The roles of phosphatidylethanol,ethyl glucuronide,and ethyl sulfate in identifying alcohol consumption among participants in professionals health programs

Direct alcohol biomarkers, including urinary ethyl glucuronide (EtG), urinary ethyl sulfate (EtS), and blood phosphatidylethanol (PEth), are used to monitor alcohol abstinence in individuals who are mandated to abstain. In this consecutive case series study, we examined 1000 forensic reports of participants enrolled in a professionals health program who were contractually obligated to abstain from alcohol and who underwent recovery status evaluations. We identified 52 evaluations in which urinary EtG, EtS, and blood PEth were measured and which produced a positive result for at least one of these analytes. PEth, at a cutoff concentration of 20 ng/mL, revealed alcohol use more frequently than EtG or EtS at our laboratory's cutoff concentrations of 100 and 25 ng/mL, respectively. This was true, as well, at alternative EtG/EtS cutoff concentrations of 200/50, 300/75, and 400/100 ng/mL. PEth was more likely than EtG/EtS to be positive in participants previously diagnosed with alcohol use disorders (AUD), whereas EtG/EtS was more likely than PEth to be positive in participants without AUD. In this study, blood PEth was the most sensitive biomarker for evidencing alcohol use.     

Ethyl sulfate: a metabolite of ethanol in humans and a potential biomarker of acute alcohol intake

This study identified ethyl sulfate (EtS) in human urine and compared the excretion characteristics of EtS with that of ethanol and ethyl glucuronide (EtG). Urine samples were collected from healthy subjects after a single ethanol dose, and also selected from routine clinical samples. Simultaneous analysis of EtS and EtG was performed by direct electrospray liquid chromatography-mass spectrometry in the negative ion mode, with selected-ion monitoring of the pseudomolecular ions at m/z 125 for EtS (M(w) 126 g/mol) and m/z 221 for EtG (M(w) 222 g/mol). The identity of EtS in authentic urine specimens was established by co-chromatography with reference substance, the presence of product ions (m/z 97 and 80 from m/z 125) with correct relative intensity, and a correct sulfur isotope ratio for (34)S (m/z 127). After healthy subjects drank ethanol, EtS showed a much longer, dose-dependent elimination half-life than the parent compound. No EtS was detected in urines collected after abstention from ethanol for several days prior to sampling. Among 354 consecutive clinical samples, 86 were positive for both EtS and EtG with a mean EtG/EtS molar ratio of 2.3 (median 1.7). Another three urine samples were only positive for EtS and four only for EtG. The present results confirm that sulfate conjugation is a normal but minor metabolic pathway for ethanol in humans, and EtS a common constituent in the urine after alcohol intake. It is also indicated that the concurrent determination of EtS and EtG will improve sensitivity, when being used as biomarkers of recent drinking.     

Development and validation of an analytical method for the simultaneous determination of the alcohol biomarkers ethyl glucuronide,ethyl sulfate,N-acetyltaurine,and 16:0/18:1-phosphatidylethanol in human blood

As alcohol is the most common addictive substance worldwide, it is inevitable to advance the established research. New and more substantial analytical methods can be applied to reply to complex questions in legal or forensic contexts. Therefore, an analytical method for the simultaneous determination of four different alcohol biomarkers—ethyl glucuronide, ethyl sulfate, N-acetyltaurine, and 16:0/18:1-phosphatidylethanol—in human blood was developed, validated, and verified. Despite the different chemical properties of the analytes, a specific determination via HPLC–MS/MS was achieved using a novel type of a Phenomenex Luna® Omega Sugar column. Furthermore, all criteria for a successful validation were fulfilled according to forensic guidelines. The method proved to be linear and demonstrates selectivity and sufficient sensitivity for every biomarker. LODs obtained with this method of 2.6 ng/ml (EtG), 4.7 ng/ml (EtS), 12.5 ng/ml (NAcT), and 6.9 ng/ml (PEth) were in an acceptable range for routine applications, and the stability of all analytes over a range of 12 h is given. The verification of the new developed method was performed with authentic samples. Thus, whole blood and postmortem samples were analyzed to obtain information about the drinking behavior, which can answer complex questions regarding alcohol consumption.     

