Professional Documents
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RESEARCH REPORT
Abstract
The Alcohol Use Disorders Identification Test (AUDIT) has been developed from a six-country WHO
collaborative project as a screening instrument for hazardous and harmful alcohol consumption. It is a
10-item questionnaire which covers the domains of alcohol consumption, drinking behaviour, and alcohol-
related problems. Questions were selected from a 150-item assessment schedule (which was administered to
1888 persons attending representative primary health care facilities) on the basis of their representativeness
for these conceptual domains and their perceived usefulness for intervention. Responses to each question are
scored from 0 to 4, giving a maximum possible score of 40. Among those diagnosed as having hazardous or
harmful alcohol use, 92% had an AUDIT score of 8 or more, and 94% of those with non-hazardous
consumption had a score of less than 8. A UDIT provides a simple method of early detection of hazardous
and harmful alcohol use in primary health care settings and is the first instrument of its type to be derived
on the basis of a cross-national study.
The primary goal of intervention is to facilitate eral items in the MAST reflect advanced
reduction in alcohol intake to non-hazardous physical dependence or severe harm, or whether
levels, and thereby lessen the risk of harmful the subject identifies as an alcoholic. Examples
consequences of drinking. There is increas- include "Have you ever had delirium tremens
ing evidence for its efficacy in this regard (DT's)?" and "Have you ever attended a meet-
(Kristenson et al, 1983; Wallace, Cutler & ing of Alcoholics Anonymous?". Among the
Haines, 1988; Institute of Medicine, 1990; broader spectrum of problem drinkers, the
Saunders & Foulds, 1992). Through early MAST is less sensitive: 59% of persons con-
identification, treatment is provided well before victed of drunken and disorderly behaviour and
the stage alcohol-affected patients usually only 11% of persons whose vehicle licences were
present for treatment, which typically is when under review because of an alcohol-related of-
they have suffered major health problems, psy- fence were identified as 'cases' (Selzer, 1971). In
chological impairment and social decline. Early a community study, Saunders & Kershaw found
intervention is particularly appropriate for pri- that the short version of the MAST and a related
mary health care settings, where the high instrument, the CAGE, identified only a minor-
throughput of patients offers great opportunities ity of problem drinkers (Saunders & Kershaw,
for systematic screening and therapy. 1980). One may conclude that these instruments
An essential component of any early interven- are useful and very sensitive in screening for
tion procedure is a simple and valid screening advanced problems such as alcoholism, but are
instrument to detect persons with hazardous or less suitable for detecting those with less severe
harmful alcohol consumption before dependence drinking problems, who actually form a larger
and permanent harm have developed. The proportion of the general population (Mayfield,
present paper describes the derivation of a 10- McLeod & Hall, 1974; Saunders & Kershaw,
item screening questionnaire which is based 1980; Bemadt et al, 1982; Jacobson, 1983;
upon experience in a World Health Organization Ewing, 1984; Hedlund & Vieweg, 1984; Bush et
collaborative study based in six countries (see al, 1987; Waterson & Murray-Lyon, 1989).
Appendix). It follows a companion paper (Saun- Similar comments may be applied to several
ders et al., 1993) which describes the prevalence other screening instruments such as the Munich
of alcohol use disorders and the inter-relation- Alcoholism Test and the MacAndrew Alco-
ships of consumption and harm in a primary holism Scale (MacAndrew, 1965; Jacobson,
health care population. The instrument, the Al- 1983; Feuerlein et al, 1986; Gottesmann &
cohol Use Disorders Identification Test Prescott, 1989).
(AUDIT) is a development of the provisional In Europe, screening techniques for alco-
'core' screening instrument described in the orig- holism have been developed which are based on
inal report of the collaborative project (Saunders the presence of abnormal physical findings. The
& Aasland, 1987). principal exponent of this approach has been the
Screening instruments for alcohol use disor- French physician Le Go. The 'Le Go Grid' (Le
ders are not new. Nearly all existing instruments Go, 1976) is a brief clinical screening procedure
have, however, been developed to detect alco- which involves the detection of, inter alia, con-
holism, and not to screen for problem drinking junctival injection, abnormal vascularization of
which is at an earlier or milder stage. The most the facial skin, coating of the tongue and hep-
widely known alcoholism questionnaire is proba- atomegaly. It has been taken up widely in France
bly the Michigan Alcoholism Screening Test for the detection of alcoholism (Babor et al,
(MAST) (Selzer, 1971), of which several ver- 1988). To date there has been little work on the
sions now exist (Pokomy, Miller & Kaplan, use of the Le Go Grid in detecting less severe
1972; Selzer, Vinokur & Van Rooijen, 1975; drinking problems.
