https://orcid.org/0000-0001-9147-783X
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Abstract
Background
Alcohol use is an important cardiovascular risk factor and a major contributor to morbidity and mortality. Successful implementation of alcohol interventions in cardiology depends on patient acceptability.
Objective
To understand patient perspectives on the feasibility of implementing alcohol interventions in cardiology services.
Methods
Multi-site qualitative study. We conducted semi-structured interviews with a heterogenous-purposive sample of 15 adult cardiology patients with hazardous alcohol use. Participants were recruited from three geographically diverse regions in Sweden (Dalarna, Gävleborg, Stockholm) and were varied in terms of sociodemographic characteristics, cardiovascular diagnosis, risk factor profile, and level of alcohol use. We applied the Capability, Opportunity, Motivation and Behaviour (COM-B) system during coding and conducted a reflexive thematic analysis.
Results
We identified 56 feasibility factors: 15 related to capability, 10 to opportunity, and 31 to motivation. Four themes emerged: 1. Alcohol use as relevant to cardiology, where participants recognized cardiovascular risk factors, expressed motivation for change, and identified a need to address alcohol use sensitively; 2. Aligning interventions with expectations and goals, where participants linked acceptability of alcohol interventions to personal goals and social norms; 3. Morbidity and shifting priorities, where participants prioritized quality of life and respect for autonomy; 4. Addressing barriers to alcohol dependence treatments, where participants saw a need to improve access to care.
Conclusions
Findings suggest that alcohol interventions are acceptable to cardiology patients with hazardous alcohol use. Implementation strategies that prioritize quality of life, respect autonomy, and align with individual expectations and goals may be among the most acceptable. We also identified an opportunity to improve access to treatments for alcohol dependence within multidisciplinary heart teams or hospital-based addiction care services.
Citation: Welfordsson P, Danielsson A-K, Björck C, Grzymala-Lubanski B, Hambraeus K, Löfman IH, et al. (2025) Alcohol use as a modifiable risk factor in cardiology: A qualitative study of patient perspectives in Sweden. PLoS One 20(8): e0328990. https://doi.org/10.1371/journal.pone.0328990
Editor: Buna Bhandari, Tribhuvan University Institute of Medicine, NEPAL
Received: November 21, 2024; Accepted: July 9, 2025; Published: August 4, 2025
Copyright: © 2025 Welfordsson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The dataset analyzed in the current study is not publicly available due to the sensitive and potentially identifiable nature of the qualitative interview data. Even after pseudonymization, there remains a risk of participant identification due to the depth and context of the interviews. Participants did not provide consent for their full transcripts or detailed data to be shared publicly, and sharing of transcripts is not permitted under the study’s ethical agreement. Data requests should therefore be directed to the Swedish Ethical Review Authority (Etikprövningsmyndigheten): Box 2110, 750 02, Uppsala; email registrator@etikprovning.se.
Funding: This work was supported by the Swedish Research Council for Health, Working Life and Welfare (FORTE) (grant number: 2021-01710), awarded to SWF, AKD, CB, BGL. The funder had no role in the study design, the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the manuscript for publication.
Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: FB is a member of the adverse event adjudication committee for Medtronic and Biotronic. FB has collaborated with industry through service contracts signed with his employer – Karolinska University Hospital – but no payment has been directly transferred to FB as a result of these activities. SWF receives book royalties for “Åter till kontrollerat drickande – en handbok för kliniker” [Controlled drinking – a handbook for clinicians] from Studentlitteratur and ”Missbrukspsykologi” [Addiction Psychology] from Liber. This does not alter our adherence to PLOS ONE policies on sharing data and materials.
Introduction
Alcohol use is an important modifiable cardiovascular risk factor and a major contributor to morbidity and mortality [1]. Healthcare interactions represent an opportunity to identify hazardous alcohol use and to offer interventions. The World Health Organization (WHO) recommends screening and brief interventions (SBI) as a population-based strategy to address hazardous alcohol use [2]. Since 2021, European cardiology guidelines have recommended that patients should be screened for alcohol use in all medical evaluations [3], yet evidence suggests that SBI is implemented inconsistently in clinical practice [4,5].
Alcohol screening typically involves the use of self-reported assessment methods, such as the WHO Alcohol Use Disorders Identification Test (AUDIT) questionnaire [6]. However, interest is growing in the use of objective, biomarker-based screening methods such as phosphatidylethanol (PEth) [7]. While questionnaire or biomarker screening can identify candidates for interventions, successful implementation depends on patient acceptability [8,9].
Patients who screen positive for hazardous alcohol use should be offered brief interventions (BIs) [10,11], which typically consist of motivational interviewing and can be delivered by non-specialist clinicians in around 5–10 minutes [12,13]. In practice, however, SBI activities can vary considerably, and may include standardized questions about alcohol use during clinical history taking, or informal conversations about lifestyle habits while performing investigations [14]. Meta-analyses indicate that BIs have modest, positive effects in general hospital settings [15,16], yet there is a paucity of studies evaluating their feasibility in cardiology. In previous research, we identified clinician-related barriers and facilitators to SBI in cardiology [17], but patient perspectives have not been studied. Findings from general hospital and primary care settings indicate that patients consider clinicians’ communication skills, the clinical environment, and the timing of SBI to be important factors affecting acceptability, yet it is unclear whether these issues apply in a cardiology context [18]. There is also evidence that individuals with hazardous drinking may experience conversations about alcohol use as uncomfortable [19,20]. There is a need to understand patients’ views and preferences to improve the implementation of BIs [21,22].
Patients who have symptoms of alcohol dependence – such as impaired control of alcohol use or a compulsion to drink – warrant diagnostic evaluation, and may require treatment for alcohol dependence [12]. Such patients may be referred to alcohol services, yet evidence suggests that many referrals do not lead to treatment [23]. It is important to understand patients’ perspectives to improve addiction services in hospital settings and bridge this care gap [24].