Testing venous carbohydrate-deficient transferrin or capillary phosphatidylethanol with concurrent ethyl glucuronide and ethyl palmitate hair tests to assess historical and recent alcohol use

Hair biomarkers, ethyl glucuronide (EtG) and ethyl palmitate (EtPa), together with blood biomarker tests, carbohydrate-deficient transferrin (CDT) or phosphatidylethanol (PEth), are commonly used in identifying patterns of alcohol consumption as they possess different windows of detection. The detection of EtG in hair samples is mainly used in combination with EtPa when hair cosmetic treatments such as hair colouring and bleaching affect EtG levels. The main purpose of our study was to investigate the differences in frequency distribution of positive CDT and PEth results indicating alcohol had been used, when EtG and EtPa were not detected, where evidence of abstinence is paramount. Of the total 602 cases, for 179 (29.7%), neither EtG nor EtPa markers were detected. Of these, 0.5% of the cases produced positive CDT. However, 18.6% produced positive PEth, a significantly higher proportion. A similar pattern emerges when results are evaluated according to whether hair had been either cosmetically treated or untreated. When hair was untreated, one case produced positive CDT, and 19.3% were positive for PEth (median of 51 ng/ml). No cases of positive CDT results, but 20.8% of PEth were positive (median of 106.5 ng/ml) when hair samples had been cosmetically treated. Whether EtG or EtPa markers were detected or not, significantly higher proportions of PEth than CDT were seen. The results of this study substantiate the case for using hair EtG in conjunction with a PEth test, rather than CDT test, for efficient monitoring of recent and historical alcohol consumption.     

Ethyl glucuronide, ethyl sulfate, and ethanol in urine after sustained exposure to an ethanol-based hand sanitizer

To assess the degree of ethanol absorption and subsequent formation of urinary ethyl glucuronide (EtG) and ethyl sulfate (EtS) following sustained application of hand sanitizer, 11 volunteers cleansed their hands with Purell(?) hand sanitizer (62% ethanol) every 5 min for 10 h on three consecutive days. Urine specimens were obtained at the beginning and end of each day of the study, and on the morning of the fourth day. Urinary creatinine, ethanol, EtG, and EtS concentrations were measured. EtG was undetectable in all pre-study urine specimens, but two pre-study specimens had detectable EtS (73 and 37 ng/mL). None of the pre-study specimens had detectable ethanol. The maximum EtG and EtS concentrations over the course of the study were 2001 and 84 ng/mL, respectively, and nearly all EtG- and EtS-positive urine specimens were collected at the conclusion of the individual study days. Only two specimens had detectable EtG at the beginning of any study day (96 and 139 ng/mL), and only one specimen had detectable EtS at the beginning of a study day (64 ng/mL), in addition to the two with detectable EtS prior to the study. Creatinine-adjusted maximum EtG and EtS concentrations were 1998 and 94 μg/g creatinine, respectively. In patients being monitored for ethanol use by urinary EtG concentrations, currently accepted EtG cutoffs do not distinguish between ethanol consumption and incidental exposures, particularly when urine specimens are obtained shortly after sustained use of ethanolcontaining hand sanitizer. Our data suggest that EtS may be an important complementary biomarker in distinguishing ethanol consumption from dermal exposure.     

