(Mis)understanding alcohol use disorder: Making the case for a public health first approach

'Alcohol use disorder' (AUD) is used by several contemporary conceptualizations to identify, treat and prevent problems associated with alcohol use. Such conceptualizations encompass diagnostic classifications and broader frameworks for policy and practice. However, current AUD concepts are subject to multiple tensions and limitations in capturing and responding to the complex and heterogeneous nature of alcohol problems. Further, public understandings of alcohol problems are heavily divergent from professional AUD concepts and remain embedded within an 'alcoholism' master narrative in which disease model stereotypes come with multiple costs for prevention and 'recovery'. The persistence of a problematic 'alcoholism' paradigm reflects the coalescing of multiple forces including the cognitive appeal of reductionism, motives to stigmatize and 'other', and an over-emphasis on AUD as an individually located biomedical problem. Public misperceptions of AUD as a matter of the individual, the individual's essence, and misconceived notions of responsibility and control have been bolstered by industry interests and the ascension of neuroscience and genetics, in turn diverting attention from the importance of the environmental and commercial determinants of health and the effectiveness of under-utilized public health policies. We call for multiple stakeholders to support efforts to prioritize a public health first approach to advancing AUD research, policy and treatment in order to make significant advances in AUD prevention and treatment. We offer several recommendations to assist in shifting public understanding and scientific limitations in AUD concepts and responses.