Patients’ views on the acceptability of alcohol interventions in cardiology may be shaped by their perceptions of alcohol as a cardiovascular risk factor [20,25,26]. Such perceptions are shaped by personal experiences, sociocultural contexts and media sources – a phenomenon known as lay epidemiology [27,28]. Pleasure and perceived social advantages are widely reported motivations for drinking alcohol [29–31]; lay epidemiology theory suggests that drinkers balance these supposed benefits against any perceived negative consequences of alcohol, including risks to health, and was applied in this study.
The application of theory in behavioural change studies provides a structure for optimizing interventions and implementation strategies. The Theoretical Domains Framework (TDF) synthesizes existing behavioural change theories and was refined by Cane and colleagues in 2012, who mapped each of its 14 domains to one of three pillars in a complementary model – the Capability, Opportunity, Motivation and Behaviour (COM-B) system – to develop an integrative model for cross-disciplinary implementation research [32]. The COM-B system is a widely-used framework that defines three inter-related factors required for a given behaviour: 1) Capability – an individual’s ability to enact a specific behaviour; 2) Opportunity, or external factors that contribute to a behaviour, and; 3) Motivation – cognitive processes affecting engagement in that behaviour [33]. Together, the TDF and COM-B provide an empirical basis for investigating implementation challenges and informing the development of effective interventions.
The aim of this study was to apply the COM-B framework to understand the feasibility of implementing alcohol interventions in cardiology services from patients’ perspectives. We answered the following research questions:
- How do cardiology patients with hazardous alcohol use describe the acceptability of SBI and alcohol dependence treatments?
- What views and preferences do these patients express regarding possible interventions?
Methods
Study design and ethical considerations
This qualitative study conformed to the Standards for Reporting Qualitative Research (SRQR, S1 File) [34]. A study protocol is publicly available [35]. The study was approved by the Swedish Ethical Review Authority (2022-02059-01).
Participation involved discussing sensitive personal information, such as alcohol use and health, which may trigger distress. To mitigate these risks, participants were informed about interview topics prior to providing verbal consent, and a clinical psychologist (SWF) was available to support any participants who experienced distress. Participants received written information about the study and provided verbal consent by responding to standardized consent statements which were audio-recorded prior to commencing interviews. Consent procedures were approved by the Swedish Ethical Review Authority. Interviews were conducted in private environments, and interviewers were not involved in patient care. Study materials were available in Swedish and English.
Participants and setting
We included a heterogenous-purposive sample of 15 cardiology patients at hospitals in three geographically diverse regions in Sweden: Stockholm (n = 4), Sweden’s capital city; Gävle (n = 9), a medium-sized town, and Falun (n = 2), a small town/rural area. Eligibility criteria included: Age ≥ 18 years; hazardous alcohol use, defined as AUDIT scores ≥6 in women or ≥8 in men [11]; consenting to an individual interview; no physical, cognitive or mental health problems preventing interview participation; Swedish or English speaker.
Most participants (n = 12) were recruited from inpatient cardiology wards, while two were recruited from ambulatory care and one from an outpatient clinic. Participants had AUDIT scores ranging from eight to 23 points; Five had AUDIT scores that indicated probable alcohol dependence (≥13 in women or ≥15 in men). The burden of cardiovascular disease (CVD) varied widely, with diagnoses ranging from atrial fibrillation to multi-cardiovascular morbidity and advanced heart failure. Similarly, participants’ risk factor profiles ranged from isolated hazardous drinking to clusters of unhealthy lifestyle habits (Table 1).
Researcher characteristics
The research team included: a PhD student who is a medical doctor from the UK and who was the primary analyst (PW); a clinical psychologist with a background in clinical addiction treatment and a PhD in alcohol research who was second analyst (SWF). Additional analytic input was provided by: a public health scientist and alcohol researcher with a PhD (AKD); a clinical psychologist and researcher with a PhD and experience of hospital-based healthcare (CB); consultant cardiologists with PhDs (BGL, KH, IHL, FB), and a specialist cardiology nurse with a PhD (ML).
Procedure
Recruitment
Potential participants were identified during a previous study that assessed lifestyle factors (alcohol use, smoking, diet, physical activity, BMI) among cardiology patients in Sweden [36]. Those with hazardous alcohol use were given the opportunity to participate in an individual interview and asked to provide contact details if interested: Of 1107 survey participants, 86 (7.8%) had hazardous alcohol use, 60 were asked to express interest in interview participation, 20 provided contact details, and 15 completed an interview.
PW contacted potential participants to assess their eligibility and to provide verbal and written information about the study. Participants were offered two cinema tickets for interview completion. Interviews were conducted between 1st December 2022–31st August 2023.
Data collection
Individual, semi-structured interviews were conducted in Swedish, either face-to-face at the hospital, or by telephone (by PW and SWF). Interviews followed an a priori topic guide (S2 File interview guide) and took around 30 minutes. We aimed to use lay terminology that was readily understandable by patients. Certain necessary jargon, such as ‘cardiovascular risk factor’, was explained to participants, however we did not differentiate between the concepts of screening, BIs, and treatment during conversations with patients. Rather, these concepts were inferred from participants’ responses. We defined screening as questions or other methods used to identify alcohol use and applied a broad definition of BIs, namely all structured conversations between patients and clinicians or other time-limited methods used to motivate individuals to reduce alcohol use. Alcohol treatment was defined as more intensive methods to address alcohol dependence, such as medication prescription or psychological treatments. Interviews were audio-recorded and transcribed verbatim.
Stopping criteria
We conducted preliminary assessments of emerging data and applied the principles of information power [37]. Sample size was thus dependent on: 1) Variation in gender, age, socioeconomic position, AUDIT score and region; 2) The depth of interview discussions (‘data richness’); 3) The extent to which data could be mapped to a deductive codebook (described below); 4) The frequency with which emergent (inductive) codes were identified. In this context, information power reflects the adequacy of the sample to support meaningful theoretical insight, rather than relying on numeric sufficiency or thematic saturation alone. In practice, our sample of 15 participants was a compromise between the principles of information power and participant availability.