Swenson & Morse, 1975). Questions were Biological markers of heavy alcohol consump-
selected for the MAST on the basis of their tion have also been used to screen for problem
capacity to discriminate between inpatient alco- drinking. They include serum gammaglutamyl-
holics and psychiatric patients who had no transferase (GGT) activity, serum aspartate and
diagnosis of alcoholism. The MAST correctly alanine aminotransferase activities (AST and
identified 98% of alcoholics and only 5% of ALT respectively), HDL-cholesterol, uric acid
non-alcoholic patients had a positive score. Sev- and erythrocyte mean cell volume (MCV)
Development of AUDIT 793
(Rosalki & Rau, 1972; Wu, Chanarin & Levi, before dependence, physical disease or major life
1974; Whitfield et al, 1978; Chick, Kreitman & problems had developed. It should be valid in
Plant, 1981; Bemadt et al, 1982; Skinner et al, different cultures. It should be suitable for pri-
1984). The sensitivity of these markers is vari- mary health care, and therefore would need to be
able: up to 80% of alcoholics admitted to general brief and easily understood to encourage its
medical or gastroenterology units have a raised widespread use.
GGT or MCV (Rosalki & Rau, 1972; Wu et al,
1974). However, in psychiatric hospitals and in
general population samples the sensitivity of
these tests for the diagnosis of alcoholism is Method
much lower, and they identify only 10-20% of Sampling frame
persons with less severe drinking problems. As described in the preceding paper (Saunders et
(Chick et al, 1981; Bemadt et al, 1982). All al, 1993), the collaborative project involved re-
these markers are also non-specific for the detec- search centres in Australia, Bulgaria, Kenya,
tion of problem drinking, being abnormal in Mexico, Norway and the USA. Subjects were
many disease states. Recently discovered mark- recruited from representative primary health care
ers, such as desialotransferrin (Stibler, Borg & facilities and classified on the basis of their re-
Joustra, 1986; Storey et al, 1987) and antibodies sponses in a structured interview as either 'non
to acetaldehyde-altered plasma proteins (Israel et drinkers' (total abstainers or those who drank
al, 1986), may prove to be more sensitive than alcohol on three or fewer occasions per year and
existing tests. Another approach is to assay alco- had never been treated for an alcohol problem),
hol in body fluids, such as saliva and sweat. This 'drinking patients' (who drank on at least four
is a highly specific method, and an 'alcohol dip- occasions per year and had never received treat-
stick' has been developed for the purposes of ment for a drinking problem) and 'alcoholics'
mass screening (Kapur & Israel, 1984). The (who had been diagnosed as alcoholic, had re-
dipstick provides a rapid, semi-quantitative ceived treatment for an alcohol-related disorder
estimate of alcohol concentration in saliva. or were seeking treatment). In all, 1905 subjects
However, all tests based on detecting alcohol are were interviewed in the six countries. After 17
limited to identifying consumption within the subjects were excluded because of incomplete
previous 24 hours and cannot in themselves esti- data on alcohol consumption, 1888 remained to
mate the severity of an underlying clinical form the study sample. Of these 678 (36%) were
syndrome. classified as non-drinkers, 913 (48%) were
At the time the present collaborative study was classified as drinking patients, and 297 (16%)
being devised (in 1983) there seemed to be were termed alcoholics. Only data obtained firom
several major limitations to the screening instru- the drinking patients were used to select items
ment currently available. Screening question- for AUDIT. The non-drinkers and alcoholics
naires, clinical examination procedures and formed reference groups for instrument valida-
laboratory tests had been developed mainly to tion.
distinguish between hospitalised alcoholics and
normal drinkers. Their suitability for identifying
the broad spectrum of problem drinkers was Assessment
limited or had not been tested. Several appeared Each subject was interviewed by a trained inter-
to be highly culturally specific, and as Room has viewer who administered a 150-item schedule
commented, 'off the shelf screening tests origi- which encompassed socio-demographic vari-
nating in North America, the United Kingdom ables, presenting conditions, current sympto-
and Europe may not be relevant for other cul- matology, past medical history, alcohol
tures (Room, 1988). Thirdly, few had been consumption, other substance use, diet, drinking
developed for primary health care settings. The behaviour, psychological reactions to alcohol,
aim of the study was therefore to develop an alcohol-related problems, family history of alco-
instrument that would screen effectively for a holism, and self-perception of an alcohol
broad spectrum of problem drinking and problem (Saunders & Aasland, 1987). The inter-
specifically for hazardous and harmful alcohol view was supplemented by a clinical exami-
consumption. Thus, it should identify subjects nation, and blood samples were taken for
794 John B. Saunders et al.
(Tables 1 and 2). There was relatively little domains, it was decided that the screening in-
variatioti from country to country. The values for strument should include questions on the
the two domains 'alcohol problems in the last following: (1) alcohol consumption; (2) drinking
year' and 'alcohol problems ever' were lower at behaviour (dependence); (3) adverse psychologi-
0.69 and 0.65 respectively (Table 3), and varied cal reactions; and (4) alcohol-related problems.