Detox shampoos for EtG and FAEE in hair – Results from in vitro experiments

The assessment of alcohol consumption behavior in hair is well established in forensic toxicology. The Society of Hair Testing (SoHT) recommends the direct alcohol markers ethyl glucuronide (EtG) and fatty acid ethyl esters (FAEE) for the detection of past alcohol consumption. In this study, we investigated if detox shampoos which are sold online can have an impact on EtG or FAEE concentrations in hair. According to customer reviews, positive drug testing results could be avoided after long‐term incubation with shampoo under a swimming cap. To evaluate the potential of four detox shampoos, we incubated distal hair samples from three subjects, obtained during a standard haircut, for 2.5, 5, 7.5, and 10 hours. For EtG, three shampoos performed similar to deionized water. The fourth shampoo showed additional heavy washout effects with a decrease of up to 86% after 2.5 hours. For the apolar FAEE, no washout was observed. Incubation with two shampoos resulted in increases in FAEE concentrations due to FAEE being present as shampoo ingredients. Further investigation of EtG washout in proximal forensic hair samples (n = 9) with the most potent shampoo showed a mean decrease in deionized water of 23% ± 25%, and a decrease by the use of detox shampoo of 73% ± 12%, compared to non‐incubated hair after 8 hours. In conclusion, detox shampoos proved to have the potential to alter EtG and FAEE concentrations in hair during in vitro experiments.     

Ethyl glucuronide, ethyl sulfate, and ethanol in urine after intensive exposure to high ethanol content mouthwash

To determine the degree of ethanol absorption and the resultant formation and urinary excretion of its conjugated metabolites following intensive use of high ethanol content mouthwash, 10 subjects gargled with Listerine(?) antiseptic 4 times daily for 3? days. First morning void urine specimens were collected on each of the four study days and post-gargle specimens were collected at 2, 4, and 6 h after the final gargle of the study. Urine ethanol, ethyl glucuronide (EtG), ethyl sulfate (EtS), and creatinine were measured. Ethanol was below the positive threshold of 20 mg/dL in all of the urine specimens. EtG was undetectable in all pre-study urine specimens, but two pre-study specimens had detectable EtS (6 and 82 ng/mL; 16 and 83 μg/g creatinine). Only one specimen contained detectable EtG (173 ng/mL; 117 μg/g creatinine). EtS was detected in the urine of seven study subjects, but was not detected in the single specimen that had detectable EtG. The maximum EtS concentrations were 104 ng/mL and 112 μg/g creatinine (in different subjects). Three subjects produced a total of eight (non-baseline) urinary EtS concentrations above 50 ng/mL or 50 μg/g creatinine and three EtS concentrations exceeding 100 ng/mL or 100 μg/g creatinine. In patients being monitored for ethanol use by urinary EtG and EtS concentrations, currently accepted EtG and EtS cutoffs of 500 ng/mL are adequate to distinguish between ethanol consumption and four times daily use of high ethanol content mouthwash.     

PEth 16:0/18:1 and 16:0/18:2 after consumption of low doses of alcohol—A contribution to cutoff discussion

Phosphatidylethanol in blood has gained recognition as a direct alcohol biomarker. Although different cutoffs have been suggested, there is no consensus for differentiating abstinence from alcohol consumption. In this study, 75 participants (72% female) consumed 20 g of ethanol on three consecutive evenings. Blood was sampled on each following day and PEth 16:0/18:1 and 16:0/18:2 were determined. PEth 16:0/18:1 ranged from 8.9–21.5, 8.7–19.3, and 8.8–42.3 ng/ml and PEth 16:0/18:2 from 8.7–31.7, 9.0–39.3, and 9.4–43.0 ng/ml after the respective days of ethanol consumption. PEth 16:0/18:1 yielded a sensitivity of 25%, 45%, and 49% and PEth 16:0/18:2 of 40%, 61%, and 68% for the consumption days, respectively (cutoff 10 ng/ml). PEth 16:0/18:1 reached >20 ng/ml in five samples overall. Sensitivity of PEth 16:0/18:2 > 20 ng/ml was better with 35% after the three drinking days. Overall, PEth 16:0/18:1 was >35 ng/ml in one sample and PEth 16:0/18:2 in three samples. Significantly, more women had PEth 16:0/18:1 > 10 ng/ml after the third day of consuming 20 g of alcohol (p = 0.02) and PEth 16:0/18:2 > 10 ng/ml after the second (p = 0.023) and the third (p = 0.002) consumption, which can be led back to the higher blood alcohol concentration women reach after consuming the same alcohol amount as men. Although the response rates of PEth to alcohol uptake are subject to strong interindividual differences, results suggest that PEth cutoff should be lowered for better detection of consumption of low to medium amounts of alcohol. Furthermore, it is advantageous to analyze both PEth 16:0/18:2 and 16:0/18:1.     