Analysis
We conducted a reflexive thematic analysis [38]. We applied a deductive-inductive, three-phase, iterative approach to coding. First, PW processed all interview transcripts, assigning data systematically to top- and second-level codes using an a priori deductive codebook (S3 File a priori codebook) that consisted of COM-B ‘sources of behaviour’ (capability, opportunity, motivation; first-level codes) [33], mapped to the TDF (second-level codes) [32,39]. Simultaneously, we analyzed text inductively, applying lay epidemiology theory to identify emergent codes. In practice, this involved highlighting responses that were based on personal experiences, sociocultural contexts, and anecdotal reports, rather than formally-acquired knowledge. We aimed to assign all relevant interview material either to our deductive codebook or to emergent codes, which were agreed with a second analyst (SWF). Third-level codes (feasibility factors) were provisionally named, described, and added to the deductive coding matrix, while emergent codes were refined, expanded upon, and transferred to the deductive codebook where relevant. PW and SWF completed a joint round of coding to assess support for these codes within the empirical data. During this stage of analysis, we were able to map all codes – both deductive and inductive – to COM-B and the TDF, to compile a single, complete study codebook, which was agreed by consensus with the research team. Finally, third-level codes were analyzed inductively to identify shared meaning, grouped, and condensed into themes. These were named, described and reported as a narrative summary with selected quotations. We used Nvivo (release 1.7.1) to assist data analysis.
Results
Feasibility factors, according to COM-B
We identified a total of 56 feasibility factors, which we mapped to COM-B and the TDF. These included 15 codes related to capability, 10 to opportunity, and 31 to motivation. These feasibility factors are described in detail, with supporting quotations, in Table 2.
Themes
We identified four themes. These are summarised in Table 3 and are discussed in detail below.
Theme 1: Alcohol use as relevant to cardiology
In general, SBI was viewed as relevant to cardiology and as a helpful reminder to reflect on drinking habits. Participants felt comfortable discussing alcohol use with clinicians – in some cases more so than with family members. Support from clinicians was appreciated, and SBI was perceived as well-intentioned and helpful. Moreover, participants noted experiencing increased motivation to modify their drinking following cardiovascular events, in preparation for medical treatments, and after being diagnosed with conditions exacerbated by alcohol, such as atrial fibrillation.
“I’ve really been reconsidering things while I’ve been lying here these last few days… Maybe this was what I needed. Health and living, that’s the most important thing. That is the best motivation. You only have that. You only have one life, that’s how it feels. So now I’ve had a nudge in the right direction.” (Carina)
While SBI was reported to be acceptable by most participants, others expressed a degree of ambivalence, or resignation associated with experiencing CVD. In some cases, participants’ statements were suggestive of possible underlying depression.
“The thing is, if you feel no hope… then you might resort to various ‘cheats’, like a glass of wine with your pasta on Friday - It’s a bit nicer than not having a glass of wine. And then if it’s nice, maybe two glasses of wine. It becomes an escape if you are not feeling good.” (Johan)
Participants generally placed a high degree of trust in cardiology clinicians. Doctors were regarded as particularly well-placed to administer SBI and one participant suggested that doctors’ advice may carry additional weight. However, clinicians’ knowledge and skills were considered more important than their profession, and participants placed value on seeing the same clinician. There was also a strong tendency for participants to report acquiring knowledge about CVD risk factors from clinicians, rather than from online or media sources.
Participants identified opportunities for SBI during healthcare interactions and reported that SBI should be integrated within cardiology. Many expressed that screening should occur early in the care-flow process, although the importance of handling alcohol use sensitively was also strongly emphasized. Some participants expressed a fear of being stigmatized regarding their drinking, although – reassuringly – none of the participants reported discrimination or unfair treatment from healthcare staff. Nevertheless, participants indicated a need for privacy and suggested that the outpatient clinic may be a more appropriate environment for BIs than the open ward.
“If we are going to talk about personal things (alcohol use), then you shouldn’t sit in an open ward – in that case you should do it in a private room. […] The nurse or the doctor, well they’re bound by confidentiality, I guess.” (Stefan)
Participants emphasized the importance of effective communication and tended to prefer verbal interviews to questionnaire-based methods or digital screening tools. While one participant noted that questionnaires may provide a more complete picture of alcohol use, others reported difficulty estimating their alcohol consumption. Participants were also open to the use of biomarker screening methods – such as PEth blood tests – although once again, the importance of careful and sensitive implementation was emphasized. Biomarkers were perceived as providing a robust basis for interventions, and as a useful way to open the conversation around alcohol. Participants reflected that positive biomarker screening results may increase motivation for change, while negative screening results may offer reassurance. However, participants emphasized the need to respect autonomy and voiced concerns that biomarker screening may be perceived as an invasion of privacy. The need for transparency was emphasized, with informed consent being obtained before blood tests.
“Based on a (PEth) blood test you can have a conversation about that it shows a high consumption of alcohol… Instead of answering a questionnaire, because that’s extremely difficult – there are these measures, and you have to count up the centiliters. It’s impossible because it’s all so different.” (Susanne)
Participants viewed alcohol use as an important CVD risk factor and said that they expected to be asked about drinking, smoking and other lifestyle habits. Prescribing encounters were identified as opportunities for SBI; participants reported increased motivation to modify their drinking in light of possible interactions with new medications.
