understand the causal chain between policy and alcohol consumption. 18 The IAC Study also examines and interprets the impact of policies that are introduced as a package, as they tend to be. 18 The IAC study was modeled on the International Tobacco Control study, which was similarly designed to determine the effects of policy changes on changes in behaviour. 22

The IAC Study draws on the World Health Organization’s (2010) Global Strategy to Reduce the Harmful Use of Alcohol 23 and the international analysis of drinking patterns, harm from alcohol and effective interventions by Babor et al. 20 as well as other sources. The main rationale for the IAC Study was the substantial global burden of disease and injury from alcohol and the pressing need for effective policy to reduce the burden. 18

The IAC Study uses several data sources. These include a longitudinal survey of individuals; a comprehensive literature review drawing on key policy, strategy, reporting and research documents; qualitative interviews with relevant stakeholders; and routinely collected and administrative data such as outlet location, alcohol price and treatment locations. 18 The IAC Study measures alcohol consumption using a within-location beverage- specific framework; this has been shown to provide estimates of consumption that are closer to alcohol sales data. Respondents are asked about mutually exclusive physical locations, types of beverage consumed for an estimate of alcohol content, number of drinks per locationsession to estimate total alcohol consumed per drinking session and the frequency of location-sessions for total monthly consumption estimates. 24 As of December 2017, there were IAC Study initiatives in 13 countries, including this pilot study in the province of Ontario. 25

Results from IAC Study initiatives for a number of countries have been published: Australia, 26 England and Scotland, 27 New Zealand 28 and the Republic of Korea. 29 Of these countries, Canada’s social culture, political structures, gross domestic product (GDP) per capita and alcohol policies are similar to those of England, Australia and New Zealand, though per capita alcohol consumption is lower at 8.9 litres per year (in England this is 11.4 L; in Australia, 10.6 L; and in New Zealand, 10.7 L). 30 The research design of a longitudinal survey of drinkers, along with analysis of the policy context, permits the examination of changes over time within and between jurisdictions.

While many organizations in Canada monitor and report on alcohol use and problems, 1 , 31 there is no comprehensive source of information on drinking behaviour and the factors that influence it. Thus, the important information on levels of alcohol consumption in Canada and alcohol-related problems of youth and adult drinkers typically do not offer insight into how and where alcohol is consumed, how much is spent on alcohol in various environments or other topics salient from a policy perspective.

Several Canadian provinces have recently made, or are considering, major changes to alcohol policies that may significantly affect alcohol use and associated practices. These changes include the introduction of beer and wine sales in grocery stores in Ontario; 32 further privatization of alcohol retailing in several provinces; 33 , 34 changes to pricing policies; 35 and the increase in sanctions for hazardous alcohol-related behaviours (e.g. the provincial government of Ontario introducing immediate penalties for a blood alcohol concentration of 0.05 mg% when driving). 36 , 37 The ability to monitor the impact of these changes to help us understand the most appropriate ways to reduce alcohol- related harms is one of the key benefits of the IAC study. 21 The IAC Study has proven to be of substantial value in informing alcohol policy in several countries in recent years. 24

In this paper, we describe a pilot assessment of the feasibility of implementing the survey component of the IAC Study in Ontario. This pilot assessment had three main purposes:

• To adapt the IAC Study survey instrument, which collects detailed information about drinking practices and contexts, to capture the heterogeneity of drinking in Canada, 38 while still providing data comparable to other IAC Study surveys in other countries;
• To administer the adapted survey in a pilot sample of participants in Ontario, Canada to test survey procedures; and
• To provide a preliminary assessment of what useful additional information could be obtained from using the IAC Study–based instrument compared with already available information.

Survey design

The Canadian pilot of the IAC Study implemented a modified version of the New Zealand and Australian versions of the IAC Study. 22 The investigating team examined the original surveys and, after running a small-scale pre-test, determined that the full instrument would likely require well over 30 minutes to administer. A pilot questionnaire was designed, with input from the research firm conducting the surveys to ensure suitability for a computer-assisted telephone survey in Ontario. This questionnaire used a split-sample strategy of questioning with two subsets of questions. This split-sample strategy also took into account the need to conduct the pilot with finite resources. Adaptations included adjustments for Canadian drink size standards, volume of drinks and slang for drink containers.

The adapted questionnaires were assessed by the IAC Study principal investigators, Drs. Sally Casswell and Tasia Huckle, to ensure suitability as IAC Study instruments. The final adapted Canadian versions, available from the authors on request, were used in field testing.