Decrease of ethyl glucuronide concentrations in hair after exposure to chlorinated swimming pool water

The direct alcohol marker ethyl glucuronide (EtG) is widely used for the assessment of alcohol consumption behavior and abstinence monitoring by hair analysis. We investigated the influence of chlorinated swimming pool water on EtG concentrations in hair in comparison to deionized water (Milli‐Q) containing no chlorine. EtG concentrations were measured with a validated online solid‐phase extraction–liquid chromatography–tandem mass spectrometry (SPE–LC–MS/MS) method. EtG positive hair samples were obtained from 3 regular drinkers and incubated for 0, 2, 4, 6, 8, and 10 hours at room temperature. EtG concentrations in hair were reduced after 2 hours of incubation in chlorinated water by 20 ± 12% (range: 4–33%), in deionized water by 24 ± 5% (range: 18–29%). Incubation for 10 hours resulted in a decrease in EtG concentrations of 57 ± 6% (range: 52–65%) for chlorinated water and 47 ± 11% (range: 32–60%) for deionized water. To demonstrate washout in forensic hair samples, 20 samples from subjects with known alcohol consumption behavior were investigated additionally. The samples were divided into 2 strands and analyzed with incubation in chlorinated water for 10 hours and for comparison without any incubation. A mean decrease of 53 ± 18% (range: 26–88%) was observed. These results clearly demonstrate that washout effects are caused by water and have a significant impact on EtG concentrations in hair. For people with hair that are regularly exposed to water for a longer period (eg. swimmers), washout effects may lead to a significant decrease of EtG concentrations in hair. Concentrations may fall below threshold concentrations used for the interpretation of consumption habits (7 pg/mg for social consumption, 30 pg/mg for excessive consumption).     

Stability of phosphatidylethanol 16:0/18:1 in authentic and spiked whole blood

Phosphatidylethanol 16:0/18:1 (PEth) is the most abundant homologue of the phosphatidylethanol group of phospholipids. Formed only in the presence of ethanol, PEth is used as a biomarker in whole blood to provide information about the consumption of alcohol. As information on the storage life of PEth is essential for its beneficial use as a biomarker, this study investigated the stability of PEth in spiked and authentic whole blood samples stored at 4°C. Human whole blood samples (n = 23) and spiked whole blood samples (n = 7) with a concentration range between 5 and 2000 ng/ml were analysed at specific time intervals, up to 90 days. Differences were evident between the stability of authentic and spiked samples. PEth was stable at 4°C for 60 days (concentrations within 15% of initial concentration) in authentic samples, whereas spiked samples were stable for up to 30 days. This study emphasizes the importance of including authentic samples in stability experiments.     

Commercial Ethyl Glucuronide (EtG) and Ethyl Sulfate (EtS) Testing is Not Vulnerable to Incidental Alcohol Exposure in Pregnant Women

Background: Ethyl Glucoronide (EtG) and Ethyl Sulfate (EtS) have shown promise as biomarkers for alcohol and may be sensitive enough for use with pregnant women in whom even low-level alcohol use is important. However, there have been reports of over-sensitivity of EtG and EtS to incidental exposure to sources such as alcohol-based hand sanitizer. Further, few studies have evaluated these biomarkers among pregnant women, in whom the dynamics of these metabolites may differ. Objectives: This study evaluated whether commercial EtG-EtS testing was vulnerable to high levels of environmental exposure to alcohol in pregnant women. Methods: Two separate samples of five nurses—one pregnant and the other postpartum, all of whom reported high levels of alcohol-based hand sanitizer use—provided urine samples before and 4–8 hours after rinsing with alcohol-based mouthwash and using hand sanitizer. The five pregnant nurses provided urine samples before, during, and after an 8-hour nursing shift, during which they repeatedly cleansed with alcohol-based hand sanitizer (mean 33.8 uses). The five postpartum nurses used hand sanitizer repeatedly between baseline and follow-up urine samples. Results: No urine samples were positive for EtG-EtS at baseline or follow-up, despite use of mouthwash and—in the pregnant sample—heavy use of hand sanitizer (mean of 33.8 uses) throughout the 8-hour shift. Conclusions/Importance: Current, commercially available EtG-EtS testing does not appear vulnerable to even heavy exposure to incidental sources of alcohol among pregnant and postpartum women.     

