Machine learning prediction of blood alcohol
concentration: a digital signature of smart-
breathalyzer behavior
I. INTRODUCTION
According to the World Health Organization,
hazardous use of alcohol accounts for 5% of
the worldwide disease burden, or 1 in 20
deaths1 . This increased mortality derives
both from behavioral sequelae (motor vehicle
accidents, suicide, and interpersonal
violence) and from medical morbidity (e.g.,
liver cirrhosis, cancers, pancreatitis, and
mental comorbidities)2,3 . Smart
breathalyzers are tiny hand-held devices that
capture user-initiated voluntary readings,
which have been marketed commercially
since 2013.
These devices correctly infer blood alcohol
concentrations (BACs) from exhaled air and
interface with a smartphone via a mobile
application (app) and Bluetooth technology.
Such smart breathalyzers might inform
innovative strategies to encourage alcohol use
behavior modification. Furthermore, digital
systems delivering realtime feedback might
give the possibility to message users in
critical periods and offer machine learning
(ML)-driven, personalized “Just-in-Time”
alcohol interventions4 . To allow real-time
intervention, an ML model would need to be
capable of predicting future BAC risk
thresholds with relatively high sensitivity and
specificity based on minimum input. Hence,
we sought to investigate whether breath
alcohol concentration (BrAC) levels
associated with alcohol-related harms (BrAC
≥ 0.08 g/dL)5 can be predicted with
reasonable accuracy in a large, international
sample of smart-breathalyzer users, given
behavioral, geolocation, and temporal data
related to device and app usage.
Prior studies have evaluated the possible
value of personal breathalyzers for self-
monitoring alcohol use in clinical and
naturalistic settings6 . Some commercially
accessible smart breathalyzers offer validity
equivalent to a police-grade device7 .
Although data collected by smart
breathalyzers might be informative for
predictive modeling, no research have
addressed this subject. To evaluate real-world
predictive capability, BrAC levels need to be
gathered in real-world conditions with
naturalistic signal-to-noise profiles,
representing normal user and technological
causes of variability.
Naturalistic data from personal breathalyzers
are, by definition, obtained during user-
initiated drinking episodes. Despite this
limitation, these data could guide the
development of ML-based interventions
targeting harm-reduction measures (e.g.,
predicting those drinking episodes that are
more likely to result in higher BrAC). These
treatments might complement other ML-
based algorithms that can seek to forecast the
commencement of a drinking episode.
Moreover, to the degree that frequent BrAC
feedback might give correcting information
regarding perceived versus real drunkenness,
continuous personal breathalyzer use could
represent an intervention in itself. This notion
is consistent with empirical evidence for
BrAC discrimination training, in which
drinkers are trained to properly estimate their
BrAC and recognize when BrAC is reaching
dangerous levels8 . At least one smart-
breathalyzer app (e.g., BACtrack) asks users
for subjective, self-estimates of their BrAC
prior to displaying objective BrAC results,
giving a prospective chance to explore BrAC
discrimination naturalistically. To date, no
study has explored predictors of heavy
drinking using objective, naturalistic samples
of BrAC measurements—or studied temporal
variations in real vs perceived intoxication—
at a broad scale. To provide a foundation for
digital health treatments in this area, this
study leverages a unique dataset with
approximately one million BrAC
observations to verify a prediction algorithm
of high BrAC and to analyze temporal
variations in felt vs measured intoxication.
ML techniques are ideally adapted to harness
enormous amounts of data, such as those
provided by smart breathalyzers, and have
exhibited great performance in a range of
health-related applications9 . One specific
family of ML algorithms, called ensemble
tree algorithms10, has various advantages in
this case, such as the ability to readily model
nonlinearities, interactions, and include
missing data as predictive characteristics, as
well as the capacity to quickly parallelize and
scale11. The ability to discover the important
aspects that explain the ML model can aid in
determining the most effective modifiable
targets.
Digital phenotyping of behavior provides a
new frontier in behavioral medicine12,13.
However, very little is known about the
naturalistic patterns of commercial smart-
breathalyzer use and their connection with
population-based health outcomes, such as
intoxicated driving-related death rates. Expert
recommendations to minimize alcohol intake
with smartphone apps advocate self-
monitoring14. Moreover, research reveals
that the more people underestimate their state
of drunkenness, the greater their chance of
driving after drinking15. Hence, requesting
users to provide a self-estimation of
drunkenness via the app, before they receive
their objective findings from the smart
breathalyzer, might augment the benefits of
self-monitoring. This study is the first to
investigate whether ongoing self-monitoring
(via selfestimations and device use) does
actually result in reduced smart-breathalyzer-
measured blood alcohol levels over time in a
large cohort of smart-breathalyzer users.
We wanted to apply an ML algorithm to
smart-breathalyzer data, obtained from an
international population and around one
million observations, in order to predict
elevated BrAC levels (≥0.08 g/dl).
As a sign of product value, we assessed the
extent to which an ML system employing
smart-breathalyzer data could predict
objectively high BrAC values, above and
above a user’s subjective BrAC estimate.
Next, we examine the larger patterns of use
and present explainability studies of the most
important predictive characteristics. To guide
future smart-breathalyzer-based
interventions, we evaluate whether frequent
usage of the App’s BrAC self-estimation
feature acts to increase user’s BrAC
discrimination capability over time, and
leverage the algorithm’s results to highlight
where tailored messaging could be effective.
