Zero tolerance for 0%? How should clinicians and other practitioners respond to the use of alcohol-free and low-alcohol products in higher risk groups.

Alcohol-free and low-alcohol drinks (no/lo drinks) are now widely available and popular with consumers in high-income countries; however, it is unclear whether clinicians and others working to prevent or treat severe alcohol-related health problems should take a zero-tolerance approach to these alcohol-like products or encourage patients to try them. We argue that no/lo drinks may have an important role to play for people who drink at high-risk levels and those with alcohol use disorders (AUD) or alcohol-related liver disease (ARLD), particularly where debate and guidance related to treatment of these problems considers goals other than abstinence. The limited available evidence available suggests no/lo drinks may be useful in supporting attempts to reduce alcohol consumption or maintain abstinence among high-risk drinkers who do not have severe AUD or ARLD; however, they may also entail significant risks of relapse in those recovering from AUD. We therefore need further experimental and longitudinal studies testing whether use of no/lo drinks can lead to, or support, reductions in alcohol consumption. We particularly need high-quality experimental studies to test whether exposure to and sustained use of no/lo drinks affects treatment and recovery outcomes. Evidence is also needed on which subgroups of AUD and ARLD patients would benefit or be at risk from use of either alcohol-free or low-alcohol drinks. Finally, guidance should recognise that many patients already use these products and that a zero-tolerance approach may alienate patients or erode trust in clinicians.