significantly among the six samples (from It was decided not to include any questions from
approximately 0.35 to 0.83). There was a mod- the non-specific domains.
erately strong correlation between the drinking
behaviour (dependence) and mean daily alcohol
consumption (r=0.53) and between adverse Selection of items
psychological reactions, alcohol problems in the From the drinking behaviour scale, three ques-
previous year and alcohol problems ever scales, tions were selected: (1) How often during the
and intake (r= 0.50, 0.50 and 0.51 respectively). last year have you found that you were not able
The non-alcohol-specific domains such as cur- to stop drinking once you had started? (2) How
rent symptoms, past medical history and clinical often . . . have you failed to do what was nor-
examination findings had much lower values for mally expected from you because of drinking?
intrascale reliability, and weaker and often non- and (3) How often . . . have you needed a first
significant correlations with mean daily alcohol drink in the moming to get yourself going after a
intake (Saunders & Aasland, 1987). Factor anal- heavy drinking session? TTie first was selected
ysis reported in more detail in the previous paper because it had the highest weighted mean item-
(Saunders et al, 1993) showed that the alcohol- to-total correlation coefficient (0.81), and
specific scales and measures of consumption showed the most uniform pattem of correlation
loaded on a dominant first factor. Current symp- across the centres (Table 1). It thus appeared to
toms was the only non-alcohol specific domain be the most representative item for the scale. It
to have a factor coefficient exceeding 0.40 (actu- refiects impaired control over consumption of
ally 0.46), and was also located in the third alcohol. The second question had the third
factor extracted, together with the clinical exam- highest overall correlation coefficient (0.78), and
ination scale. On the basis of these analyses and a narrow range of valuesfi-omcentre to centre. It
to ensure adequate coverage of the most relevant represents salience of drinking, i.e. neglect of
796 John B. Saunders et al.
Table 2. Item correlations and intrascale reliability coefficients for the scale 'adverse psychological reactions'
Weighted mean
Australia Bulgaria Kenya Mexico Norway USA correlation
1. Had a feeling of remorse
after drinking 0.38 0.31 0.73 0.69 0.56 0.55 0.53
2. Become depressed
after drinking 0.49 0.15 0.70 0.46 0.21 0.31 0.44
3. Been unable to remember
what happened the night before
because you had been drinking 0.48 0.20 0.59 0.51 0.47 0.29 0.44
4. Become angry after drinking 0.31 0.26 0.63 0.46 0.37 0.59 0.43
Cronbach's alpha 0.64 0.73 0.76 0.90 0.79 0.75 0.81
Table 3. Item correlations and intrascale reliability coefficients for 'alcohol problems ever'
Weighted mean
Australia Bulgaria Kenya Mexico Norway USA correlation
1. Family or friend concemed
about your drinking 0.38 0.31 0.73 0.69 0.56 0.55 0.53
2. Work difficulties because
of drinking 0.49 0.15 0.70 0.46 0.21 0.31 0.44
3. Doctor or other health worker
concemed about your drinking
or suggested that you cut down 0.48 0.20 0.59 0.51 0.47 0.29 0.44
4. Legal trouble in connection
with drinking 0.31 0.26 0.63 0.46 0.37 0.59 0.43
5. You or someone else injured
as a result of your drinking 0.42 0.22 0.48 0.61 0.26 0.42 0.40
Cronbach's alpha 0.65 0.40 0.83 0.77 0.60 0.67 0.65
Questions 1-3 measure alcohol consumption, for "alcohol problems in the last year" it ranged
4-6 drinking behaviour, 7-8 adverse reactions from 91% to 100% (Table 4). The overall sensi-
and 9-10 alcohol-related problems. Each ques- tivity for hazardous and harmful alcohol use was
tion is scored fi-om 0 to 4, and the range of 87% to 96%, with an overall value of 92%
possible scores isfi-om0 to 40. The performance (Table 4). The corresponding specificity was
of AUDIT was examined in two ways, firstly by 81% to 98%, with an overall value of 94%.