“You can’t (drink) with this medicine. You have to go without alcohol for at least two weeks […] Not one glass of wine […] because then it can really get crazy, they said […]. And you can’t lie about that – then it becomes dangerous.” (Carina)
Theme 2: Aligning interventions with expectations and goals
Participants’ views and preferences highlighted the importance of aligning interventions with patients’ expectations and goals. Participants were generally aware of their own hazardous alcohol use, suggesting that generic interventions which focus on general health risks and drinking guidelines may fail to address individuals’ specific drivers of alcohol use. A range of motivations for alcohol use were cited, including pleasure, socialization, and celebration. Similarly, participants’ motivations for cutting down were not limited to health; two participants cited economic reasons. While participants were generally well-informed about potential negative health consequences of alcohol consumption, two participants reported drinking alcohol due to its perceived medicinal effects, including as an alternative to sleeping pills.
“If I have a glass of wine or something, then I can fall asleep without (atrial) fibrillation. I think it has a calming effect […]. Perhaps if I’d had a sedative tablet it would have had the same effect. It’s helped me in a way, but still, I’ve gotten very high blood pressure instead. So that’s not good.” (Erik)
Participants demonstrated knowledge of a range of CVD risk factors, although there appeared to be some variation in how the concept of risk was interpreted. Participants tended to focus on mitigating short-term risks when cutting down, such as avoiding hangovers and improving general wellbeing – rather than on modifying longer-term CVD risks. In addition to healthcare sources, participants’ knowledge of risk factors was often derived from personal experiences, or those of family and friends. These personal experiences tended to align with participants’ individual expectations and goals for CVD prevention, for example aiming to losing weight with the expectation of improving mobility or preventing diabetes.
“I could get diabetes, and you can also get CVD if you are severely overweight – I weighed 140kg. And that’s too much [...] My mother and father died from it.” (Carina)
Many participants identified interactions between lifestyle factors, such as the calorie-dense nature of alcoholic beverages or the tendency to drink less when exercising regularly. This suggests that there may be advantages to embedding SBI in multi-lifestyle CVD interventions that target patients’ self-reported goals.
“Alcohol is a culprit regarding to the kilos, especially when it comes to the beers.” (Bengt)
Participants reported overlooking their unhealthy lifestyle habits when well, and generally regarded other CVD risk factors, such as smoking, obesity, and physical inactivity, as being more important than alcohol use. However, all participants recognized that excessive alcohol consumption can be detrimental to health, and several participants reported feeling motivated to make lifestyle changes to minimize harm. While participants’ responses highlighted a need to consider individual motivations for alcohol use, responses also indicated a need to adapt SBI to societal norms, attitudes and values. For example, participants tended to normalize alcohol use in certain contexts, such as in social situations, with meals, or at weekends. In the same way, drinking wine or beer rather than spirits – particularly at levels that do not lead to visible intoxication – was generally viewed as acceptable.
“I almost never drink on weekdays, but I do drink at parties. And […] maybe a bottle of wine with dinner […]. I only drink alcohol in positive contexts.” (Annika)
Theme 3: Morbidity and shifting priorities
Participants’ responses highlighted changes in alcohol use across the life course, and shifting priorities associated with multimorbidity in later life. Participants with advanced illness described two opposing directions in which age and morbidity may affect the acceptability of SBI. On the one hand, several participants described a deterioration in taste and a reduced tendency to drink alcohol – the so called ‘sick quitter’ effect. These participants described morbidity as a trigger to reconsider their drinking habits, and were generally open to SBI.
“Since I became ill, I think about it more when I drink. Maybe I won’t take that extra half glass of wine, or that whiskey, but instead I’ll stay at a level that feels comfortable and cosy.” (Susanne)
On the other hand, some participants reported lacking the energy required to successfully make lifestyle changes and feeling “too old” for SBI. These participants commented that SBI is more relevant during healthcare assessments for younger people.
“Say I’d been ten years or 20 years younger, then, hell, I would have tried how to quit because I would have 30 or 40 years left. But as a 67-year-old; Many people say, you fight to become smoke- and alcohol-free, it takes several years. And that is quite impossible. That’s why I think healthcare should take these tests, yes, when you’re younger and then continue now.” (Susanne)
Older and sicker participants tended to prioritize quality-of-life over harm reduction, and were generally less accepting of SBI. While most participants were aware that their level of alcohol use was associated with health risks, older and sicker participants tended to view these risks as less important than aspects such as the taste of alcoholic beverages or pleasure derived from drinking them.
“I don’t know how much time I have left to live. I think I can enjoy [laughs] what I do.“(Lena)
Nevertheless, many participants pointed out that their alcohol use had changed over time, often unintentionally. Retirement was noted as a common trigger for changes in alcohol use and may be an important opportunity for SBI; some participants reported increasing their alcohol use due to having more free time (“it’s Friday everyday”) and less responsibility to drive. Others reported a reduction in alcohol consumption after retirement, and pointed to the availability of alcohol and pressure to drink in certain jobs, such as those in the hospitality sector as risk factors for alcohol use. Changes in alcohol use were also reported in relation to disrupted social networks following retirement and isolation during the COVID-19 pandemic.
“I know it’s harmful for me to drink, but I have nothing to do all day. I just sit alone at home.” (Thomas)
Increasing symptom burden and stressful life events were reported as important drivers of alcohol use, and participants’ responses suggest that it may be important to acknowledge these during SBI. Participants reported experiencing physical and mental ill health that had resulted in profound losses of mobility and erosion of personal independence – limitations that prevented participation in non-drinking activities. Some participants who had experienced traumatic events tended to view these as antecedent factors, or triggers that provided a rational explanation for alcohol use. These participants tended to view SBI as less relevant to cardiology care.
“I used to drink more… I had a partner who died four years ago […] Then I increased my alcohol consumption a bit. But now it has gotten better.” (Per)
Overall, the importance of respecting autonomy and protecting choice was emphasized. Participants articulated their wishes to exercise control over their lives, in some cases by choosing to drink alcohol when other hedonic activities were no longer possible.
