Globally, 5.9% of deaths are attributed to alcohol consumption, and 5.1% of the global burden of disease and injury is attributed to its use [1]. In Australia, alcohol consumption is estimated to cause 3.2% of the total burden of disease. Including harms to nonusers, alcohol consumption contributes about 188,000 disability-adjusted life years, causes 5550 deaths, and costs approximately AU $30 billion/year [2,3]. Australian guidelines provide recommendations for the general adult population specifying that, to reduce the risk of alcohol-related harm over the lifespan, average consumption should be 2 or fewer drinks per day. To reduce the risk of injury from a single occasion of drinking, 4 or fewer drinks are recommended. Further, more stringent recommendations are made for specific groups (eg, pregnant women, those with a family history of alcohol disorders) where the risk of alcohol-related harms is greater [4].

Considered against the 2 main guidelines, in 2016, about 17% of adults were at-risk from their average alcohol consumption, about 26% from their single-occasion use [5], and 37% from either single occasion or average use [6]. Notably, most alcohol-related harm arises from those who consume in an at-risk manner rather than those with an alcohol disorder, with a much greater number of at-risk drinkers than those with disorders [7]. Furthermore, less than 17% of those with an alcohol disorder ever receive treatment for their condition [8], and among those people with less severe alcohol problems, most are unlikely to seek help for their drinking [9].

One approach to addressing alcohol use among those with less severe problems is opportunistic screening and brief intervention (SBI), with the evidence base for the effectiveness of SBI being substantial [10-13]. Under the rubric of SBI, programs can range from a simple screening question combined with a minimal amount of feedback, eg, normative data on alcohol use, through to the use of standardized screening instruments and more intensive interventions that can include components of motivational interviewing and cognitive behavioral therapy. Typically, SBI can be incorporated into a single treatment session in a few minutes but can be several sessions lasting a few hours [14]. However, some, but not all, studies suggest that SBI may be more effective with males than females, and there is an absence of evidence for their effectiveness for those with more severe alcohol use problems [10,11,15]: these people are typically referred for more intensive treatment [16]. Overall, SBI does not appear to have been widely adopted into primary care, and questions remain about its practical implementation, especially within the context of the Australian drinking culture [17,18].

Therefore, alternative approaches to complement existing programs are required. Web-based SBI alcohol interventions have been developed, evaluated, and found to be effective in both college student samples and the general public, excluding students [19,20], with typical effects in the small to medium range (eg, effect size g=0.20-0.44) [19,21]. Web-based interventions in their briefest form (eg, single session) typically rely on normative feedback on the self-reported quantity of alcohol consumed, whereas more complex interventions may involve multiple sessions and draw on a range of psychological approaches including motivational enhancement, cognitive behavior therapy, and behavioral control [19,21], similar to the components used in traditional SBI. Nevertheless, Web- or mobile-based SBI has potential advantages over traditional formats, including extended reach, anonymity, timely accessibility, treatment fidelity, the potential to model behavior, and access without the involvement of professionals [21,22]. The evidence to date for the effectiveness of mobile phone–based alcohol interventions is inconclusive, with outcomes ranging from significant improvements on some alcohol measures to significant declines on other measures [23,24].

The benefits of including additional resources to support internet-based interventions are currently unclear. A meta-analysis of internet interventions for depression found a large effect size (g=0.78) [25], where all except one of the studies included therapist support. In contrast, a meta-analysis of self-guided internet interventions for depression reported a small effect size (d=0.28) [26]. However, a comparison of alcohol interventions found no significant difference between guided (effect size g=0.23) versus unguided (effect size g=0.20) interventions, although the authors note that this may be due to the small number of guided studies [19]. Nevertheless, benefits have been shown in improving alcohol outcomes (and other health behaviors) from using multiple modes of delivery such as text messages, drawing on theoretical models, and incorporating multiple behavioral change techniques [27,28].

Observational data show that a person’s social network can either increase or decrease their alcohol use [29]. Social networks now include those formed on the internet. These sites range from simple bulletin boards through to virtual lives, but typically allow users to post blogs (text) and images that stimulate discussion and the formation of social groups [30]. The effects of these networks on behavioral change have been evaluated with inconsistent effects found with respect to diet and exercise [31], but to date, the effectiveness of social networks in reducing alcohol consumption has not been determined [30,31], but it is currently being trialed in youth with depression and who engage in binge drinking [32]. In contrast, the persuasive effects of Web-based social networks have been extensively harnessed by alcohol brands to engage with alcohol consumers, with some brands having attracted millions of followers [33,34]. This trial will evaluate the effectiveness of the online coaching component of Hello Sunday Morning’s Daybreak program and associated support as a means of reducing alcohol consumption.

Hello Sunday Morning is an Australian social media health promotion movement that asks participants to publicly set a personal goal to stop drinking or reduce their consumption for a set period of time (typically 3, 6, or 12 months [35]), and to record their reflections and progress on blogs and social networks [35,36]. The platform was created in 2010, with the aim of motivating members and holding them accountable by asking them to set a public goal. Further development included gamification features, which were structured games that facilitated participation and engagement with the internet community. Participants in the legacy Hello Sunday Morning platform were recruited by social marketing tactics, leveraging the idea of a movement toward a better drinking culture through social media, word of mouth, and a television commercial. A large portion of members were also recruited through Google AdWords. This platform is no longer actively recruiting participants, and as such individuals are now directed toward the Daybreak program.

