Exploring Phosphatidylethanol Cutoffs for Self-Reported Unhealthy Alcohol Use: An International Multi-Site Analysis

Authors

• Pamela M. Murnane, University of California, San Francisco, San Francisco, CA
• Fan Xia, University of California, San Francisco, San Francisco, CA
• Majid Afshar, University of Wisconsin-Madison, Madison, Wi
• Jennifer L. Brown, Purdue University, West Lafayette, IN
• Gabriel Chamie, University of California San Francisco, San Francisco, CA
• Robert L. Cook, University of Florida, Gainesville, FL
• Marie Claude Couture, University of San Francisco, San Francisco, CA
• Ralph J. DiClemente, New York University, New York, NY
• Robin Fatch, University of California San Francisco, San Francisco, CA
• Tekeda Ferguson, LSU Health Sciences Center - New OrleansFollow
• Joel M. Francis, University of the Witwatersrand, Johannesburg, South Africa
• Jessica E. Haberer, Massachusetts General Hospital, Boston, MA
• Karen R. Jacobson, Boston University, Boston, MA
• Amy C. Justice, VA Connecticut Healthcare System, West Haven, CT
• Saidi Kapiga, Mwanza Intervention Trials Unit, Mwanza, Tanzania
• Theresa W. Kim, Boston University, Boston, MA
• Evgeny Krupitsky, Pavlov University, St. Petersburg, Russia
• Gregory M. Marcus, University of California San Francisco, San Francisco, CA
• Patricia E. Molina, LSU Health Sciences Center - New OrleansFollow
• Winnie R. Muyindike, Mbarara University of Science and Technology, Mbarara, Uganda
• Bronwyn Myers, Curtin University, Western Australia, Australia
• Kimberly Page, University of New Mexico, Albuquerque, NM
• Shane A. Phillips, University of Illinois at Chicago, Chicago, IL
• Mariann R. Piano, Vanderbilt University School of Nursing, Nashville, TN
• Veronica L. Richards, University of Oklahoma, Tulsa, OK
• Kaku So-Armah, Boston University, Boston, MA
• Scott Stewart, University at Buffalo, Buffalo, NY
• Mark S. Sulkowski, Johns Hopkins University, Baltimore, MD
• et al

Document Type

Article

Publication Date

6-25-2026

Publication Title

Alcohol Clinical and Experimental Research

Abstract

Background: Unhealthy alcohol use is a preventable cause of morbidity and mortality, yet screening is hampered by inaccurate reporting. Phosphatidylethanol (PEth) is a biomarker that quantifies total drinking over the past 2-4 weeks, but PEth cutoffs for unhealthy drinking have not been well-examined. Methods: We pooled data from 22 studies (11,088 persons globally) that previously collected PEth and self-reported alcohol use. Within a 90% training set, we calculated PEth cutoffs per Youden's J in 1000 bootstrapped samples and explored differences by region, age, sex, race/ethnicity, body mass index (BMI), HIV status, hemoglobin level, and an indirect serum marker of liver fibrosis, FIB-4. For each cutoff, we estimated sensitivity, specificity, and positive and negative predictive values in a 10% validation dataset. We used two definitions for self-reported unhealthy drinking per Alcohol Use Disorders Identification Test Consumption (AUDIT-C) and National Institute on Alcohol Abuse and Alcoholism (NIAAA). Results: Optimal PEth cutoffs using self-reported alcohol use as the reference standard differed substantially by region. The cutoff for AUDIT-C-measured unhealthy alcohol use in studies from the United States (US) was 14.0 ng/mL (95% CI: 12.3-18.6) with 73.0% sensitivity (95% CI: 67.3-79.1) and 77.4% specificity (95% CI: 73.2-81.4); and was 65.7 ng/mL (95% CI 19.3-90.7) in studies from Africa, with 71.7% sensitivity (95% CI: 64.4-78.7) and 65.2% specificity (95% CI: 58.1-72.7). Cutoffs for AUDIT-C did not differ between subgroups in the US, but within Africa, cutoffs were higher for men and lower for those with BMI ≥ 25 kg/m2. Cutoffs for NIAAA defined unhealthy alcohol use were similar to those using the AUDIT-C. Conclusions: Using self-report as the reference standard, PEth cutoffs differed substantially by region and by some other characteristics, which may be attributable to differences in PEth formation, elimination and/or reporting bias. Further work using objective gold-standard measures of alcohol consumption is needed for more definitive conclusions.

PubMed ID

42345465

Volume

50

Issue

6

Comments

See article for full author list

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Recommended Citation

Murnane, Pamela M.; Xia, Fan; Afshar, Majid; Brown, Jennifer L.; Chamie, Gabriel; Cook, Robert L.; Couture, Marie Claude; DiClemente, Ralph J.; Fatch, Robin; Ferguson, Tekeda; Francis, Joel M.; Haberer, Jessica E.; Jacobson, Karen R.; Justice, Amy C.; Kapiga, Saidi; Kim, Theresa W.; Krupitsky, Evgeny; Marcus, Gregory M.; Molina, Patricia E.; Muyindike, Winnie R.; Myers, Bronwyn; Page, Kimberly; Phillips, Shane A.; Piano, Mariann R.; Richards, Veronica L.; So-Armah, Kaku; Stewart, Scott; Sulkowski, Mark S.; and al, et, "Exploring Phosphatidylethanol Cutoffs for Self-Reported Unhealthy Alcohol Use: An International Multi-Site Analysis" (2026). School of Public Health Faculty Publications. 596.
https://digitalscholar.lsuhsc.edu/soph_facpubs/596
10.1111/acer.70361