Patients are more likely than ever to tell you they’ve quit drinking or cut back. Maybe they’re “sober curious,” joining the wellness movement, or finally getting the memo that past research on the benefits of moderate drinking was wrong.

When that happens, standard screening tools such as SBIRT (Screening, Brief Intervention, and Referral to Treatment) may not flag a risk, leaving clinicians tempted to check that box and move on.

But that’s a missed opportunity.

“It’s important to understand the patient’s motivations for change and what’s been working or not working,” said Daniel Siconolfi, PhD, a behavioral scientist at RAND in Pittsburgh, who studies substance use in emerging and young adults. “Some patients may also benefit from formal support, and physicians can facilitate those referrals.”

The trouble with past alcohol research is that it grouped healthy abstainers with “sick quitters” (former drinkers who’d stopped due to health problems), creating a bias that made moderate drinkers look healthy by comparison. Newer, better-designed research shows no benefits and reveals heightened risks — such as cancer, cardiovascular problems, and liver disease — associated with even light drinking.

Now, data show Americans are drinking at historically low rates, particularly Gen Z. Today’s 20- and 30-somethings have a pronounced belief that alcohol is harmful, Siconolfi said. Unlike those “sick quitters,” many are abstaining proactively — not for illness but for wellness.

“I’m always looking at it in reverse,” said Akhil Anand, MD, addictions psychiatrist at Cleveland Clinic in Cleveland. “As doctors, we’re always looking at pathology, and you start to have this almost biased thinking…but it can be refreshing to tilt our frame of thinking.”

“We’re at an inflection point,” Siconolfi said. “Evidence about the health risks of alcohol use is becoming clearer, along with a growing visibility of sober curiosity and abstinence challenges like Dry January and the proliferation of nonalcoholic options in nightlife and retail settings. Health and wellness goals are primary drivers for many people.”

Engaging Today’s Healthy Abstainers

The cultural change may be fledgling, but the body of knowledge on substance use offers key guidance that clinicians can put into practice today, experts said.

Take any opening your patient offers.

“If someone is telling you that they cut back, the number one thing to do is to cheerlead, support, and congratulate them,” said Anne Fernandez, PhD, clinical psychologist and associate director of health services and policy at Rutgers University’s Addiction Research Center. “Ask them how they did it and why — get a conversation going, and try to be supportive. That may lead to them opening up more about what their goals are.”

Drinking patterns today are different from past generations, Anand said. Some who say they’ve cut back may still participate in high-intensity drinking — 10 or more drinks on a single occasion — and “that’s happening more and more,” he said. “Binge drinking is as bad, if not worse, for your liver, so we’re seeing younger people get sicker.” Others may have gone Cali sober: More young people use cannabis daily or near daily than report drinking.

People of all ages can succumb to the “abstinence violation effect, where a setback becomes all-or-nothing thinking that leads to abandoning the goal entirely,” Siconolfi said. Abstinence or reduction is known to be nonlinear, and you can help prepare your patient and normalize setbacks.

A Shift in Clinical Approach

The new way to approach changes in alcohol use is to avoid a focus on quitting. The addictions field no longer views alcohol use as binary — that someone uses or abstains, Fernandez said. That’s because there are so many paths one can take when moving away from alcohol.

One philosophy that clinicians can bring to the conversation is that there are routes to sobriety yet to be discovered, Anand said.

“I had a patient the other day, and he’s not doing anything textbook — no evidence-based therapy, he’s not taking any medications for cravings, he’s not going to AA [Alcoholics Anonymous] meetings, and he didn’t go to residential treatment,” Anand said. “He’s medically ill, and what he has done is he’s been meeting with his pastor frequently. He actually started going to church again and joined a church community.”

“It’s weird — I’m a doctor, and I can look at labs and look at the PHQ-9 [Patient Health Questionnaire-9], but I’m always following what patients are doing in their community. For a lot of folks who do drink, alcohol is really part of their community,” Anand said.

When working with patients who don’t meet alcohol use disorder criteria, you can still take a page from the growing body of evidence around nonabstinent recovery, such as examining whether patients are making safer choices or if their quality of life improves.

“I think a lot about, ‘What is a good outcome for someone?’” Fernandez said.

Another source for practice guidance is natural recovery evidence, and interestingly, it links back to what many say are the underlying factors driving the cultural turn against alcohol. A systematic review found that the most important factor for people who self-recover from alcohol use disorder is social support or a change in social group.

The New Toast to the Future

Today’s youth are experiencing what some consider delayed adulthood. Traditional milestones like marriage, parenthood, and finding a long-term career are happening later in life, and researchers are seeing a parallel shift in social risk-taking behaviors, including alcohol use, Fernandez said.

“People aren’t going to parties. Bars are struggling,” and have started marketing to the 40-something crowd, she said.

A generation from now, public health data could look very different if the trend holds. Age of first alcohol use is a cornerstone in the risk formula for substance use disorder. In theory, young people’s lack of alcohol use should translate to reduced risk for problematic drinking later in life and, in turn, fewer alcohol-related health conditions.

“A snowball effect is likely playing a part here, too, given what we know about the power of social norms,” Siconolfi said. “There are multiple cues in the environment that it’s OK and even normative to abstain. Fewer people are drinking, bars and restaurants are offering a wider range of alcohol-free options, Dry January is gaining visibility and participation, and people are sharing on social media about their experiences cutting back.”

Siconolfi and a team of RAND researchers are currently studying the longitudinal links between interpersonal connection and drug use. “For this study, adults complete a survey each year about their alcohol and other drug use, health and mental health, and social relationships,” including experiences of isolation and overconnection, Siconolfi said. The goal is to better understand real-world peer influences to help “inform better prevention and treatment.”

So, the next time a patient mentions cutting back, don’t just check the box. The guidance you offer today might just ripple out to a generation.

The experts cited in this article reported having no relevant disclosures.