Alcohol variables

Three derived variables representing drinking patterns were calculated according to the method reported by Chaiyasong et al. 39

“High frequency drinking” refers to engaging in drinking sessions once a week or more frequently, at any location, over a six-month period. For the pilot study, a drinking session was defined as any occasion during which the respondent drank any amount of drink of at least 4% alcohol by volume.

“Typical occasion quantity” was defined as the weighted mean of standard drinks consumed per session across locations, taking into account location frequency. High quantity per session drinking was defined as drinking a mean of 8 or more standard drinks per occasion.

Definitions for standard drink sizes in terms of alcohol content vary across jurisdictions, with Australian standards containing less alcohol than Canadian standards. In comparisons between the results of the Chaiyasong et al. study 39 and this pilot study, numbers reflect the Australian standard drink size.

All other descriptions reflect Canadian standards (13.6 g of pure alcohol). Several variables related to risky drinking practices were also included. Binge-drinking is defined as 5 drinks or more per drinking session for men and 4 drinks or more per session for women. Pre-drinking refers to drinking alcohol before going to a location where drinking is also planned. Overdrinking refers to consuming more alcoholic drinks than planned.

Data collection

Survey participants had to be permanent residents of Ontario; living in private households (institutionalized populations were excluded, as is typical in telephone surveys, 40 because residents often do not have access to a telephone or appear on landline lists); aged 18–65 years; able to complete the survey in English; and have consumed at least one alcoholic beverage in the past six months. The plan was to survey an equal number of male and female respondents. The sample focused on current drinkers as most of the survey is concerned with capturing drinking behaviours.

Data were collected over a six-week period in the winter of 2017 through telephone surveys conducted by Focal Research. Due the limited resources of the pilot project, a sample of 500 participants was sought. Participants were drawn from two primary samples: a simple random sample of Ontario households with landline telephones, and a sample of Ontario residents with only cellphones. A small number were sampled from a research panel of Ontario residents maintained by Focal Research to achieve the desired number of young men.

A two-tiered sampling strategy was used. Households were first screened to identify any adult aged 18–65 years. Among these households, a brief survey was conducted to compile a roster of eligible adults, their age and sex. Each consenting adult was screened for alcohol consumption in the past six months, and one of these adults was randomly invited to participate in the survey and randomly allocated to either split sample.

About halfway through data collection, it became clear that the simple random sample initially planned might not provide enough younger or male participants for meaningful comparisons. A quota sampling procedure was then introduced to increase the number of men and participants aged under 45 years.

Of 5381 households invited to participate, 1827 (34%) were successfully contacted and agreed to participate. Of these, 1409 households were disqualified because they did not meet the inclusion criteria (i.e. no alcohol was consumed in the past six months) and/or their sex and age quota had been reached (which accounted for the largest number of disqualified households).

Due to low response rates in younger age groups, more respondents were drawn from older age categories. Upon completing an interview, if the respondent said that another eligible adult was in the household and they agreed to participate, that adult was randomly allocated to a split sample and also interviewed.

An average of 1.03, 1.25 and 1 participants per household were in the cellphone only, landline and research panel samples, respectively. A total of 500 participants from 418 households were included in this pilot study, with 87, 387 and 26 participants from the cellphone only, landline and research panel samples, respectively.

Data were cleaned and verified, with ranges examined to identify any responses outside of expected values and ensure that the study dataset included valid and meaningful responses. Data analysis and reporting of preliminary results were designed to address the three principle goals of the research. Results were weighted by age, sex and highest educational attainment, estimated based on the results of the 2016 census data for Ontario. All analyses were conducted using statistical package SPSS version 22 for Windows (IBM Corp., Armonk, NY, USA).

This project received research ethics approval from the Centre for Addiction and Mental Health (CAMH) REB certificate #114/2016.

Consistent with the sampling approach, the participating sample was evenly split between men and women ( Table 1 ). The largest proportion of respondents (30.8%) was aged between 45 and 54 years, followed by those 55 and above (28.6%). The smallest proportion was made up the youngest respondents aged 18 to 24 (8.4%), followed by those aged 25 to 34 (13.6%). These proportions differ from census data, particularly in the overrepresentation of adults aged 45 to 54 years (18.5% in the census). 41

