key: cord-0307485-p5n0mnrh
authors: Kastaun, S.; Garnett, C.; Wilm, S.; Kotz, D.
title: Prevalence and characteristics of hazardous and harmful drinkers receiving general practitioners' brief advice on and support with alcohol consumption in Germany: results of a population survey
date: 2022-04-26
journal: nan
DOI: 10.1101/2022.04.25.22274258
sha: bbe7d50d24fb4de1b3c0498e08f39ce18863db36
doc_id: 307485
cord_uid: p5n0mnrh

Objective The German treatment guideline on alcohol-related disorders recommends that general practitioners (GPs) offer brief advice on, and support with, reducing alcohol consumption to hazardous (at risk for health events) and harmful (exhibit health events) drinking patients. We aimed to estimate the implementation of this recommendation using data from the general population in Germany. Design Cross-sectional analysis of data (2021/2022) of a nationally representative household survey. Setting Population of Germany. Participants Representative sample of 2,247 adult respondents (>18 years) who reported hazardous or harmful drinking according to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; score females: 4-12, males: 5-12). Main outcome measure Ever receipt of ''brief GP advice on, or support with, reducing alcohol consumption''. Differences in the likelihood of ever receiving advice and/or support (yes/no) relative to respondents' sociodemographic, smoking, and alcohol consumption characteristics were estimated using logistic regressions. Results Ever receipt of GP advice on/support with reducing alcohol was reported among 6.3% (95%CI=5.3%-7.4%), and the offer of support among 1.5% (95%CI=1.1%-2.1%) of the hazardous and harmful drinking respondents. The likelihood of having ever received advice/support was positively associated with being older (odds ratio (OR)=1.03 per year, 95%CI=1.01-1.04), a current or former (versus never) smoker (OR=2.36, 95%CI=1.46-3.80; OR=2.17, 95%CI=1.23-3.81), and with increasing alcohol consumption (OR=1.76 per score, 95%CI=1.59-1.95). One in two harmful drinking respondents (AUDIT-C score 10-12) reported appropriate advice/support. The likelihood was negatively associated with being female (e.g., OR=0.32, 95%CI=0.21-0.48), having a medium and high (versus low) education, and with increasing household income. Conclusions A small proportion of people drinking at hazardous and harmful levels in Germany report having ever received brief GP advice on, or support with, reducing alcohol consumption. The implementation of appropriate advice or support seems to be strongly linked to specific sociodemographic characteristics, tobacco smoking, and the alcohol consumption level.

• The principal strength of this study is the large, nationally representative population sample. 2

• The cross-sectional study design and temporality issues with our measures (alcohol 3 consumption was measured with reference to the present and the outcome as "ever receipt 4 of GP advice or support") limited our ability to explore causal relationships. 5

• The outcome measure had a complex, not entirely hierarchical structure, which may have led 6 to respondents being unsure of which response option to select. 7

• Data were collected during the COVID-19 pandemic, during which alcohol consumption in 8 Germany seemed to have changed. It is unclear how this might have influenced GPs ' 9 behaviour. 10

• Due to the socially loaded topic, respondents may not have answered truthfully or repressed 11 a previous conversation with their GP on their alcohol consumption. We did not assess the 12 GPs' view on the topic. 13 14 

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The copyright holder for this preprint this version posted April 26, 2022 1 Hazardous drinking is defined as a quantity or a repeated pattern of alcohol consumption that places 2 a person at risk for adverse health events, whereas harmful drinking verifiably results in such events. [1-3 3] Alcohol dependence, on the other hand, is seen as a complex drinking pattern, characterised by 4 persistent consumption despite harmful consequences, craving, the prioritisation of drinking over 5 other activities, tolerance development, and withdrawal symptom. [1] [2] [3] Although this terminology is 6 now commonly used and acknowledges the spectrum of risk that tends to increase with increasing 7