Non-oxidative ethanol metabolism in human hepatic cells in vitro: Involvement of uridine diphospho-glucuronosyltransferase 1A9 in ethylglucuronide production

Ethanol is the most frequently psychoactive substance used in the world, leading to major public health problems with several millions of deaths attributed to alcohol consumption each year. Metabolism of ethanol occurs mainly in the liver via the predominant oxidative metabolism pathway involving phase I enzymes including alcohol dehydrogenases (ADH), cytochrome P450 (CYP) 2E1 and catalase. In a lesser extent, an alternative non-oxidative pathway also contributes to the metabolism of ethanol, which involves the uridine diphospho-glucuronosyltransferase (UGT) and sulfotransferase (SULT) phase II enzymes. Using liquid chromatography-high resolution mass spectrometry, ethylglucuronide (EtG) and ethylsulfate (EtS) produced respectively by UGT and SULT conjugation and detected in various biological samples are direct markers of alcohol consumption. We report herein the efficient non-oxidative metabolic pathway of ethanol in human differentiated HepaRG cells compared to primary human hepatocytes (HH). We showed dose- and time-dependent production of EtS and EtG after ethanol (25 or 50 mM) treatment in culture media of differentiated HepaRG cells and HH and a significant induction of CYP2E1 mRNA expression upon acute ethanol exposure in HepaRG cells. These differentiated hepatoma cells thus represent a suitable in vitro human liver cell model to explore ethanol metabolism and more particularly EtG and EtS production. In addition, using recombinant HepG2 cells expressing different UGT1A genes, we found that UGT1A9 was the major UGT involved in ethanol glucuronidation.     

Phosphatidylethanol in blood (B-PEth): a marker for alcohol use and abuse

Phosphatidylethanol (PEth) represents a group of glycerophospholipid homologues where ethanol by phospholipase D has been bound at the position that normally contains an amino-alcohol. Since the formation of PEth is specifically dependent on ethanol, the diagnostic specificity of PEth as an alcohol biomarker is theoretically 100%. The half-life of PEth in blood is approximately 4 days. The amount of alcohol consumed correlates to blood concentration of PEth and PEth has been shown to be a more sensitive indicator of alcohol consumption than traditional alcohol markers, such as CDT (carbohydrate-deficient transferrin), GGT (γ-glutamyl transferase), and MCV (mean corpuscular volume) or a combination of these. Almost all clinical data so far available are based on a high performance liquid chromatography (HPLC) method with limited analytical sensitivity. With the advent of methods with considerably higher analytical sensitivity (e.g. mass spectrometric methods), clinical sensitivity will increase correspondingly. The possibility of determining very low concentrations of PEth by new sensitive analytical techniques may, however, have both ethical and legal consequences that have to be considered.     

An overview of alcohol testing and interpretation in the 21st century

Ethanol analysis is the most commonly carried out drug testing in a forensic toxicology laboratory. Determination of blood alcohol concentration (BAC) is needed in a multitude of situations, including in postmortem analysis, driving under the influence (DUI) and drug-facilitated sexual assault (DFSA) cases, workplace drug monitoring, and probation investigations. These analyses are carried out by direct measurement of ethanol concentrations as well as of metabolic by-products, such as ethyl glucuronide (EtG) and ethyl sulfate (EtS). This review article will discuss pharmacokinetics, including absorption, distribution, and elimination of ethanol, methods for the detection of ethanol, the effect of ethanol on human performance, the role of alcohol in injuries and fatalities, and information regarding the interactions that may occur between alcohol and other drugs. Finally, an explanation will be given on how to interpret alcohol levels as well as the extrapolation and calculation of blood alcohol levels at times prior to sample collection.     