“I also think that one should respect, for example, ‘no, I can’t stop smoking”’ or ‘I choose to live this way”. So you don’t get nagged about it. (Annika)
Theme 4: Addressing barriers to alcohol dependence treatments
Participants whose AUDIT scores indicated probable dependence described additional challenges with regards to alcohol use, such as cravings and a loss of control of drinking. These participants perceived barriers to alcohol dependence care, such as issues with self-reported screening methods, ambivalence regarding external help, and limited access to pharmacological treatments. Participants preferred direct questions about alcohol use, which were believed to facilitate accurate self-reporting. Participants stressed the importance of honest self-reporting, suggesting that this is an important step in exercising control over alcohol use. In some cases, openness about alcohol problems appeared to be source of pride for participants, perhaps reflecting a belief that they had ‘taken ownership’ of their drinking. Interestingly, several participants asserted that they always respond honestly to questions about alcohol use, yet suggested that others may not.
“My guess is that most people either underreport their (alcohol) consumption, or deny it, because it is shameful to admit it. I’ve never kept it a secret – I’ve said it openly. ‘I have drunk alcohol. Yes, I drink alcohol’.” (Hans)
Alcohol biomarkers were conceptualized as a useful tool which can help patients to overcome inaccurate or dishonest self-reporting of alcohol use – widely perceived as a barrier to treatment – by flagging the possibility of excessive alcohol consumption to clinicians. It was also suggested that cardiology patients may be more likely to disclose alcohol use to doctors than to other clinicians – possibly reflecting concerns that withholding this information may compromise the medical team’s ability to provide effective care.
“You have to be honest. Why lie about things when you are trying to get treatment? It doesn’t work […] You have to be honest because then you can receive the right care.” (Stefan)
Some participants expressed views that patients have a personal responsibility to seek help, and that those with alcohol dependence may struggle to acknowledge their own drinking. Nevertheless, responses generally suggested that SBI remains acceptable to those who believe that external help is not needed, and to those who prefer to manage their alcohol use independently.
“The doctors were very clear with me (about alcohol use) and I’m grateful for that, but it’s up to me in this case. Healthcare staff cannot give treatment... Well, they can make suggestions, but... yes” (Susanne)
Participants with probable alcohol dependence reported experiencing a range of alcohol dependence treatments, including support groups, psychological treatments, medications, and residential treatments. Overall, these participants reported a need for improved collaboration between cardiology services, addiction care, and primary care. In particular, participants highlighted a role for improved access to pharmacological treatments, and expressed a preference for this to be available at the cardiology department.
“I’d be happy if I got it (pharmacological treatment) at once […] even if it’s from a cardiologist. It would be easier to get it here, because… if, when I’m being discharged, they say, “Ok, now you can go to the addiction treatment centre”, then I will promise to go there. But then, before I get there, I might have different idea. So, it’s better to prescribe it here.” (Erik)
Discussion
This qualitative study mapped cardiology patients’ views on SBI to the COM-B system. In general, SBI was acceptable, and participants identified implementation opportunities within routine care. Four themes emerged: alcohol use as relevant to cardiology; aligning interventions with expectations and goals; morbidity and shifting priorities, and addressing barriers to alcohol dependence treatment. Overall, participants highlighted the importance of effective communication and of individualizing preventive cardiology.
Our finding that cardiology patients with hazardous alcohol use view SBI as acceptable is consistent with studies in general hospitals [18,20,40], primary care [41–43], and in the general public in Scandinavia [44]. These results are further consistent with a broader picture of acceptability regarding lifestyle modification strategies [45], including smoking cessation [46] and dietary interventions, in cardiology settings [47]. Our study identified challenges surrounding self-reported measures of alcohol use, yet participants were generally accepting of questionnaire and biomarker screening methods – a finding also reported in primary care [48,49]. Like those studies, our findings highlight the importance of handling SBI sensitively. Earlier work suggests that some patients experience discomfort when discussing alcohol use [20], and that risky drinkers may have negative attitudes towards discussing alcohol with clinicians [19,50]. Groves et al reported that patients felt that doctors were dismissive of their alcohol problems, and preferred interactions with nurses [18]. In contrast, participants in our study described positive healthcare experiences, and considered doctors well-placed to administer SBI. This may suggest that alcohol stigma is reducing, or is context specific. Our findings balance clinicians’ concerns about being perceived as judgemental or of harming the clinician-patient relationship [17]. Still, participants emphasized the importance of clear communication and privacy, suggesting that the outpatient cardiology clinic may be an appropriate context for BIs. Nurse-led outpatient consultations may be a particularly promising environment for BIs, since cardiology nurses may already be skilled in behaviour change strategies such as motivational interviewing. Given that cardiologists are typically responsible for prescribing medications and other medical aspects of care, outpatient cardiology nurses may also have more time to dedicate to addressing lifestyle habits such as alcohol use.
Our findings highlight the importance of tailoring SBI to the individual, a finding also reported by Groves et al [18]. Participants recognised that alcohol use has negative health consequences, were generally aware of their own hazardous use, and described a range of motivations for reducing consumption. These motivations were typically related to participants’ lived experiences and included weight loss and saving money; incentives that were also reported in the Alcohol Toolkit Study [51]. Participants also drew on pervasive norms, attitudes, and values surrounding alcohol. For example, binge drinking at parties was viewed as less problematic than drinking alone at home – a phenomenon also reported in Australia [52] – despite conferring equivalent somatic health risks. Our findings suggest that, to ensure relevance to patients, BIs should be embedded in multi-lifestyle interventions that target patients’ self-reported goals, and should strike a balance between addressing the quantity of alcohol consumed, the context in which drinking takes place, and the consequences of alcohol use. Cardiac rehabilitation programmes may be an appropriate setting for such interventions, given their multi-modal nature.