drinking, universal cut-offs with regard to consumption levels and associated risks are missing, making 8 a clear distinction of these theoretical drinking patterns often difficult in practice. [1-3] 9 Alcohol misuse contributes to around 3 million deaths each year globally, and is responsible for around 10 5.1% of global disability-adjusted life-years. [4] Germany ranks above the average level in the European 11 Union of pure alcohol consumption per capita and year in the adult population (13.4 litres of pure 12 alcohol versus 9.8 litres). [4] Latest nationally representative prevalence data show that around 20% of 13 the adult population consume alcohol at least at a hazardous level, [5] including a smaller proportion 14 (approximately 3% per group, [6] ) of harmful and alcohol dependent drinkers. There is strong evidence 15 of a dose-response relationship between alcohol consumption and alcohol-related harms, [7, 8] 16 whereby any person drinking at a hazardous level or above would benefit from reducing their alcohol 17 consumption. 18

The implementation of brief interventions in primary healthcare settings is both an effective [9] [10] [11] [12] [13] 19 and cost-effective [4] approach to reducing hazardous and harmful drinking. Brief interventions usually 20

include feedback on consumption, brief advice to reduce or quit drinking, motivational enhancement 21 and goal setting, and further support such as referral to specialised treatment or the development of 22 a personal reduction plan. [10, 14] 23 General practitioners (GPs) are well placed to address alcohol use disorders as they commonly see 24 patients of various ages with a broad range of (alcohol-related) health conditions, [14] and the long-25

lasting patient-GP relationship can help to reduce feelings of stigmatisation and irritation in the 26 patient. [2] The current German clinical guideline on the treatment of alcohol-related disorders [2] 27 recommends that brief interventions should be offered to hazardous and harmful drinkers in the 28 primary care setting. Identification of patients can be carried out by means of screening and pragmatic 29 case-finding (i.e., when the issue is raised by the patient or when the GP notices alcohol-related 30 conspicuousness). [2] The latter seems to be common in the GP setting. [ Up-to-date and representative national figures on the provision of brief alcohol interventions in GP 6 settings are needed to be able to precisely inform health policy and -if needed -the development of 7

interventions aiming at improving the implementation of treatment recommendations on brief alcohol 8 interventions in primary care. It is also important to report whether the provision of brief alcohol 9

interventions differs by recipients' characteristics in order to identify potentially underserved groups 10 of society. This study therefore aimed to explore the following questions using data from a nationally 11

representative sample of adults (aged >18) in Germany who self-report hazardous or harmful drinking 12

(operationalised using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C)). [ 3) Are there any differences in the likelihood of ever (versus never) receiving brief GP advice on, 24 or support with, reducing alcohol consumption within each measured recipient characteristic? 25

Since the clinical guideline does not provide a clear recommendation on the exact level of alcohol 26 consumption at which a brief intervention should take place, [2] our study will address individuals 27 consuming alcohol at least at a hazardous level. From a preventive medicine perspective, we most 28 likely expect an intervention from GPs among this group of risk. 29

We used data from the cross-sectional German Study on Tobacco Use (DEBRA: "Deutsche Befragung 33 zum Rauchverhalten"): an ongoing representative household survey on tobacco and nicotine product 34 use in Germany (www.debra-study.info). [23] The study is conducted by a market research institute, 35 has been registered at the German Clinical Trials Register (DRKS00011322, DRKS00017157), and 36 received approval by the ethics committee of Heinrich-Heine-University Düsseldorf (HHU 5386R). Since 37 2016, the DEBRA study collects data every other month from computer-assisted, face-to-face 38 household interviews of people aged >14. 39 40 Data were aggregated from seven survey waves (waves 28-34) collected between February 2021 and 41

February 2022 (N=14,327). Since January 2020, respondents are selected by using a dual frame design: 42 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 26, 2022. ; https://doi.org/10.1101/2022.04.25.22274258 doi: medRxiv preprint a composition of random stratified sampling (50% of the sample) and quota sampling (50% of the 1 sample). This sampling design has been described in detail elsewhere: osf.io/s2wxc/. Details on the 2 general sample selection have been published in a study protocol. [ 