Initial research conducted on the platform explored the blog content and qualitative reports of change. Text analytics of the blog posts on the platform show that participants typically begin with descriptions of their drinking practices, which over time change to posts reflecting their efforts to change their behavior [37]. Research on the Australian users has found that 84% of participant’s report completing the program time they signed-up to without a slip-up, defined as drinking alcohol before finishing. These participants reported reduced alcohol use and desire to drink alcohol for fun or to relieve tension, and improved mental health [38]. Participants have also reported feeling more positive about themselves, improved productivity and engagement in new activities, as well as new and/or improved relationships and financial savings [39].

Australian users of Hello Sunday Morning are more likely to be female (61%) than male, with most aged less than 50 years (89%). Few (5%) are classified as low-risk alcohol users as assessed by the alcohol use disorders identification test [40] (AUDIT) (score=0-7), with 42% classified in the hazardous or harmful range (AUDIT 8-19) and 53% classified as probably dependent (AUDIT≥20) [35]. Limited follow-up data (n=49) on a subsample of Victorian Hello Sunday Morning participants (n=345) found that the prevalence of probably dependent drinkers fell from 45% at baseline to 7% at 1 month and 24% at 3 months [41].

The aim of the study was to evaluate the effectiveness of the online coaching component of the Daybreak program in reducing alcohol consumption via a randomized controlled trial. The Daybreak program is a smartphone app developed by Hello Sunday Morning, based on the original Web-based program. Daybreak consists of the same social-networking peer-support forum as the Hello Sunday Morning program but also includes clinically based activities known as behavioral experiments and chat-based coaching. The primary hypothesis is that those randomized to receive Daybreak including peer-support, behavioral experiments (see Content of the interventions for details) plus online coaching, will show a greater reduction in alcohol-related problems that those randomized to just access the Daybreak program including peer-support and behavioral experiments (without online coaching). Consistent with the literature, the secondary hypotheses are that greater improvements will be shown for those with lower AUDIT scores (8-19), than those in the higher score category (≥20), and finally, greater improvements are expected for male participants [15,42].

Enrollment of participants started in February 2018, with recruitment projected to be completed in November 2018, with the 6 month follow-up completed by the end of May 2019. Data analysis has yet to start.

To the best of our knowledge, this will be the first formal evaluation of the effectiveness of a smartphone-based peer support platform with coaching in reducing alcohol consumption and associated harms. It will assess critical, clinically relevant outcomes, including changes in alcohol consumption and improvements in mental health and quality of life. The minimal use of incentives in the project design will mean that the findings will be generalizable to real-world settings, with the long period of follow-up important in establishing the persistence of any behavioral changes.

Currently, there is no definitive evidence to support the effectiveness of standard brief interventions among those with more severe alcohol disorders, with equivocal findings for both reductions in alcohol use and improving treatment seeking [15]. Nearly half of Hello Sunday Morning participants score in the probable dependence range on the AUDIT [35], so the outcomes for this subgroup of participants is of particular importance in addressing the gap in the provision of effective alcohol consumption interventions.

The study has been powered to detect effects within critical subgroups, namely, those with people with potential alcohol dependence and by gender. Therefore, in addition to reporting statistical significance results for the main analyses, which may represent trivial changes given the overall size of the sample, we will report effect sizes and discuss effects in terms of their clinical significance, eg, changes in categorical levels on the K-10 and AUDIT.

With respect to the continuing provision of the service, Daybreak is a service of the organization Hello Sunday Morning, which is funded through a range of commercial and corporate partnerships, grants, and government contracts. These will allow ongoing dissemination of the service including hosting the program and funding its health coaches. If successful, outcomes of the study will be used to advocate for further funding and wider dissemination via other sites, such as general practitioners and hospital emergency departments.

The study raises some ethical issues, particularly with respect to the age of participants and the adverse outcomes that can occur in unsupported withdrawal from alcohol use. Although we will ask participants to confirm that they are aged 18 years or older, and thus able to provide informed consent, the noninvasive nature of the intervention reduces the concerns about underage participants entering the trial. To mitigate against the potential for unsupported severe withdrawal symptoms, we will advise participants considered to be at higher risk to seek professional guidance before reducing or ceasing consumption.

The study relies on self-reported data, which is common for Web-based alcohol interventions [19]. Other than the identification of acute intoxication, objective quantification of alcohol use even over a limited period (such as 7 days) is difficult. None of the standard clinical markers (eg, gamma glutamyltransferase) perform adequately as screening tests for this task, particularly with women and at intermediate levels of alcohol use, or provide a quantification of the amount of alcohol consumed [61]. Therefore, we believe that there is no other method of determining the extent of alcohol use that is more reliable than self-report, without implementing far more demanding procedures, such as twice daily breath testing, as used in some judicial programs [62].