comparing scores against the diagnoses of haz- When the cut-off point of 10 was taken, sensitiv-
ardous and harmful alcohol use in the samples of ity was lower (Table 5), with an overall value of
drinking patients, and secondly by calculating its 80% for the combined index. The specificity was
sensitivity among the extemal reference group of correspondingly higher: for the combined index
known alcoholics. Cut-off points for AUDIT values ranged from 95 to 100%, and the overall
were determined by receiver operating character- value was 98%.
istic (ROC) analysis. The sensitivity and The validity of AUDIT was then determined
specificity of scores from 0 to 40 were calculated among the extemal reference groups of known
for the diagnoses of (1) hazardous daily alcohol alcoholics and non-drinkers. Of the alcoholics,
consumption and/or recurrent intoxication, (2) 99% had a score of 8 or more, 98% had a score
abnormal drinking behaviour, (3) alcohol related of 10 or more and when those who were cur-
problems in the last year, and (4) the combined rently abstinent were excluded, all scored 10 or
index of hazardous and harmful alcohol con- more. Only three of 678 non-drinkers (0.5%)
sumption. Two cut-off points, 8 and 10 were had a score of 8 or more. As a final check on the
identified which resulted in maximal sensitivity accuracy of the process for selecting items, the
and specificity. AUDIT questions were compared vnxh 20 other
The results which are presented in Tables 4 combinations of questions for their ability to
and 5 should be regarded as interim estimates of discriminate between patients with hazardous or
the sensitivity and specificity of AUDIT. They harmful alcohol use and those with non-
represent a comparison between the AUDIT hazardous consumption. The AUDIT questions
scores and diagnoses based on multiple items of classified subjects as accurately as any other
information obtained during a comprehensive, combination.
structured interview, supplemented by physical
examination and laboratory findings. Using the
lower cut-off point of 8, the sensitivity of Discussion
AUDIT for hazardous alcohol consumption The development of screening instruments is
ranged fi-om 95% to 100%, for abnormal drink- necessarily linked to prevailing concepts of alco-
ing behaviour fi-om 93% to 100%, for the hol problems. The first screening tests were
alcohol dependence syndrome it was 100%, and aimed at identifying alcoholics and were success-
798 John B. Saunders et al.
Table 4. Sensitivity and specificity of the 'AUDIT' questionnaire at cut-off point of 8
Hazardous Abnormal drinking behaviour Combined index
consumption/ (at least one element of Alcohol-related of hazardous
recurrent dependence at specified problems in the and harmful
intoxication minimum frequency) last year alcohol use
Australia 100/74 .97/75 95/81 93/82
Bulgaria 95/76 100/74 100/72 96/87
Kenya 97/66 97/69 100/71 95/81
Mexico 100/77 93/89 94/98 88/98
Norway 100/89 94/91 91/94 87/97
USA 96/74 97/79 92/83 90/92
All countries 97/78 96/81 95/85 92/94
ful in doing so. Sensitivities exceeding 95% for show promise as more specific markers of heavy
the MAST and its progeny attest to this. How- drinking, but further research is needed to
ever, the ability of this family of instruments to confirm their usefulness in routine screening
identify patients with hazardous or harmful alco- (Stibler et al, 1986; Israel et al, 1986; Storey et
hol use is much lower (Selzer, 1971; Saunders al, 1987). The ideal biological marker would be
& Kershaw, 1980; Hedlund & Vieweg, 1984). one that is even more sensitive and able to
Another problem with these questiotmaires is identify gradations in alcohol use. Such a marker
that because questions are phrased in terms of is not yet available.
lifetime occurrence, it may be impossible to Composite instruments have been devised
distinguish current alcoholics or problem which seek to capture a broad spectrum of phys-
drinkers from those who have ceased drinking or ical and psychosocial consequences of alcohol
are no longer symptomatic. Indeed, this problem use. It was hoped this would increase the sensi-
has led to the development of a revised response tivity and yield of the screening process. Wilkins
format for the MAST that provides better dis- developed a two-stage procedure which incorpo-
crimination between current and lifetime rated a check-list of clinical indicators and a
symptoms. Reworking of the MAST has not, disguised questionnaire, the "Spare Time Activi-
however, resulted in an instrument which em- ties Questionnaire" (Wilkins, 1974). The
braces the broad spectrum of problem drinkers. Munich Alcoholism Test (MALT) (Feuerlein et
Clinical examination findings (Le Go, 1976; al, 1986) and the Alcohol Clinical Index (Skin-
Skinner et al., 1986; Babor et al., 1988) have also ner et al, 1986) also include clinical findings as
been employed to screen for alcoholism and its well as questionnaire items. Although they are
physical sequelae. Although the medical impact conceptually appealing and, for example, the
of heavy drinking is widespread, clinical abnor- Alcohol Clinical Index provides good discrimina-
malities occur relatively late in the evolution of a tion between non-dependent problem drinkers
drinking problem (Babor, Kranzler & Lauerman, and non-problem drinkers, they are relatively
1987) and appear to be of limited value for early complex and they have not been taken up widely
intervention. Other correlates of chronic drink- in clinical practice. Any method based on clinical
ing, such as hypertension, are not sufficiently examination findings would normally require the
specific to be of much value in screening. How- involvement of a medical practitioner. Likewise,
ever, they may help to confirm an impression most biological tests require sophisticated labo-
that alcohol consumption is harmful. Established ratory equipment and computer technology
biological markers have also proved relatively which might preclude their use in primary health
insensitive in screening for hazardous alcohol care settings, particularly in developing coun-
consumption (Whitfield et al., 1978; Chick et al, tries.