Alcohol consumption was measured with the AUDIT-C; [22] a three-item measure including questions 4 on 1) frequency, 2) quantity, and 3) frequency of occasional heavy drinking; full details are given in 5  Table 1 . The AUDIT-C overall score indicates the level of alcohol consumption and ranges from 0 to 6 12. [22] As recommended in the German treatment guideline on alcohol-related disorders [2] and in 7

underlying studies, [24, 25] a gender-specific AUDIT-C cut-off score of >5 in males, and of >4 in females 8 was used to operationalise "at least hazardous drinking". Respondents who answered that they never 9 drink alcohol did not receive questions 2 and 3, and were excluded from the analysis. The study 10 population included all adults (aged >18 years, n=14,026) who reported at least hazardous drinking, 11 resulting in a total sample of n=2,712 (19.3%) hazardous or harmful drinkers. Respondents aged 14 to 12 17 were excluded from the analysis as 16 is the national legal age of sale for beverages containing 13 <15% of alcohol by volume (ABV), and 18 is the legal age of sale for beverages with >15% ABV. 14 Outcome measure 15 Respondents were asked about "ever receipt of GP advice on, or support with, reducing alcohol 16

consumption", using a question that was adopted from previous studies on GP advice on smoking 17 cessation in the German, [26] and in the Dutch and English population, [27] and which was critically 18 reviewed by an experienced GP (see Table 1 ). 19

For further analyses, the response options for this question were dichotomised into 'no' (options 1-2; 20 0) and 'yes' (options 3-5; 1), see Table 1 . Respondents who answered "I don't remember" (n=443) or 21 refused to answer (n=22) were excluded from the analyses. 22

The following sociodemographic characteristics were measured: age; sex (female versus male); region 24 of residence (rural versus urban setting), migration background (yes versus no), current tobacco 25 smoking status (current, former, never), and alcohol consumption as a continuous variable (AUDIT-C  26 score with a possible range of 4-12 among women and of 5-12 among men who drink at least 27 hazardously). 28

Alcohol consumption varies between regions of residence, with a majority of studies reporting higher 29 drinking rates in rural communities. [28] We assumed that this somehow affects the awareness and 30

behaviour of GPs with regard to advice on drinking. This variable was assessed by using the national 31 classification of regions ("BIK Regionsklassifizierung", [29] ), consisting of five categories (e.g., 32 metropolitan area or subcentres) which were dichotomised for the analyses: urban versus rural 33 setting. 34

German population surveys suggest that individuals with migration background relative to those 35 without consume less alcohol. [30] Respondents were asked: "Was one of your parents born abroad?". 36 Migration background applied if at least one parent did not have German nationality by birth. income calculated per person (details on the calculation can be found here: https://osf.io/387fg/). 40 Income was entered as a continuous variable coded from 0 (€0 income/month) to 7 (>€7,000/month) 41 in the regression models. For descripitive purposes, income was categorised into: low (<20th 42 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 26, 2022. ; https://doi.org/10.1101/2022.04.25.22274258 doi: medRxiv preprint percentile), medium (20th to 80th percentiles), and high (>80th percentile), approximately reflecting 1 the distribution in the German population. 2

The study protocol and analysis plan was written prior to analysing data and pre-registered on the 4

Open Science Framework: osf.io/3fe87. 5

Data were analysed and reported unweighted as information on true population parameters of the 6 population of hazardous drinkers were not available. Analyses were performed with IBM SPSS Statistics 7

for Windows, Version 27.0 (Armonk, NY: IBM Corp). 8

To address research question 1, we report descriptive prevalence data on the various levels of GP 9

advice on, or support with, reducing alcohol consumption as percentages together with 95% 10 confidence intervals (95%CI). 11

To address research question 2, we present prevalence data including 95%CI of the dichotomous 12 outcome variable "ever receipt of GP advice on, or support with, reducing alcohol consumption (=yes 13 versus no)" stratified by all categorical exposure variables. For the continuous scaled AUDIT-C score 14 we present a figure showing the prevalence of "ever receipt of GP advice/support (=yes)" in relation 15 to the range of possible AUDIT-C scores among the sample of hazardous and harmful drinkers. 16

