Heavy drinking is the third greatest risk to public health in developed countries , although most of this risk is avoidable . In the United Kingdom, a quarter of the population is affected adversely by their drinking behaviour . Thus, preventing alcohol-related harm is a key public health imperative. This conclusion was reached by the World Health Organization (WHO) some 30 years ago, and it led to the emergence of screening and brief intervention techniques to help reduce heavy drinking. A veritable industry of research has ensued, and there have now been more than 60 controlled trials of brief alcohol interventions spanning two decades [4,5]. Hence, Nilsen's review  is a timely stock-take of this substantial evidence base and directions for future research and practice.
With the benefit of hindsight, the brief intervention field seems to be a model example of the evaluation of a complex intervention . Early development of screening and brief intervention tools led to tightly controlled efficacy trials, then more pragmatic trials of effectiveness in clinically meaningful contexts. Attention then shifted to dissemination, implementation  and wider-scale roll-out . As Nilsen rightly points out, most of this research focused upon primary care . However, other settings have learned from this 20-year case study. For example, research in emergency care has moved from efficacy  to effectiveness trials  in half the time. One hopes that this accelerated evaluative process might also occur in other settings where brief alcohol interventions may be of value.
Research that builds upon previous work should save public time and money. While replication is an important part of the scientific method, a field needs to progress rather than merely generate volume. In the case of primary care, a recent systematic review included 29 randomized controlled trials which enrolled more than 7000 patients . This and numerous other reviews have reported consistent benefits of brief alcohol intervention in primary care. Thus the question of whether brief intervention can work in this setting is not really in doubt. Yet, despite all this research, we still cannot identify the ‘active ingredients’ of successful brief interventions. Should this be just screening and feedback, structured advice, life-style counselling or motivational interviewing? We currently do not know; nor do we know if one approach works equally well for different types of heavy drinkers. Lastly, we are not certain if brief interventions can be exported usefully to settings beyond health care. However, three ongoing Screening and Intervention Programme for Sensible Drinking (SIPS) trials in England will compare the impact of brief advice and/or motivational counselling in primary care, emergency care and probation offices [12–14]. These research findings, which are due in 2010, will help to answer the unresolved question of whether structured advice is sufficient to change drinking behaviour or if motivational counselling is required, and whether brief interventions can work in a context where health outcomes may not be the primary consideration.
Looking further forward, the key challenge for the brief intervention field seems to be to conduct appropriate translational research which moves the evidence into practice so that it reaches the patients it is intended to benefit . I agree with the view that we need to move beyond listing practitioner-level barriers to brief intervention. A more productive approach is to work in partnership with practitioners in order to understand their world-view more clearly and identify mutual ways of embedding brief interventions in practice. This work might include negotiating over essential and non-essential aspects of brief intervention, as has occurred recently in England, Catalonia and New Zealand . In addition, we need to address system-level factors. Despite extensive knowledge about health problems resulting from smoking and a solid evidence base supporting brief smoking interventions, routine delivery occurred only once it was prioritized in health policy and incentivized in practice. The same requirements for brief alcohol intervention were endorsed by key informants in a Delphi exercise . Thus we need to shift from merely persuading practitioners about the merits of brief intervention to shaping the policy, commissioning and practice arenas which create the necessary conditions in which brief intervention can happen. To do this successfully, researchers and practitioners need to work together to decode evidence generated primarily by academics into a meaningful form for those working in practice. This is happening currently in a Programme Development Group convened by the National Institute for Health and Clinical Excellence (NICE) to prepare guidance for England on the prevention of alcohol-related problems in adults and adolescents . Hopefully, this guidance plus a nationally directed enhanced service with specific funding for brief alcohol intervention  will mean that the pieces are falling into place for wide-scale delivery.