1981; Bemadt et al, 1982). They are also
affected by substances other than alcohol as well Selection of items for AUDIT was guided
as diseases unrelated to drinking. Serum trans- both by the statistical analysis and certain opera-
ferrin and new immunological tests developed to tional requirements. The latter included the
measure acetaldehyde bound to plasma protein desirability of representing the conceptual do-
mains of alcohol consumption, dependence and
Development of AUDIT 799
Table S. Sensitivity and specificity of the AUDIT' questionnaire at cut-off point of 10
Hazardous Abnormal drinking behaviour Combined index
consumption/ (at least one element of Alcohol-related of hazardous
recurrent dependence at specified problems in the and harmful
intoxication minimum frequency) last year alcohol use
Australia 97/86 88/86 85/92 79/98
Bulgaria 84/87 92/85 84/82 79/96
Kenya 94/79 94/82 97/84 91/95
Mexico 100/83 91/95 84/100 79/100
Norway 90/94 88/96 74/98 67/99
USA 86.81 86/85 87/91 76/96
All countries 92/87 90/90 86/92 80/98
problems, the need for a rounded number of this will reduce under-reporting of adverse
questions and for all questions to be easily un- effects. Not surprisingly, there are also some
derstandable, valid across different cultures, and similarities with existing instruments. Two of the
capable of providing the framework for subse- ten items (guilt about drinking, and drinking in
quent intervention. Analysis revealed that in the moming) are similar to those in the CAGE
some scales (for example, drinking behaviour) (Ewing, 1984), and five resemble questions in
many items were virtually interchangeable in the MAST (Selzer, 1971). AUDIT is shorter
terms of their correlation with total scores, or than both the full AdAST and a more recently
capacity to distinguish between hazardous and introduced instrument wth a similar conceptual
harmful drinkers and those in the non- basis, the Canterbury Alcoholism Screening Test
hazardous range. The final 10-item instrument (Elvy & Wells, 1984). It can be embedded within
included three questions on intake, four on alco- general health and lifestyle questionnaires with-
hol-related problems and adverse reactions, and out making them unwieldly or upsetting their
three on drinking behaviour. Because these do- balance. This would provide an element of dis-
mains conform approximately to the concepts of guise which may be useful in some settings.
hazardous alcohol use, harmful use and depen- The comparative merit for screening purposes
dence in WHO terminology and the ICD-10 of "consumption" questions and "adverse conse-
psychoactive substance use disorders section quences" ones has been the subject of debate.
(World Health Organization, 1992), the test was Ryder and colleagues reported that questions on
named the Alcohol Use Disorders Identification alcohol-related problems were more sensitive in-
Test (AUDIT). dicators of problem drinking than consumption
The differences between AUDIT and most ones (Ryder et al., 1988). In an antenatal popu-
existing questionnaires can be summarised as lation, however, quantity-frequency questions
follows. Firstly, it seeks to detect problem gave a higher yield than the CAGE or Brief
drinkers at the less severe end of the spectrum, MAST (Waterson & Murray-Lyon, 1989). The
rather than targetting persons with established main conclusion from these and related studies is
dependence or alcoholism. Secondly, it places that a screening instrument for general purposes
considerable emphasis on hazardous consump- should combine consumption and conse-
tion and firequency of intoxication compared quences questions (Barrison et al., 1982; Cutler,
with drinking behaviour and adverse conse- Wallace & Haines, 1988; Cyr & Wartman, 1988;
quences. It refers to alcohol experiences in the Persson & Magnusson, 1988; Babor et ai,
past year as well as lifetime experience. This 1989a).