To address research question 3, a series of univariate logistic regression models were conducted to 17 explore potential differences in the likelihood of ever (yes vs. no) receiving brief GP advice on, or 18 support with, reducing alcohol consumption for all exposure variables. Regression models were 19 adjusted for survey wave as a potential confounding variable. 20 A considerable number (16.3%) of respondents did not remember if a GP had ever addressed their 21 alcohol consumption and some refused to answer (0.8%). For the analyses of research questions 2 and 22

3, this group was excluded. We compared whether this group differed systematically from respondents 23 who provided an answer on our outcome question by using the chi-square test and Mann-Whitney U 24 test (Supplemental Table 1 ). 25

Missing data were sparse (<0.6% for all variables except for income (2.9%) and migration background 27 (4.8%)), and data were analysed using complete cases. Due to an incorrect questionnaire instruction 28

in four survey waves (28-31), 22.6% of respondents who reported to the first AUDIT-C question with 29

"at least once a month or less" did not receive the AUDIT-C questions 2 and 3, and were not 30 interviewed on the primary outcome. However, an analysis of AUDIT-C data from earlier waves of the 31 DEBRA study [5] with the correct questionnaire instruction showed that only 1% of respondents who 32

provided the same answer, were identified as hazardous or harmful drinkers. We thus assume that 33 around 1% of hazardous or harmful drinkers were lost across four of the seven survey waves due to 34 this mistake. These missing data were assumed to be completely at random, and thus excluded from 35 the analyses. 36

The final analytic sample consisted of all adult respondents who reported at least hazardous drinking, 39 and provided an answer on, or could remember, whether or not a GP had advised them on reducing 40 alcohol consumption (n=2,247). The sample is described in Table 2 . The mean age of this group was 41 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Respondents who didn't remember whether or not they received GP advice seem to be more often 4 current smokers and lower educated but did not systematically differ from respondents who did 5 remember (Supplemental Table 1 ). 6

Proportion of hazardous or harmful drinking adults reporting various levels of GP advice/support 7 Among hazardous or harmful drinkers, 82.2% (95%CI=80.5%-83.7%; n=1,846) reported that a GP had 8 never asked them about their alcohol consumption, 11.5% (95%CI=10.2%-12.9%; n=259) reported that 9 they had ever been asked about drinking by a GP, and 6.3% (95%CI=5.3%-7.4%; n=142) said that a GP 10 had ever advised them to drink less, or offered either help or support or advised or helped them to 11 make use of medical or psychological support to drink less (see Figure 1 ). Such support was reported 12 by 1.5% (95%CI=1.1%-2.1%) of the hazardous and harmful drinking respondents. 13

Proportion of hazardous or harmful drinking adults reporting ever receipt of GP advice/support 14 stratified by recipients' characteristics 15

Men (compared with women), respondents of higher age (65+ years), those with low (compared with 16 medium and high) education and household income, and current and former smokers (compared with 17 never smokers) reported relatively more often to have ever received brief GP advice on, or support 18 with alcohol consumption, see Table 2 . 19

The higher the overall AUDIT-C score, the higher the rate of reporting ever receipt of GP advice on, or 20 support with, reducing alcohol consumption, see Figure 2 . In persons with an AUDIT-C score >9 -which 21 is viewed as harmful or potentially dependent drinking pattern [37] -51.5% (n=17/33) have ever 22 received GP advice on, or support with reducing alcohol consumption. 23

The likelihood of ever receipt of brief GP advice on, or support with, reducing alcohol consumption 25 was positively associated with being older, being a former or a current smoker, and reporting a higher 26 alcohol consumption level at the time of the survey, see Table 2 . The likelihood was negatively 27 associated with being female, having medium and high (compared with low) educational qualification, 28 and with increasing monthly household income. 29 No significant differences were detected relative to the respondents' migration background or region 30 of residence. 31

In a large representative sample of the general population of adults in Germany who report hazardous 34 or harmful drinking, about 12% reported having ever been asked by a GP about their alcohol 35 consumption, and about 6% reported having ever received GP advice to drink less, including 1.5% who 36

were also offered support to drink less or to make use of psychological or medical assistance for that 37 purpose. However, in the subgroup of people reporting harmful or potentially dependent drinking 38

(AUDIT-C score 10-12, [31] ) around half had ever received brief GP advice on, or support with, reducing 39 alcohol consumption. 40 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 26, 2022. ; https://doi.org/10.1101/2022.04.25.22274258 doi: medRxiv preprint To our knowledge, this is the first nationwide study to estimate the implementation of the clinical 1 guideline recommendation on the provision of GPs' brief advice on, or support with alcohol 2 consumption in the population of Germany. Our findings are broadly consistent with a previous study 3

(not methodologically comparable) in a single federal state in Germany, [21] and a population survey 4

in England (with comparable methodology).