We found that older and sicker participants, particularly those who believed they were approaching the final years of their life, were generally less accepting of SBI, and tended to prioritize pleasure, “quality of life”, and self-determination, over harm reduction. This finding has been reported previously [53,54] and is consistent with lay epidemiology theory, which suggests that subjective experiences are an influential contributor to risk perceptions and health behaviours [27]. Additionally, we found that some older patients believe that it is ‘too late’ to cut down, a finding that has been reported previously [55]. Importantly, this belief is not supported by empirical evidence; Studies report favourable outcomes with SBI among older adults [56], and the American Heart Association recommends multi-component behaviour change interventions for middle-aged and older adults [57]. Nevertheless, our findings emphasize that SBI should be tailored to the individual [43], and suggest that quality of life may be an important discussion point with cardiology patients.
Our study illustrates the breadth of needs among cardiology patients with hazardous alcohol use, and suggests that there is an opportunity to integrate alcohol dependence treatments into cardiology, for example in a multidisciplinary heart team or hospital-based addiction care service [24]. Such care may include pharmacotherapy, which is underutilized in clinical practice [58,59]. Participants’ experiences mirrored earlier work that casts doubt on the effectiveness of referring patients to addiction services, with many failing to receive treatment [60]. These findings are consistent with results from a qualitative study of cardiology clinicians in Sweden [17] and reinforce wider calls to strengthen addiction care in general hospital settings [24].
An emerging approach to SBI involves screening for alcohol use with PEth [49], – a direct biomarker of alcohol consumption – to obtain an objective indication of alcohol use over the previous 2–4 weeks [61]. A major advantage of PEth is that screening results are not susceptible to underreporting and recall bias. However, ethical and legal aspects must be considered carefully before widespread implementation of biomarker-based alcohol screening methods [62]. Possible patient concerns, such as disruption to the healthcare staff/patient relationship or feeling stigmatized also need to be taken into consideration.
Our findings are from a Swedish context and we note that the acceptability of SBI may vary internationally [50]. However, a degree of transferability is anticipated. For example, increasing symptom burden in older age is a common problem in countries with aging populations, and barriers to alcohol dependence treatments are reported widely, with the majority of those affected not receiving care [63,64].
Strengths and limitations
Study strengths included recruitment of adults with hazardous alcohol use – a group that tends to be underrepresented in research. However, while we applied the principles of information power, we acknowledge that our sample of 15 interviews may not capture the full heterogeneity of patient perspectives across underrepresented groups or different cultural norms regarding alcohol use. A further limitation was that we did not manage to recruit younger participants, even though hazardous alcohol use is more prevalent among younger cardiology patients [36]. Our findings thus reflect the views of older adults and may not be consistent with those of younger patients or those who are not receiving hospital-based care. We also note that the views of participants may differ from those who declined to participate. This may have introduced bias into our results, since awareness of hazardous drinking and perceptions of stigma may have influenced participants’ views on SBI acceptability, as well as their decision to participate in a research interview. Interpretative limitations included our intentionally broad definitions of alcohol screening and BIs, which aimed to facilitate a wider dialogue around SBI but may have led to confusion among some participants. We also note that participants had hazardous alcohol use, and that non-drinkers’ views on SBI may differ. However, previous studies indicate that acceptability for SBI is high among general hospital patients [40,45] – our study adds evidence that this may also be the case among cardiology patients with hazardous alcohol use.
Conclusions
This study suggests that SBI is acceptable to cardiology patients with hazardous alcohol use, who viewed alcohol use as relevant to cardiovascular care. However, we found that older cardiology patients and those with advanced disease may be less accepting of SBI. Our findings suggest that interventions and implementation strategies that prioritize quality of life, respect autonomy, and align with individual expectations and goals may be among the most acceptable to cardiology patients. We also identified an opportunity to improve access to treatments for alcohol dependence within multidisciplinary heart teams or hospital-based addiction care services. Future research should prioritize capturing the perspectives of younger individuals and those in the earlier stages of CVD to optimize secondary prevention strategies.
References
- 1. GBD 2016 Alcohol Collaborators. Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2018;392(10152):1015–35. pmid:30146330
- 2.
World Health Organization. International guide for monitoring alcohol consumption and related harm. 2000.
- 3. Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice: Developed by the Task Force for cardiovascular disease prevention in clinical practice with representatives of the European Society of Cardiology and 12 medical societies With the special contribution of the European Association of Preventive Cardiology (EAPC). Eur Heart J. 2021;42(34):3227–337. pmid:34458905
- 4. Gobeil K, Medling T, Tavares P, Sawalha K, Abozenah M, Friedmann PD, et al. Frequency of hazardous and binge drinking alcohol among hospitalized cardiovascular patients. Am J Cardiol. 2021;153:119–24. pmid:34210505
- 5. Welfordsson P, Danielsson A-K, Björck C, Grzymala-Lubanski B, Hambraeus K, Löfman IH. Implementation of alcohol screening and brief interventions in cardiology: A cross-sectional study of practice in Sweden. Scandinavian Cardiovascular Journal. 2024.
- 6. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption--II. Addiction. 1993;88(6):791–804. pmid:8329970
- 7. Hahn JA, Fatch R, Barnett NP, Marcus GM. Phosphatidylethanol vs transdermal alcohol monitoring for detecting alcohol consumption among adults. JAMA Netw Open. 2023;6(9):e2333182. pmid:37698861
- 8. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017;17(1):88. pmid:28126032
- 9. Sekhon M, Cartwright M, Francis JJ. Acceptability of health care interventions: A theoretical framework and proposed research agenda. British Journal of Health Psychology. 2018;23(3):519–31.
- 10.
Socialstyrelsen. Nationella riktlinjer 2024: Vård vid ohälsosamma levnadsvanor. Stockholm: Socialstyrelsen. 2024.
- 11.
Babor TF, et al. AUDIT: the Alcohol Use Disorders Identification Test: guidelines for use in primary health care. 2nd ed. Geneva: World Health Organization. 2001.
- 12.
World Health Organization. The SAFER technical package: five areas of intervention at national and subnational levels. 2019.