Levels and types of alcohol biomarkers in DUI and clinic samples for estimating workplace alcohol problems

Widespread concern about illicit drugs as an aspect of workplace performance potentially diminishes attention on employee alcohol use. Alcohol is the dominant drug contributing to poor job performance; it also accounts for a third of the worldwide public health burden. Evidence from public roadways--a workplace for many--provides an example of work-related risk exposure and performance lapses. In most developed countries, alcohol is involved in 20-35% of fatal crashes; drugs other than alcohol are less prominently involved in fatalities. Alcohol biomarkers can improve detection by extending the timeframe for estimating problematic exposure levels and thereby provide better information for managers. But what levels and which markers are right for the workplace? In this paper, an established high-sensitivity proxy for alcohol-driving risk proclivity is used: an average eight months of failed blood alcohol concentration (BAC) breath tests from alcohol ignition interlock devices. Higher BAC test fail rates are known to presage higher rates of future impaired-driving convictions (driving under the influence; DUI). Drivers in alcohol interlock programmes log 5-7 daily BAC tests; in 12 months, this yields thousands of samples. Also, higher programme entry levels of alcohol biomarkers predict a higher likelihood of failed interlock BAC tests during subsequent months. This paper summarizes the potential of selected biomarkers for workplace screening. Markers include phosphatidylethanol (PEth), percent carbohydrate deficient transferrin (%CDT), gammaglutamyltransferase (GGT), gamma %CDT (γ%CDT), and ethylglucuronide (EtG) in hair. Clinical cut-off levels and median/mean levels of these markers in abstinent people, the general population, DUI drivers, and rehabilitation clinics are summarized for context.     

Urinary concentrations of ethyl glucuronide and ethyl sulfate as thresholds to determine potential ethanol-induced alteration of steroid profiles

The suppression of steroid biotransformation resulting in a decrease of the major urinary metabolites--androsterone and etiocholanolone--and the elevation of testosterone/epitestosterone (T/E) ratios following ethanol administration is well described. At least the latter parameter T/E represents an important indicator for endogenous steroid abuse in doping control. The quantitative correlation between ethanol consumption markers and steroid profile alteration was evaluated, aiming to differentiate between permitted ethanol administration and potential steroid abuse. Steroid profiles, ethanol, ethyl glucuronide (EtG), and sulfate (EtS) were quantified after administration of ethanol (intended maximum ethanol concentration in blood was 1 mg/g) to 21 male and 15 female volunteers. EtG concentrations in urine (corrected by either specific gravity or creatinine concentration) were found to be most suitable for quantitative evaluations. Gender specific urinary EtG concentrations of 48 ug/ml (men) and 15.5 ug/ml (women) may be considered as useful thresholds for a potential ethanol-induced suppression of steroids biotransformation.     

Quantitative determination of ethyl glucuronide in sweat

In this study, ethyl glucuronide (EtG), a specific metabolite of ethanol, was for the first time detected in sweat after alcohol consumption by human volunteers. Sweat was collected using a sweat patch (PharmChek). After collection, chemicals accumulated on the patch were extracted with water and extracts were purified by solid phase extraction. EtG was determined by gas chromatography with mass spectrometric detection in negative chemical ionization mode. In parallel, the amount of sodium deposited on the patch was determined by capillary electrophoresis and used as a correction factor to calculate the volume of sweat accumulated on the patch and, hence, the concentration of EtG in sweat. The EtG sweat concentration observed ranged from 1.7 to 103.0 microg/L for alcohol consumption from 38.0 to 154.6 g equivalent pure ethanol. No EtG was detected in subjects who did not consume alcohol. Our results demonstrate that after ethanol consumption, EtG is detectable in sweat collected using a sweat patch. The simultaneous determination of sodium allows the estimation of the volume of sweat accumulated on the patch and to calculate the concentration of EtG in sweat. This represents the first quantitative determination of a xenobiotic in sweat collected using a sweat patch. This study suggests that EtG determination in sweat could represent an interesting alternative to urine or serum analysis for the control of abstinence of patients included in treatment programs.     

