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In small studies, Screening, Brief Intervention and Referral to Treatment (SBIRT) in Emergency Departments (EDs) is effective in reducing hazardous alcohol use.To examine the effectiveness of SBIRT at an inner-city ED in routine clinical practice.Of the 41 900 consecutive ED patients aged 18 years and older, 22 537 (53.8%) were screened using the Alcohol Use Disorders Identification Test (AUDIT-C). Patients with positive AUDIT-C scores (men≥5 and women≥4) received educational leaflets. Brief interventions were performed by ED personnel trained in motivational interviewing. At 3 months, patients were contacted by telephone and recent drinking pattern was assessed.Out of 22 537 patients, 2209 (9.8%) had an elevated AUDIT-C score. Male sex, alcohol-related reason for ED visit, alcohol or other intoxication at ED visit, head injury, stomach or intestinal bleeding and wounds were significant predictors of hazardous alcohol use in both univariate and multivariate analysis (all P<0.001). Out of 2209 patients, 894 (40.5%) AUDIT-C-positive patients received an intervention: of these 894 patients, 70% received educational material and 30% received motivational intervention and educational material. In the subset of patients available for follow-up, 34.9% either reduced or stopped alcohol use.Our study shows that in a large inner-city ED, SBIRT can be implemented in daily care. Screening uncovered large numbers of patients with hazardous alcohol use and identified several risk factors. Moreover, screening and intervention appeared to be effective in reducing alcohol intake.