Most respondents were married (76.6%); born in Canada; not of Indigenous ethnicity (83.4%); and employed for wages (62.8%). Most respondents were living in a household with no children under the age of 18 (56.1%; data not shown). The mean (SD) number of household residents was 3.1 (1.4). Most of the sample reported completing either college (28.2%) or university (24.6%), while 13.8% reported some college or university and 5.6% reported a trade certificate. The proportion of the current sample who had completed some postsecondary training or education (71.2%) was high in comparison to the 2016 census for Ontario (65.2%). 42 Total family incomes were high, with nearly half of those responding (46.1%) reporting an annual family income of $100 000 or more, a higher median income than reported by Statistics Canada ($86 081). 43

The IAC Study procedures result in higher consumption estimates, in terms of mean drinks per month, than those seen in a well-regarded survey of the adult population in Ontario, the 2016 CAMH Monitor survey ( Table 2 ). The CAMH Monitor obtained its estimates using a typical quantity–frequency method. 44 Among female drinkers, IAC Study procedures resulted in an estimate of number of drinks consumed per month that was 3.12% higher than the CAMH Monitor survey estimate (statistically nonsignificant). Among male drinkers, IAC Study procedures resulted in a 10.13% higher estimate of number of drinks consumed per month ( t = 2.707, p < .001). In the total population of drinkers, IAC Study procedures resulted in an 6.89% higher estimate of monthly number of drinks consumed, which is shown to significant in a two-tailed impendent samples t -test ( t = 3.175, p = .002).

The mean number of drinks consumed per drinking session varied substantially across drinking locations ( Table 3 ). At 1.27 (0.51) and 1.70 (1.38), respectively, the fewest mean (SD) number of drinks per occasion were reported for drinking at work or restaurants. At 3.09 (2.23), about twice as many drinks per occasion were consumed when drinking at home. The average number of drinks per occasion was 6.12 (5.84) when drinking at a cottage/ cabin or while camping and 4.24 (3.01) at public special events, indicative of binge-drinking.

Approximately 53.6% of the Ontario pilot study sample reported high frequency drinking, defined as engaging in a drinking session once a week or more frequently at all locations over a six-month period, while 6.5% of participants drank on average 8 or more drinks per drinking session ( Table 4 ). The Ontario pilot study results are somewhat lower than those of England, Scotland and New Zealand for high frequency drinking, and much lower than all other countries for heavy typical occasion. Data from the WHO Global Status Report on Alcohol and Health 2018 indicate that total per capita alcohol consumption for Canada is somewhat lower than for England, Scotland and New Zealand, consistent with the survey data we present here. 30

When asked if they or anyone else had been injured as a result of their drinking, 91.2% said this had never happened and 7.5% said it had happened but not in the past six months ( Table 5 ). When asked if a relative, friend, doctor or other health care worker had been concerned about their drinking or had suggested they cut down, 92.4% said that this had never happened to them, 5.3% said that this had happened but not in the past six months and 2.2% said that this had happened in the past six months. When asked if they had ever been involved with police as a result of their drinking, 98.1% said that this had never happened to them.

When asked about getting injured as a result of someone else’s drinking, 86.4% said that this had never happened to them, 10.3% said that this had happened but not in the past six months and 3.3% said that this had happened in the past six months ( Table 5 ). When asked if they had ever experienced other negative effects on their lives as a result of others’ drinking, 63.3% said that this had never happened to them, 25.6% said that this had happened but not in the past six months and 11.2% said that this had happened in the past six months.

When asked if they supported restrictions on the number of alcohol outlets, the largest proportion of participants (44.2%) opposed or strongly opposed them such restrictions, while the next largest proportion (30.5%) neither supported nor opposed them ( Table 6 ). About half of the respondents (51.6%) strongly opposed and about one-quarter (26.3%) opposed an increase in the price of alcohol. While the largest proportion of respondents neither supported nor opposed restrictions on alcohol advertising (35.0%), 31.0% supported and 5.9% strongly supported advertising restrictions. The largest proportion (41.4%) opposed and 20.6% strongly opposed earlier closing times for buying alcohol, while 24.6% neither supported nor opposed this. Of note, almost two-thirds of respondents (64.2%) strongly supported more police spot checks to detect drinking and driving.

A policy change at the time of the survey was the introduction of the sale of beer and wine in large grocery stores in Ontario; this began in 2015. 45 Among those who had purchased alcohol in the previous six months, there was little variation by age or sex between those who had and those who had not purchased alcohol at a large grocery store ( Table 7 ). However, the rate of over-drinking was higher among those who had purchased alcohol from a large grocery store than among those who had not (53% vs. 40%, respectively; p = .039), while there was no statistically significant difference in the prevalence of binge-drinking (62.13% vs. 58.75%, respectively; statistically nonsignificant).