improves its relevance to current drinking status. The unique feature of AUDIT is that it has
It does not require the individual to identify as a been derived from a cross-national data set. Only
problem drinker. The responses are not yes/no those questions which could be translated, liter-
ones but are based on the frequency of the ally and idiomatically, into multiple languages
experience, and range from 'never' and 'less than were included in the original assessment sched-
monthly' through to daily. It is anticipated that ule. Questions were selected on their repre-
800 John B. Saunders et al.
sentativeness in the pooled data set and checks which form AUDIT were embedded within the
were made to ensure that none performed poorly assessment schedule and were not administered
in an individual national sample. The sensitivity separately. An individual's response to questions
and specificity of AUDIT (Tables 4 and 5) are which are grouped together may differ from
similar from country to country, and there is no when they form part of a larger schedule. In
evidence of dominance by one particular culture practice, however, AUDIT may be used more
as judged by these parameters. Experience using fi-equently when embedded within a broadly-
existing screening instruments in other cultures based lifestyle questionnaire than as a discrete
has often been unsatisfactory. Only five of the 31 alcohol screening instrument. Secondly, a com-
criteria in the Munich Alcoholism Test, derived posite question was formed to inquire of concem
in Germany, were found to be 'relatively firee of shown by family or health professionals. Thirdly,
cultural differences' when the test was applied in the response categories for the two questions on
Spain and Ecuador (Gorenc et al., 1984). Use of alcohol-related problems differ from those used
an alcoholism questionnaire in an Alaskan Es- in the assessment instrument. Finally, the criteria
kimo population resulted in 75% of the adult against which AUDIT was judged (e.g. haz-
population being classified as 'probable alco- ardous consumption, abnormal drinking
holics', a proportion considered to be far in behaviour, alcohol-related problems) are repre-
excess of actuality (Klausner & Foulks, 1982). sented in it. Validating a new screening test by
The problem is less when there is careful selec- reference to a broader assessment schedule
tion of items and adequate checks on translation: which incorporates the same key elements may
the MAST discriminated well between alcoholic result in classification accuracy and validity
and non-alcoholic subjects in an Italian sample coefficients being infiated (Babor & Kadden,
(Garzotto et al., 1988). One can be optimistic 1985). Nevertheless, the present study included
that AUDIT will prove useful in countries with an extemal criterion group (known alcoholics)
similar cultural, political and economic charac- and AUDIT performed well with this sample.
teristics to those represented in the present
It is now appropriate to submit the instrument
study.
to extensive field testing. A user's manual and
The validity of AUDIT was examined in rela- research agenda have been developed for this
tion to its ability to discriminate between persons purpose (Babor et al., 1989b). Among the ques-
with harmful or hazardous alcohol consumption tions that need to be answered are its accuracy
and those with non-hazardous consumption. and usefulness in different health care facilities,
This approach brings certain problems in its such as general practitioners' (family physicians')
wake. Definitions of hazardous alcohol intake, rooms, community health clinics, hospital outpa-
recurrent intoxication, abnormal drinking be- tient clinics, and inpatient services. It may also
haviour and alcohol-related problems had to be find a place in epidemiological surveys of general
established by the collaborating investigators (i.e. non-clinical) populations. Although the
since there were no intemationally agreed crite- countries represented in the present project were
ria at the time the analyses were undertaken. culturally diverse, it would be appropriate in the
They were based on the level of consumption or next phase of work to include additional cul-
harm above which intervention was judged to tures. The issue of whether AUDIT should be
be preferable to no intervention. A composite administered as it exists at present or incorpo-
reference standard was also defined which rated into a larger questiormaire which enquires
encompassed these entities and also included the of other lifestyle issues (such as diet, cigarette
presence of an alcohol-related disease and ac- smoking and exercise), merits exploration: a de-
knowledgement by the subject of a drinking gree of disguise to the purpose of screening may
problem. This reference standard was judged to facilitate accurate self-reporting. Ultimately, the
incorporate the key elements of hazardous and predictive validity of the instmment needs to be
harmful consumption, as defined by WHO and documented. Reassessment of sub-samples of
in the ICD-10 system, then in the process of subjects in the present study is presently being
development. undertaken three years after they were originally
interviewed.