Microwave assisted extraction for the determination of ethyl glucuronide in urine by gas chromatography-mass spectrometry

Alcohol is the most frequently abused 'addictive substance' that causes serious social problems throughout the world; thus alcoholism is of particular interest in clinical and forensic medicine. Ethyl glucuronide (EtG) is a marker of recent alcohol consumption that detects alcohol use reliably over a definite time period. The present paper describes a new method for the determination of EtG in urine. It was based both on microwave assisted extraction (MAE) to extract the analyte from urine samples, and gas chromatography-mass spectrometry (GC-MS) to identify and quantify the EtG in selected ion monitoring (SIM) mode. The method was applied to 33 urine samples from alcohol users, obtaining positive results in all cases. It was fully validated including a linear range (0.1-100 microg ml(-1)) and the main precision parameters. In summary, the use of microwave assisted extraction turned out to be a substantially simpler, faster and more sensitive procedure than any other conventional sample preparations.     

Homelessness predicts attrition but not alcohol abstinence in outpatients experiencing co-occurring alcohol dependence and serious mental illness

Background: Adults experiencing homelessness and serious mental illnesses (SMI) are at an increased risk of poor mental health and treatment outcomes compared with stably housed adults with SMI. The additional issue of alcohol misuse further complicates the difficulties of those living with homelessness and SMI. In this secondary data analysis, the authors investigated the impact of homelessness on attrition and alcohol use in a contingency management (CM) intervention that rewarded alcohol abstinence in outpatients with SMI. Methods: The associations between housing status and attrition and alcohol abstinence during treatment, as assessed by ethyl glucuronide (EtG) urine tests, were evaluated in 79 adults diagnosed with alcohol dependence and SMI. Results: Thirty-nine percent (n = 31) of participants reported being homeless at baseline. Individuals who were homeless were more likely to drop out of CM (n = 10, 62.5%) than those who were housed (n = 4, 16.7%), χ²(1) = 8.86, P < .05. Homelessness was not associated with attrition in the noncontingent control group. Accounting for treatment group and prerandomization EtG levels, neither the effect of housing status nor the interaction of housing status and group were associated with EtG-assessed alcohol abstinence during treatment. Conclusions: Individuals experiencing homelessness and co-occurring alcohol dependence and SMI receiving CM had higher rates of attrition, relative to those who were housed. Homelessness was not associated with differences in biologically assessed alcohol abstinence.     

Estimation of alcohol and nicotine consumption in 11 cities of Turkey using wastewater-based epidemiology

Alcohol and tobacco are the most frequently consumed substances in the world. Both are significantly associated with the increasing number of different diseases. Thus, monitoring nicotine and alcohol use is vital for public health planning and intervention strategies. This study aimed to calculate estimates of alcohol and nicotine use in 11 cities of Turkey using wastewater-based epidemiology. In 2019, daily composite wastewater samples from 18 wastewater treatment plants were collected for a week per season. The 24-h composite samples were collected via auto-samplers. Sample preparation for wastewater samples collected was done using liquid–liquid extraction and solid-phase extraction. Nicotine and ethyl sulfate (EtS) were analyzed using validated liquid chromatography–tandem mass spectrometry method. The estimated average nicotine consumption was 2.84 mg/p/day, and the average alcohol consumption was 3.46 ± 1.83 ml/p/day. The highest nicotine consumption was observed in Kayseri city; the highest alcohol consumption was calculated for Mersin city. In this study, the cigarette and alcohol consumption estimate obtained by wastewater-based epidemiology (WBE) was found to be higher than the Turkey Tobacco and Alcohol Market Regulatory Authority report. To our knowledge, this study is the most comprehensive one so far applied using WBE for 11 cities in Turkey and evaluates alcohol and nicotine use together.