The purpose of this study was to pilot the IAC Study instrument in Canada in order to (1) adapt the IAC Study instrument to the Canadian context; (2) pilot the survey tool in a sample of participants in Ontario; and (3) provide a preliminary assessment of the information that can be gathered from the IAC Study–based instrument compared with the data collected by other IAC Study sites.

There were challenges and opportunities in adapting the original IAC Study instrument for use in Canada. A number of terms used in New Zealand for types of alcohol beverages and beverage sizes needed to be adapted. Also, typical drinking occasions differed between the two countries. For example, the Ontario sample showed far fewer heavier typical drinking occasions, as shown in Table 4 . Before the instrument was ready for use in Ontario, the specific terminology related to beverages, sizes and drinking locations needed rewording, with care taken to avoid altering the essential meaning.

The decision to use a split-sample approach was a pragmatic one as it allowed all main survey dimensions to be piloted without imposing a time burden on respondents. The final average length for Sample 1 was 27.2 minutes and for Sample 2 was 30.4 minutes. These adjustments demonstrate that, with some reasonably small methodological modifications, the IAC Study instrument can be applied to the Ontario population.

The IAC Study method of collecting information on alcohol consumption based on information session location, type of drink and number of drinks per session results in higher estimates of consumption. 46 The IAC Study method of calculating consumption resulted in 35.6% higher estimates of average monthly consumption for the total sample compared to the standard quantity–frequency method used in the well-regarded CAMH Monitor survey of the Ontario adult population. 44

It has long been recognized that surveybased measures of alcohol consumption substantially underestimate population alcohol consumption, as reflected by per capita consumption measures based on alcohol sales data. 47 Thus, while surveybased measures of alcohol use provide useful and valuable indicators of harmful drinking, their underestimation of population alcohol consumption lead to concerns about their utility for health planning and policy purposes. 47 Survey methods, like the IAC Study, that account for some of the “missing” alcohol may provide important additional value to efforts to understand and address harmful alcohol consumption.

The ability of the IAC Study methods to detect a higher level of consumption in Ontario demonstrates consistency between the pilot study and existing research on the IAC and supports the appropriateness of its use in Ontario.

Other results point to the importance of collecting the more comprehensive and nuanced data on alcohol use that is available with the IAC Study instrument. For example, heavy episodic or binge-drinking is widely recognized as a hazardous form of drinking, in part because on binge occasions individuals are more likely to be intoxicated and experience injuries, get into fights, drive while impaired and so on. Data on where binge-drinking occurs are sparse, and there is a common belief that binge-drinking occasions is common in bars. 48 However, we observed that the average number of drinks per drinking occasion was relatively low in bars compared with other locations. This may point to the success of efforts in the past few years to control heavy or excessive drinking in bars, taverns and pubs. 49

Of particular interest, we found that the average or typical drinking occasion when staying at a cottage/cabin or camping and at public special events is equivalent to binge-drinking. This may be influenced by the relative isolation and control over such events, which might lower the chances for drinking at several locations in the same day, for example, pre-drinking before going to a bar. Identifying locations where heavy or binge-drinking are most common may help inform more effective prevention efforts.

Compared to other jurisdictions that have used the IAC Study design, high frequency drinking and high quantities in typical drinking occasions are relatively low in this pilot study. According to the WHO Global Status Report on Alcohol and Health 2018 , Canada does have lower drinking rates than many of the comparators used. 30

Despite employing several sampling strategies to try to increase the number of younger adult respondents, this pilot study had a disproportionately large number of adults aged over 45. This likely resulted in underestimating heavy drinking as binge-drinking tends to be more common in younger age groups in Ontario. 50 Despite this possible bias, the relative drinking patterns of Ontarians this pilot study determined were proportional to the findings of other current sources of information on drinking behaviour patterns. 30 That the study data are in line with comparisons between Canada and other countries 30 also indicates the appropriateness of the IAC Study for use in Canada.

Only about 8% of respondents said they had personally experienced harm or other problems linked with their own drinking ( Table 5 ). However, nearly 14% reported being injured as a result of others’ drinking, and about 37% reported experiencing negative effects as a result of someone else’s drinking. The latter is substantially higher than that reported in surveys of Ontario in 2006 6 although the 2006 survey included non-drinkers, who may be less likely to have experienced harm from others. 51

Implementation of the IAC Study in Canada would expand the collection of important data on Canadians’ attitudes towards alcohol policy. The findings on attitudes on five alcohol policies ( Table 6 ) show some support for effective policies but rejection of others that are also known to be very effective, such as alcohol pricing. 2 , 52 , 53 The proportion ranged from 84% supporting police spot checks to detect drinking and driving, to only 8% supporting an increase in the price of alcohol. However, it is noteworthy that 37% supported restrictions on alcohol advertising and promotion. These findings are generally in line with previous research focusing on Ontario adults, 54 and at least partially support a claim by Room et al. 2 that popular policies are largely ineffective, and effective policies are unpopular.