[18] Both studies indicate insufficient implementation of 5 brief alcohol interventions in primary care. 6

In the current study there were significant differences in the likelihood of having ever received GP 7 advice or offer of support by personal characteristics. Hazardous and harmful drinkers of older age, 8 current or former smokers, and those with higher alcohol consumption had higher odds of reporting 9 ever receipt of GP advice on, or support with alcohol consumption, whereas females (versus males) 10 and respondents with higher income or medium and high (versus low) educational qualification had 11 substantially lower odds. Higher likelihood of receiving GP advice on alcohol consumption among older 12 respondents and among current or former smokers might be associated with awareness among GPs 13 of existing (alcohol-related) health conditions and of polysubstance use, as well as with demand for 14 treatment among patients. The implementation of alcohol screening and brief intervention in 15 individuals with co-morbidities seems to be largely accepted among GPs and higher than in those 16 without co-morbidities. [32-35] 17 Our findings suggest that hazardous and harmful drinking women and those with higher SES are under-18 recognized by GPs when it comes to brief alcohol intervention. This is concerning as, although 19 prevalence of hazardous and harmful drinking is higher among men, yet around one in 10 women 20 report drinking at least at a hazardous level. [5] In addition, evidence is good that individuals with 21 higher compared to with lower SES may consume similar or even greater amounts of alcohol and show 22

higher prevalence rates of hazardous drinking. [5, 36] Gender gaps in GP-delivered alcohol 23 interventions have been reported before [18, 37, 38] but we can only speculate on underlying reasons. 24 This could be due to greater concerns about stigmatisation or shame, leading women and individuals 25 with higher SES less often admit alcohol use to their GPs. On the other hand, implicit cognitive bias and 26 stereotypes might influence the GPs' decision on who to screen for alcohol misuse. [39] Another 27 possible explanation might be that specific groups of society are less likely to consult a GP, which has 28 been reported for higher SES groups, [40, 41] though is not the case for women who tend to visit their 29 GP more often than men. [ 

Implications for policy and practise 31

GPs are a major force to improve the prevention of alcohol-related harm on a population level, and as 32 this study shows, they already intervene in about half of harmful drinking patients. However, from a 33 preventive medicine perspective, this study reveals a need to improve the implementation of guideline 34 recommendations for hazardous drinking in the GP setting. Whilst the clinical guideline does not 35 provide a clear recommendation on the exact level of alcohol consumption at which a brief 36 intervention should take place, [2] alcohol-related harms are dose-dependent and therefore it is 37 important to provide brief interventions for all individuals at alcohol-related risk. Previous studies 38

showed that education and post-graduate training predicts the GP delivery of brief alcohol 39

interventions to hazardous drinkers, [32] and that training GPs can significantly increase alcohol 40 screening and brief intervention rates in primary care. [43] This is particularly the case when being 41 tailored to the barriers and facilitators towards the implementation of such interventions in the GP 42 setting and when being developed on the basis of a behaviour change theory. [44] Further synergistic 43 effects have been shown when financial incentives, training and support were offered together. [ 