- 13. Miller WR. The evolution of motivational interviewing. Behav Cogn Psychother. 2023;51(6):616–32. pmid:37170826
- 14. Schøler PN, Søndergaard J, Rasmussen S, Nielsen AS. Adjusting the 15-method to Danish general practice: identification of barriers, facilitators, and user needs. BMC Prim Care. 2024;25(1):248. pmid:38971738
- 15. McQueen J, Howe TE, Allan L, Mains D, Hardy V. Brief interventions for heavy alcohol users admitted to general hospital wards. Cochrane Database Syst Rev. 2011;2011(8):CD005191. pmid:21833953
- 16. Tanner-Smith EE, Parr NJ, Schweer-Collins M, Saitz R. Effects of brief substance use interventions delivered in general medical settings: a systematic review and meta-analysis. Addiction. 2022;117(4):877–89. pmid:34647649
- 17. Welfordsson P, Danielsson A-K, Björck C, Grzymala-Lubanski B, Hambraeus K, Lidin M, et al. Feasibility of alcohol interventions in cardiology: a qualitative study of clinician perspectives in Sweden. Eur J Cardiovasc Nurs. 2024;23(6):668–74. pmid:38445448
- 18. Groves P, Pick S, Davis P, Cloudesley R, Cooke R, Forsythe M, et al. Routine alcohol screening and brief interventions in general hospital in-patient wards: Acceptability and barriers. Drugs: Education, Prevention and Policy. 2010;17(1):55–71.
- 19. Lid TG, Karlsson N, Thomas K, Skagerström J, O’Donnell A, Abidi L, et al. Addressing Patients’ Alcohol Consumption-A Population-Based Survey of Patient Experiences. Int J Public Health. 2021;66:1604298. pmid:34795555
- 20. Broyles LM, Rosenberger E, Hanusa BH, Kraemer KL, Gordon AJ. Hospitalized patients’ acceptability of nurse-delivered screening, brief intervention, and referral to treatment. Alcohol Clin Exp Res. 2012;36(4):725–31. pmid:22250713
- 21. Saitz R. Screening and brief intervention enter their 5th decade. Subst Abus. 2007;28(3):3–6. pmid:18077299
- 22. Heather N. The efficacy-effectiveness distinction in trials of alcohol brief intervention. Addict Sci Clin Pract. 2014;9(1):13. pmid:25127717
- 23. Glass JE, Hamilton AM, Powell BJ, Perron BE, Brown RT, Ilgen MA. Specialty substance use disorder services following brief alcohol intervention: a meta-analysis of randomized controlled trials. Addiction. 2015;110(9):1404–15. pmid:25913697
- 24. Englander H, Jones A, Krawczyk N, Patten A, Roberts T, Korthuis PT, et al. A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews. J Gen Intern Med. 2022;37(11):2821–33. pmid:35534663
- 25. Tam CWM, Leong L, Zwar N, Hespe C. Alcohol enquiry by GPs - Understanding patients’ perspectives: A qualitative study. Aust Fam Physician. 2015;44(11):833–8. pmid:26590625
- 26. Bates S, Holmes J, Gavens L, de Matos EG, Li J, Ward B, et al. Awareness of alcohol as a risk factor for cancer is associated with public support for alcohol policies. BMC Public Health. 2018;18(1):688. pmid:29866082
- 27. Lovatt M, Eadie D, Meier PS, Li J, Bauld L, Hastings G, et al. Lay epidemiology and the interpretation of low-risk drinking guidelines by adults in the United Kingdom. Addiction. 2015;110(12):1912–9. pmid:26212155
- 28. Welfordsson P, Danielsson A-K, Björck C, Grzymala-Lubanski B, Lidin M, Löfman IH, et al. Mixed messages? Exposure to reports about alcohol’s suggested cardiovascular effects and hazardous alcohol use: a cross-sectional study of patients in cardiology care. BMC Public Health. 2024;24(1):1302. pmid:38741107
- 29. Harrison L, Kelly P, Lindsay J, Advocat J, Hickey C. ‘I don’t know anyone that has two drinks a day’: Young people, alcohol and the government of pleasure. Health, Risk & Society. 2011;13(5):469–86.
- 30. Järvinen M. A will to health? Drinking, risk and social class. Health, Risk & Society. 2012;14(3):241–56.
- 31. Hallett J, McManus A, Maycock BR, Smith JS, Howat P. Excessive drinking – an inescapable part of university life? A focus group study of Australian undergraduates. BDJ. 2014;218:19.
- 32. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37. pmid:22530986
- 33. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42. pmid:21513547
- 34. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51. pmid:24979285
- 35. Welfordsson P, Danielsson AK, Björck C, Grzymala-Lubanski B, Hambraeus K, Lidin M. Alcohol use as a modifiable risk factor in cardiology: A qualitative study of patient perspectives in Sweden. Open Science Framework (OSF). 2024.
- 36. Welfordsson P, Danielsson AK, Björck C, Grzymala-Lubanski B, Hambraeus K, Lidin M. Hazardous alcohol use in cardiology: A cross-sectional study in Sweden. J Public Health (Oxf). 2025.
- 37. Malterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual Health Res. 2016;26(13):1753–60. pmid:26613970
- 38. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77–101.
- 39. Rosário F, Santos MI, Angus K, Pas L, Ribeiro C, Fitzgerald N. Factors influencing the implementation of screening and brief interventions for alcohol use in primary care practices: a systematic review using the COM-B system and Theoretical Domains Framework. Implement Sci. 2021;16(1):6. pmid:33413487
- 40. Lid TG, Tvedt H, Idsøe BN, Hustvedt IB, Nesvåg S. Is it acceptable to be asked about alcohol habits when admitted to a somatic hospital ward. Sykepleien Forskning. 2020;15:e-80932.