Calculations of sensitivity and specificity in the
present report should be supplemented by re- At the outset of the study it was hoped to
sults of further field studies. The questions identify questions which did not mention alcohol
Development of AUDIT 801
instrument for use with hospitalised patients. New between different methods of detecting patients with
Zealand Medical Joumal, 97, pp. 111-115. excessive consumption of alcohol, Acta Medica Scan-
EWING, J. A. (1984) Detecting alcoholism—the CAGE dinavica, 223, pp. 101-109.
questionnaire, Joumal of the American Medical Associ- PoKORNY, A. D., MILLER, B . A. & KAPLAN, H . B .
ation, 252, pp. 1905-1907. (1972) The Brief MAST: a shortened version of the
FEUERLEIN, W . , RINGER, C, KUFNER, H . & ANTONS, Michigan Alcoholism Screening Test, American
K. (1986) The diagnosis of alcoholism—the Munich Joumal of Psychiatry, 129, pp. 342-345.
Alcoholism Test (MALT), Intemational Joumal of ROOM, R . (1988) Cross-cultural research in alcohol
Rehabilitation Research, 2, pp. 533-534. studies: research traditions and analytical issues, in:
GARZOTTO, N . , BARATTA, S., PISTOSO, S . & FACCIN- TOWLE, L . H . & HARFORD, T . C . (Eds) Cultural
CANI, C. (1988) Validation of a screening Infiuences and Drinking Pattems: A Eocus on Hispanic
questionnaire for alcoholism (MAST) in an Italian and Japanese Populations. NIAAA Research Mono-
sample. Comprehensive Psychiatry, 29, pp. 323-329. graph No. 19 (Washington, D C , US Govemment
GoRENC, K.-D., BRUNER, C . A . , NADELSTICHER, A . , Printing Office).
PACURUCH, S . & FEUERLEIN, W . (1984) A compari- ROSALKI, S. B . & RAU, D . (1972) Serum G G T activity
son of German, Spanish and Ecuadorian alcoholics in alcoholism, Clinica Chimica Acta, 39, pp. 41-47.
using the Munich Alcoholism Test (MALT), Ameri- RYDER, D . , LENTON, S., HARRISON, S . & DORRICOTT,
can Joumal of Drug and Alcohol Abuse, 10, pp. J. (1988) Alcohol-related problems in a general hos-
429-446. pital and a general practice: screening and the
GoTTESMAN, I. I. & PRESCOTT, C. A. (1989) Abuses preventive paradox. Medical Joumal of Australia, 149,
of the MacAndrew MMPI alcoholism scale: a critical pp. 355-360.
review. Clinical Psychology Review, 9, pp. 223-242. SAUNDERS, J. B. (1987) The WHO projects an early
HEDLUND, J. L. & VIEWEG, B . W . (1984) The Michi- detection and treatment of harmful alcohol con-
gan Alcoholism Screening Test (MAST); a sumption, Australian Drug and Alcohol Review, 6, pp.
comprehensive review, Joumal of Operational Psychi- 303-308.
atry, 15, pp. 55-65. SAUNDERS, J. B. & AASLAND, O . G . (1987) WHO
iNSTlTt/TE OF MEDICINE (1990) Broadening the Base of Collaborative Project on the Identification and Treat-
Treatment for Alcohol Problems (Washington, DC, Na- ment of Persons with Harmful Alcohol Consumption.
tional Academy Press). Report on Phase I: Development of a Screening Instru-
ISRAEL, Y . , HURWITZ, R . , NIEMELA, O . & ARNON, R . ment (Geneva, World Health Organization).
(1986) Monoclonal and polyclonal antibodies SAUNDERS, J. B. & FOULDS, K . (1992) Brief and early
against acetaldehyde-containing epitopes in ac- intervention: experience from studies of harmful
etaldehyde-protein adducts. Proceedings of the drinking, Australian and New Zealand Joumal of
National Academy of Sciences of the United States of Medicine, 22, pp. 224-230.
America, 83, pp. 7923-7967. SAUNDERS, W . M . & KERSHAW, P. W. (1980) Screen-
JACOBSON, G.R. (1983) Detection, assessment and ing tests for alcoholism: findings from a community
diagnosis of alcoholism: current techniques, in: study, British Joumal of Addiction, 75, pp. "il-AX.
GALANTER, M . (Ed.) Recent Developments in Alco- SAUNDERS, J. B., AASLAND, O . G . , AMUNDSEN, A. &
hoUsm, pp. 377-413 (New York, Plenum Press). GRANT, M . (1993) Alcohol consumption and related
KAPUR, B . M . & ISRAEL, I. (1984) Alcohol Dipstick—A problems among primary health care patients. WHO
Rapid Method for Analysis of Ethanol in Body Fluids Collaborative Project on Early Detection of Persons
(Toronto, Addiction Research Foundation). with Harmful Alcohol Consumption. I, Addiction,
KLAUSNER, S . Z . & FOULKS, E. F. (1982) Eskimo 88, pp. 349-362.