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The copyright holder for this preprint this version posted April 26, 2022. ; https://doi.org/10.1101/2022.04. 25.22274258 doi: medRxiv preprint In Germany, appropriate training is not offered by default, neither during medical education nor as 1 post-graduate training for physicians. As a consequence, many GPs [46] , as well as medical 2 students, [47] in Germany do not feel adequately trained to diagnose and treat patients with alcohol 3

problems. This lack of training had also been identified as a major barrier towards the routine 4

implementation of brief alcohol intervention in primary care in the United Kingdom. [16] 5 Strengths and limitations 6 A major strength of this study is the large, nationally representative sample. However, there are also 7 limitations. First, data was self-reported, introducing risk for recall bias that may have affected the 8 prevalence estimates, most likely resulting in an under estimate. Secondly, the cross-sectional study 9

design and that GP advice and support was measured as "ever receipt", whereas alcohol consumption 10

was measured with approximate reference to the present, limited our ability to explore causal 11 relationships. Comparable temporality issues might also occur for some of the sociodemographic 12 characteristics such as income or place of residence. Based on this, we did not conduct multivariable 13 regression analyses, and our results are not adjusted for potential confounding through interaction 14 effects between the exposure variables. Future research should look to estimate the potential causal 15 effect of someone's characteristics and the likelihood of ever receipt of GP advice on, or support with, 16

reducing alcohol consumption. 17

Thirdly, the question on "ever receipt of GP advice and support" had a complex structure (participants 18 are asked about GP advice on as well as different types of support with drinking less), which could have 19 led to difficulties in understanding. However, the face-to-face interview method and support available 20 from the interviewers may have mitigated this risk. In addition, this measure did not follow an exact 21 hierarchical structure and there was no clear distinction between "internal support" (e.g., offered by 22 the GP), and "external support" (e.g. psychosocial services). This may have led to respondents being 23 unsure of which response option to select. Fourthly, data were collected during the COVID- 19 24 pandemic, during which alcohol consumption in Germany seemed to have decreased on average but 25 increased in specific subgroups of the population. [48, 49] It is unclear how this might have influenced 26 the behaviour of GPs. Finally, due to the socially loaded topic, respondents may not have answered 27 truthfully or repressed a previous conversation with their GP on the topic. It is therefore important to 28 also assess the GPs' view on the topic, including in-depth information on barriers to the 29 implementation of the treatment guideline recommendations in their daily practice. Previous surveys 30

among GPs, however, usually only assessed how often, in general, GPs screen for alcohol or provide 31 brief intervention, but not in relation to the number of their hazardous drinking patients. [32, 50] 

Conclusion 34

Our findings suggest that hazardous drinking -that places a person at risk for adverse health events -35

does not seem to be adequately addressed by GPs in Germany, particularly among women and 36

individuals from higher SES groups. From a preventive medicine perspective, this results in missed 37 opportunities to reduce alcohol-related harm. However, the probability of having ever received brief 38 alcohol intervention by a GP increases with increasing drinking levels. Around every second harmful 39

drinking person seems to have ever received brief GP advice on, or support with, reducing alcohol 40

consumption. Although we did not analyse causal relationships, this study is a call for action in order 41 to further explore underlying reasons why clinical guideline recommendations on brief alcohol 42

interventions are not implemented more often in the German general practice setting, as well as to 43 explore potential approaches for improvement. 44 45 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 26, 2022.

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans 24 of this research. 25

SK coordinates the DEBRA study, conceptualised and drafted the analysis protocol, drafted the 27 manuscript, analysed and interpreted the data. CG and SW: provided expert advice on the study 28 protocol and critically revised the analysis protocol and the manuscript. DK conceived the DEBRA study, 29 supervised the analyses, and critically revised the analysis protocol and the manuscript. All named 30

authors contributed substantially to the manuscript and agreed on its final version. 31 32 Data Availability Statement 33

The data underlying this study are third-party data and are available to researchers on reasonable 34

request from the corresponding author (sabrina.kastaun@med.uni-duesseldorf.de). All proposals 35

requesting data access will need to specify how it is planned to use the data, and all proposals will 36