The pilot study was also able to capture information on a relatively recent policy change in Ontario, the sale of beer of and wine in grocery stores. Though grocery store purchasing showed no difference in sex and age, there was a significant difference in rate of over-drinking with grocery store purchasers drinking more than they had planned in a drinking session more often. Though the differences in predrinking, planned intoxication and bingedrinking were not significant, they were fairly large and would likely show significance in a sample with greater statistical power.

More frequent risky drinking practices among grocery store purchasers has important implications for policy decisions when considered through the lens of the total consumption model of alcoholrelated harm. This model holds that an increase in the accessibility of alcohol is associated with an increase in the consumption, which in turn, is strongly predictive of the extent of alcohol-related harms. 55 The association of over-drinking with grocery store purchasing in particular suggests that the introduction of alcohol purchasing in grocery stores presents a risk to population health. It should be noted that the direction of this relationship is not discernible given the current cross-sectional design. In order to determine whether availability increases the risk of harmful drinking practices or whether those who engage in riskier drinking practices are likely to buy alcohol at any location (including grocery stores) more frequently, longitudinal analysis of drinking patterns is necessary. Implementation of the longitudinal component of the IAC Study would make such a determination possible.

Limitations

An important feature of the IAC Study is its longitudinal design, which allows the tracking of changing drinking behaviours across policy changes, but longitudinal data collection was outside the scope of the current pilot project. The results of this pilot suggest that implementing a longitudinal design would be a necessary next step in implementing the IAC Study in Canada. However, as is the trend in much survey research, low response rates continue to be a challenge. Future research should consider methods for increasing participation rates, such as provision of incentives while reducing the potential for bias in participation.

Another important limitation of this current study was the limited representativeness of the sample. Quota sampling and inclusion of a cellphone sampling frame were implemented in order to bring the age distribution closer to the age profile of Ontario adults. However, the sample was not reflective of the age distribution of Ontario, with adults over the age of 45 overrepresented. Weighting procedures were used to help reduce the effect of this bias, but the limitations of the sample should still be kept in mind when interpreting the study results.

A small degree of clustering was present in our sample, with 500 participants drawn from 418 households. Our analyses did not account for the clustered nature of the sample, and variance may be underestimated due to this. This relatively small sample also means that the current analyses are likely to be underpowered.

The survey design also relied on selfreporting of drinking and purchasing behaviours, the experience of harm and attitudes on policy. As such, findings in this study may reflect recall or social desirability bias on part of survey respondents.

The results of this pilot study suggest that the IAC Study can be feasibly applied in the Canadian context. The IAC Study represents an important opportunity to improve the quality of information on drinking behaviours in Ontario and other Canadian jurisdictions at a time when recent, ongoing and suggested changes in alcohol policy may increase drinking and drinking-related harms. Improved methods for identifying harmful drinking patterns, attitudes towards alcohol policy and negative consequences of drinking alcohol plus the ability to compare these findings with those in other countries will likely improve prevention of these harms.

Despite the potential value of the IAC Study in Canada, the pilot also identified potential problems in the length of survey administration, difficulties in obtaining an appropriate sample and the limited insight of a cross-sectional pilot for a longitudinal study.

Acknowledgements

We are pleased to acknowledge the extensive contribution of Focal Research to the refinement of the survey instrument, the planning and the execution of the field work. Sally Casswell and Taisia Huckle provided detailed feedback on our adaptation of the survey instrument to the Ontario context. Sarah Callinan and Robin Room provided access to the version of the IAC Study survey and technical report used in Australia and advice based on their experience.

Funding for this pilot study was provided by the Public Health Agency of Canada to the CAMH.

Conflicts of interest

RG is the Editor-in-Chief of the HPCDP Journal, but recused himself from taking any editorial decisions on this manuscript.

Authors’ contributions and statement

RG, NG and RM conceived the study. NG, RM, MvM and GS managed data collection. RG and HO provided study guidance and support. MvM analysed the data. NG, RM, MvM and HO interpreted the results. NG, MvM and HO wrote the manuscript. All authors reviewed and approved the final manuscript.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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