Capitalists: Oil, Politics and Alcohol (Totowa, NJ, SELZER, M . L . (1971) T h e Michigan Alcoholism
Ailanheld Osmun). Screening Test: the quest for a new diagnostic in-
KRISTENSON, H . , OHLIN, H . , HULTEN-NOSSLIN, strument, American Joumal of Psychiatry, 127, pp.
M-B., TRELL, E . & HOOD, B . (1983) Identification 1653-1658.
and intervention of heavy drinking in middle-aged SELZER, M . L . , VINOKUR, A. & VAN ROOIJEN, L . (1975)
men: results and follow-up of 24-60 months of long A self-administered Shon Michigan Alcoholism
term study with randomized controls. Alcoholism: Screening Test (SMAST), Joumal of Studies on Alco-
Clinical and Experimental Research (NY), 7, pp. 2 0 3 - hol, 36, pp. 117-126.
209. SKINNER, H . A., H O L T , S., SCHULLER, R . , ROY, J. &
LE G O , P . M . (1976) Le Depistage Precoce et Systema- ISRAEL, Y . (1984) Identification of alcohol abuse
tique du Buveur Excessif (Paris, Department using laboratory tests and a history of trauma. Annals
d'Alcoologie Therapeutic de Rion Laboratories). of Intemal Medicine, 101, pp. 847-851.
MACANDREW, G . (1965) The differentiation of male SKINNER, H . A., RINGER, S., SHEU, W . J. & ISRAEL, Y .
alcoholic outpatients from non-alcoholic psychiatric (1986) Clinical versus laboratory detection of alco-
outpatients by means of the MMPI, Quarterly Jour- hol abuse: the Alcohol Clinical Index, British Medical
nal of Studies on Alcohol, 26, pp. 238-246. Joumal, 292, pp. 1703-1708.
MAYFIELD, D . G . , M C L E O D , G . & HALL, P. (1974) STIBLER, H . , BORG, S . & JOUSTRA, M . (1986) Micro
The CAGE questionnaire: validation of a new alco- anion exchange chromatography of carbohydrate-
holism screening instrument, American Joumal of deficient transferrin in serum in relation to alcohol
Psychiatry, 131, pp. 1121-1123. consumption. Alcoholism: Clinical and Experimental
PERSSON, J. & MAGNUSSON, P. H. (1988) Comparison Research, 10, pp. 535-544.
Development of AUDIT 803
STOREY, E. L., ANDERSON, G. J., MACK, U., POWELL, WHITFIELD, J. B., HENSLEY, W. J., BRYDEN, D . &
L. W. & HALUDAY, J. W. (1987) Desialated trans- GALLAGHER, H . (1978) Some laboratory correlates
ferrin as a seroiogical marker of chronic excessive oi drin\^nghdh\K, Annals of Clinical Biochemistry, 15,
alcohol consumption. Lancet, i, pp. 1292-1294. pp. 297-303.
SWENSON, W. M . & MORSE, R. M . (1975) The use WILKINS, R. (1974) The Hidden Alcoholic in General
of a self-administered alcoholism screenng test Practice (London, Elek Science).
(SAAST) in a medical center. Mayo Clinical Proceed- WORLD HEALTH ORGANIZATION (1980) Problems Re-
ings, 50, pp. 204-208. lated to Alcohol Consumption. Report ofa WHO Expert
WALLACE, P., CUTLER, S. & HAINES, A. (1988) Ran- Committee. Technical Report Series No. 650 (Geneva,
domised controlled trial of general practitioner Worid Health Organization),
intervention in patients with excessive alcohol con- WORLD HEALTH ORGANIZATION (1992) Intemational
sumption, British Medical Joumal, 297, pp. 663-668. Classification of Diseases, 10th revision. Chap. 5.
WATERSON, E. J. & MURRAY-LYON, I. M. (1989) Mental and Behavioural Disorders due to Psychoactive
Screening for alcohol related problems in the ante- Substance Use (Geneva, World Health Organization),
natal clinic: an assessment of different methods, Wu, A., CHANARIN, I. & LEVI, A. J. (1974) Macrocyto-
Alcohol and Alcoholism, 24, pp. 21-30. sis of chronic alcoholism. Lancet, i, pp. 829-831.
Appendix
AUDIT
Questions 1-8 are scored 0, 1, 2, 3 or 4. Questions 9 and 10 are scored 0, 2 or 4 only. The response coding is as
follows:
0 1 2 3 4
Question 2 1 or 2 3 or 4 5 or 6 7 to 9 10 or more