- 41. O’Donnell A, Hanratty B, Schulte B, Kaner E. Patients’ experiences of alcohol screening and advice in primary care: a qualitative study. BMC Fam Pract. 2020;21(1):68. pmid:32321440
- 42. Nilsen P, Bendtsen P, McCambridge J, Karlsson N, Dalal K. When is it appropriate to address patients’ alcohol consumption in health care--national survey of views of the general population in Sweden. Addict Behav. 2012;37(11):1211–6. pmid:22749342
- 43. O’Donnell A, Hanratty B, Schulte B, Kaner E. Patients’ experiences of alcohol screening and advice in primary care: a qualitative study. BMC Fam Pract. 2020;21(1):68. pmid:32321440
- 44. Karlsson N, Skagerström J, O’Donnell A, Abidi L, Thomas K, Nilsen P, et al. Public perceptions of how alcohol consumption is dealt with in Swedish and Norwegian health care. Nordisk Alkohol Nark. 2021;38(3):243–55. pmid:35310609
- 45. Timm C, Krolo-Wicovsky F, Tiede A, Spielmann M, Gaertner B, John U, et al. General hospital patients’ attitude towards systematic health risk behavior screening and intervention. BMC Public Health. 2024;24(1):2877. pmid:39425090
- 46. Berndt N, Lechner L, Mudde A, De Vries H, Bolman C. Feasibility and acceptability of a telephone- and face-to-face-delivered counseling intervention for smoking cessation in Dutch patients with coronary heart disease. Res Nurs Health. 2017;40(5):444–58. pmid:28715122
- 47. Heo S, Moser DK, Lennie TA, Payne-Emerson H, Welch JL, Weaver M. Development and testing of the feasibility and acceptability of a tailored dietary intervention in patients with heart failure. J Cardiovasc Nurs. 2015;30(3):213–21. pmid:24695076
- 48. Miller PM, Thomas SE, Mallin R. Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol Alcohol. 2006;41(3):306–10. pmid:16574672
- 49. Thurfjell Å, Sandlund C, Adami J, Hasselström J, Hagströmer M, Lundh L. GPs’ experiences of phosphatidylethanol in treatment of hypertension: a qualitative study. BJGP Open. 2023;7(4):BJGPO.2023.0037. pmid:37463721
- 50. Karlsson N, Skagerström J, O’Donnell A, Abidi L, Thomas K, Nilsen P, et al. Relationship Between Educational Level and Attitudes Towards Alcohol Conversations in Healthcare: A Cross-Sectional Survey Conducted in Four European Countries. Int J Public Health. 2023;68:1605634. pmid:37035102
- 51. Beard E, Brown J, Kaner E, West R, Michie S. Predictors of and reasons for attempts to reduce alcohol intake: A population survey of adults in England. PLoS One. 2017;12(3):e0173458. pmid:28278218
- 52. Cook M, MacLean S, Callinan S. Home alone: Patterns and perceptions of solitary home alcohol consumption in an Australian convenience sample. Drug Alcohol Rev. 2023;42(5):1018–27. pmid:36645079
- 53. Kostadinov V, Bartram A. I’d be willing to take that risk for the enjoyment of the time that I have: a COM-B influenced analysis of older people’s perspectives on their alcohol consumption. Psychology & Health. 2023:1–16. pmid:37936405
- 54. Wilson GB, Kaner EFS, Crosland A, Ling J, McCabe K, Haighton CA. A qualitative study of alcohol, health and identities among UK adults in later life. PLoS One. 2013;8(8):e71792. pmid:23940787
- 55. Haighton C, Wilson G, Ling J, McCabe K, Crosland A, Kaner E. A Qualitative Study of Service Provision for Alcohol Related Health Issues in Mid to Later Life. PLoS One. 2016;11(2):e0148601. pmid:26848583
- 56. Lemieux C, Purser G. Brief alcohol interventions with older adults: results of a systematic review of literature. Innov Aging. 2021;5(Suppl 1):225.
- 57. Laddu D, Ma J, Kaar J, Ozemek C, Durant RW, Campbell T, et al. Health Behavior Change Programs in Primary Care and Community Practices for Cardiovascular Disease Prevention and Risk Factor Management Among Midlife and Older Adults: A Scientific Statement From the American Heart Association. Circulation. 2021;144(24):e533–49. pmid:34732063
- 58. Wallhed Finn S, Lundin A, Sjöqvist H, Danielsson A-K. Pharmacotherapy for alcohol use disorders - Unequal provision across sociodemographic factors and co-morbid conditions. A cohort study of the total population in Sweden. Drug Alcohol Depend. 2021;227:108964. pmid:34518028
- 59.
Månsson ADA, Sjöqvist H, Glatz T, Lundin A, Wallhed Finn S. Pharmacotherapy for alcohol use disorder among adults with medical disorders in Sweden. 2024.
- 60. Frost MC, Glass JE, Bradley KA, Williams EC. Documented brief intervention associated with reduced linkage to specialty addictions treatment in a national sample of VA patients with unhealthy alcohol use with and without alcohol use disorders. Addiction. 2020;115(4):668–78. pmid:31642124
- 61. Hahn JA, Piano MR, Hwang C-LL, Justice AC. Phosphatidylethanol Can Improve Detection and Treatment of Unhealthy Alcohol Use. Am J Prev Med. 2025;68(3):638–41. pmid:39547265
- 62. Steensland Å, Segernäs A, Larsson M, Johansson Capusan A, Kastbom L. B-phosphatidylethanol testing to identify hazardous alcohol use in primary health care-a game changer and a challenge for general practitioners: a qualitative study. Scand J Prim Health Care. 2025;43(2):463–75. pmid:39881501
- 63. Finn SW, Mejldal A, Nielsen AS. Perceived barriers to seeking treatment for alcohol use disorders among the general Danish population - a cross sectional study on the role of severity of alcohol use and gender. Arch Public Health. 2023;81(1):65. pmid:37087483
- 64. Mekonen T, Chan GCK, Connor J, Hall W, Hides L, Leung J. Treatment rates for alcohol use disorders: a systematic review and meta-analysis. Addiction. 2021;116(10):2617–34. pmid:33245581