need approval of the DEBRA study team before data release. 37 38 39 40 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 26, 2022 (n=2,247) , and prevalence estimates on the ever receipt of brief GP advice on/support with reducing alcohol consumption (=yes) relative to the respondents' characteristics; including results of univariate regressions models on associations between these characteristics and ever receipt of GP advice. Data are presented as column percentages (number), row percentages (number, 95% confidence interval (95%CI)), and as Odds Ratios (OR) together with 95% CI around OR. ORs were adjusted variable "survey wave" (as design factor); ***p<0.001, **p<0.01, *p<0.05. Variables with missing data: educational qualification: 0.6%, household income: 2.9%, migration background: 4.8%, smoking status: 0.1%. § According to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) [22] ; an AUDIT-C score of >5 in male respondents, and of >4 in female respondents was used to operationalise hazardous drinking [2, 24, 25] . †German educational qualification levels: low (9 years of education, or no graduation), medium (10 years of education), high (>12 years of education). # Monthly net household income per person in the household, based on the Organisation for Economic Co-operation and Development (OECD)-modified equivalence scale [29] . The variable was categorised into three levels: low (<20th income percentile), medium (20th to 80th income percentiles), and high (>80th income percentile), approximately reflecting the distribution of income in the German population [30] [31] [32] . ¥ Entered as continuous variable in regression analysis. ¤ Gender-specific mean values (incl. median and standard deviation) for the sample are reported in the results section of this manuscript.

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The copyright holder for this preprint this version posted April 26, 2022. ; https://doi.org/10.1101/2022.04.25.22274258 doi: medRxiv preprint FIGURE LEGENDS Figure 1 : Prevalence estimates on the various levels of GP advice on, or support with, reducing alcohol consumption (self-reported) among the total sample of adult hazardous or harmful drinkers (n=2,247) reported as percentages together with 95% confidence intervals.

Ever receipt of GP advice on, or support with, reducing alcohol consumption (yes, selfreported) relative to the total AUDIT-C score among the total sample of adult hazardous or harmful drinkers (n=2,247) reported as percentages together with 95% confidence intervals (black line; dotted line: trend line, polynomial function, R 2 =0.97).

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The copyright holder for this preprint this version posted April 26, 2022. ; https://doi.org/10.1101/2022.04.25.22274258 doi: medRxiv preprint

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Frequent attenders in the German healthcare system: determinants of high utilization of primary care services. Results from the crosssectional German health interview and examination survey for adults (DEGS)

Do men consult less than women? An analysis of routinely collected UK general practice data

Training primary care clinicians in maintenance care for moderated alcohol use

Efficacy of a theory-driven program to implement alcohol screening and brief interventions in primary health-care: a cluster randomized controlled trial

Improving the delivery of brief interventions for heavy drinking in primary health care: outcome results of the Optimizing Delivery of Health Care Intervention (ODHIN) five-country cluster randomized factorial trial

Are German family practitioners and psychiatrists sufficiently trained to diagnose and treat patients with alcohol problems?

How fit are medical students from Dresden to treat alcohol-related disorders?

Alcohol Use in Germany and Europe during the SARS-CoV-2 Pandemic

Did self-reported tobacco smoking, alcohol consumption, and physical activity change during the COVID-19 restrictions in Germany in spring 2020? Findings from a population survey (the DEBRA study)

Moderation of alcohol consumption as a recommendation in European hypertension management guidelines: a survey on awareness, screening and implementation among European physicians

 2  The authors thank Erika Baum for her constructive feedback on the outcome measure (the question  3 on GP advice on alcohol consumption) as well as on the first version of the analysis protocol. The 4authors also thank Constanze Cholmakow-Bodechtel and Franziska Wenng from the market research 5institute "Kantar" for the collection of the data. 6 7 Competing Interests 8The authors have no competing interests to declare. CG is a paid scientific consultant for the behaviour 9change and lifestyle organization, One Year No Beer. 10 11Funding 12From 2016 to 2019 (waves 1-18), the DEBRA study was supported by the Ministry of Innovation, 13Science and Research of the German State of North Rhine-Westphalia (MIWF) in the context of the 14 "NRW Rückkehrprogramm" (the North Rhine-Westphalian postdoc return program). Since 2019 (wave 15 19 onwards), the study has been supported by the German Federal Ministry of Health. 16 CG is funded by Cancer Research UK and the National Institute for Health Research. 17

The study protocol has been peer-reviewed and approved by the ethics committee of Heinrich-Heine-19University Duesseldorf, Germany (HHU 5386/R). The fieldwork is conducted by the market research 20institute Kantar, Germany. Interviewers from Kantar make sure that all participants give oral informed 21consent. This method of consent has been approved by the ethics committee. 22