Mobile phone technology for reduced drinking : novel methods for measuring alcohol consumption and treating alcohol dependence

Background: Studies on the use of smartphone applications (apps) to curb alcohol consumption are limited but increasing. Previous studies show promising effects, especially on samples in the general population. The aim of this thesis was to enhance the understanding of using apps within addiction treatment. The research questions ranged from estimating the effectiveness (Study I) and examining the perceptions of the users (Studies II and IV), to testing the agreement between app reports and traditional methods for measuring alcohol consumption (Study III), and assessing factors needed for successful implementation (Study IV).

Methods: The project was based on a randomised controlled trial (RCT). Alcohol-dependent patients with recent patterns of heavy drinking, no co- occurring drug dependence and limited psychosocial problems were recruited at an alcohol addiction clinic or by social media advertisements and were randomised to either treatment as usual (TAU) or TAU complemented with a drink-counting or breathalyser-coupled app for 12 weeks (Study I). TAU comprised four therapy sessions for 12 weeks, that could also be complemented with pharmacotherapy. Effects were measured at 12 weeks (post-intervention) and 26 weeks after randomisation (follow-up). The primary outcome was heavy drinking days in the past month at 26 weeks. A purposive sample of 21 participants that had used the apps later partook in individual interviews on their experiences (Study II). The apps were further tested in a subsequent study where app-based data (e.g., number of drinks, drinking days and heavy drinking days) were compared with traditional methods for assessing consumption (e.g., Timeline FollowBack) (Study III). Since the two apps were linked to online portals that shared data with clinic staff, focus group discussions were undertaken to explore clinicians' views on incorporating the apps into their treatment delivery (Study IV).

Results: Results from Study I showed that the breathalyser-coupled app given as a complement to TAU was more effective than TAU alone in reducing heavy drinking days at 26 weeks (30-33 % lower rate). In Study II, results showed that the apps were considered relevant and helpful adjuncts to TAU by the patients. Nonetheless, app usage was hindered by primarily technical problems but also non-personalised procedures and features and usage among other people. Similarly, in Study IV, the clinicians believed that the apps offered several advantages for their patients, and that the portals could provide valuable support during treatment sessions. However, the breathalyser was considered unreliable, which further was believed to affect both their own, and their patients', motivation for sustained use. In Study III, it was found that the data from the drink-counting app, but not the breathalyser, well agreed with consumption reported in TLFB and PEth. For the successful implementation of the apps, Study IV found that ensuring their technical stability, protecting data security, and identifying patients at risk of adverse events were considered crucial. Additionally, several other factors, including education, support, additional time, and continuity, were deemed essential.

Conclusion: Taken together, the results of this thesis show that a breathalyser- coupled smartphone application may be effective in reducing heavy drinking, and that a drink-counting app may be a useful and available tool for reporting alcohol consumption. Both apps have relevant features considered useful in treatment and provide an opportunity to enhance patient accountability in the change process. A person-centred approach is essential when using the smartphone-based interventions within addiction treatment, along with ensuring the necessary conditions (e.g., guidance, support, workflow and time management) for clinicians to effectively utilise the tools. Technical issues with the apps are a main barrier to their reliability and use and must be resolved before they can be integrated into routine care.

List of scientific papers

I. Östh, J., Lundin, A., Wennberg, P., Andréasson, S., & Danielsson, A. K. (2025). The effectiveness of a drink-counting and a breathalyser- coupled smartphone application for reduced heavy drinking among alcohol-dependent adults in Sweden: a randomised controlled trial. Addiction.
https://doi.org/10.1111/add.16769

II. Östh, J., Danielsson, A. K., Lundin, A., Wennberg, P., Andréasson, S., & Jirwe, M. (2024). Keeping Track of My Drinking - Patient Perceptions of Using Smartphone Applications as a Treatment Complement for Alcohol Dependence. Substance Use & Misuse, 59(2), 291-299.
https://doi.org/10.1080/10826084.2023.2269578

III. Östh, J., Lundin, A., Wennberg, P., Andréasson, S., & Danielsson, A. K. Measuring alcohol use: Comparing instant smartphone application- based reports with Timeline Followback, Alcohol Use Disorders Identification Test Consumption, and Phosphatidylethanol. [Manuscript]

IV. Östh, J., Lundin, A., Wennberg, P., Andréasson, S., & Danielsson, A. K. Clinicians' Perspectives on Integrating Smartphone Application Data into Routine Alcohol Dependency Treatment: Factors Influencing Implementation. [Manuscript]