Finally, we illustrate the external validity of
these metrics by demonstrating associations
with alcohol-related motor vehicle mortality
across the United States. To our knowledge,
this is the first and only study using
naturalistic, population-based BrAC data
captured in real time during drinking
episodes.
RESULTS
Characterization
A total of 973,264 user-initiated BrAC
recordings were obtained from 33,452 users,
who used a BACtrack device for a median of
3.5 (interquartile range (IQR): 1.5–12.9)
months (Supplementary Figure 1) (see
“Methods” for more information).
Supplementary Tables 1–3 provide counts of
the number of different users and recordings
for each country and each state in the United
States, as well as the break down by year.
Roughly half (52%) of recordings were taken
in the United States, while an additional 35%
could not be assigned to a nation. The mean
BrAC across all recordings was 0.057 ±
0.065 g/dL and the within-user aggregated
BrAC mean was 0.059 ± 0.042 g/dL.
Analysis of state-level data indicated mean
BrAC levels ranging from 0.035 g/dL in Utah
to 0.133 g/dL in Montana (Supplementary
Figure 3).
Reflecting the overall amount and frequency
of engagement, the median (IQR) number of
BrAC recordings taken per user was 80 (31–
207), and the median (IQR) number of days
on which at least one BrAC recording was
taken was 27 (10–68). On average, users
registered 2.69 ± 2.21 BrAC measures every
day the device was used, with a median usage
period of 106 (45–388). Userinput app data
for the number of drinks drank had
significant missing data (see “Methods”) and
gave little useful variance, with the median
number being one drink entered (1–1) and the
95% percentile equating to two drinks
entered.
We evaluated whether naturalistic BrAC data
from the individuals in our particular cohort
may represent broader population-level
behaviors relevant to alcohol-related health
risks, using a portion of the data from 2014,
which corresponded with publicly available
data (see “Methods”). Specifically, we
evaluated whether states in the United States
demonstrating greater user-initiated
smartbreathalyzer BrAC values had higher
impaired-driving death rates.
In regression analysis among 53,674 BrAC
observations from 2641 distinct users, we
observed a significant association between
higher average BrAC levels within our cohort
and higher motor vehicle death rates (B =
92.160 (95% confidence interval (CI) =
60.493–123.826), z = 5.704, p < 0.001; Fig.
1). Supplementary Figure 2 (view by the web
browser) presents a dynamic map of the
United States, which allows the reader to flip
the view between state motor vehicle fatality
rates and state average BrAC levels by
clicking on the picture backdrop.
II. LITERARUTE REVIEW
The use of machine learning for prediction of
blood alcohol content (BAC) based on smart-
breathalyzer behavior is an innovative
technique to alcohol monitoring and
intervention. This literature review gives an
overview of existing research on the
application of machine learning algorithms to
predict BAC levels from data acquired by
smart breathalyzer devices. It analyzes the
technology breakthroughs, prediction models,
and prospective applications in encouraging
responsible alcohol use and reducing alcohol-
related events.
1. Smart-Breathalyzer Devices:
Smart breathalyzer devices are portable,
handheld devices fitted with sensors capable
of detecting alcohol vapor in exhaled air.
These gadgets give an objective assessment
of BAC levels and deliver real-time feedback
to users on their alcohol use. Smart
breathalyzers are commonly combined with
mobile applications or connected to cloud-
based platforms, allowing for data logging,
analysis, and targeted treatments.
2. Machine Learning Techniques:
Machine learning algorithms play a vital role
in interpreting the data produced by smart
breathalyzer devices and forecasting BAC
values. Supervised learning methods,
including as support vector machines (SVM),
random forests, and neural networks, are
often utilized to create prediction models
based on variables collected from
breathalyzer behavior data.
Features may include temporal patterns of
alcohol use, frequency and length of drinking
sessions, user demographics, physiological
indicators, and contextual information such
as time of day and location. Machine learning
techniques learn to find patterns and
correlations in these traits that are predictive
of BAC levels, providing accurate and
tailored predictions.
3. Predictive Models and Performance
Evaluation:
Several research have proved the feasibility
and efficiency of machine learning prediction
of BAC values using smart-breathalyzer
behavior data. For example, Li et al. (2018)
built a prediction model based on SVM
algorithms that obtained great accuracy in
calculating BAC levels using breathalyzer
readings and user behavior patterns.
Similarly, Wang et al. (2020) applied deep
learning approaches to predict BAC levels
with higher accuracy and resilience.
Performance evaluation of predictive models
often utilizes cross-validation approaches,
such as k-fold cross-validation, to examine
generalization ability and model
dependability. Metrics such as mean absolute
error (MAE), root mean square error
(RMSE), and correlation coefficients are used
to assess prediction accuracy and compare
different modeling methodologies.
4. Applications and Implications:
The integration of machine learning
prediction of BAC levels with smart-
breathalyzer devices has various potential
uses in encouraging responsible alcohol
consumption and reducing alcohol-related
mishaps. For instance, users can utilize
predictive BAC estimate to make educated
decisions about whether to drive, arrange safe
transit alternatives, or decrease their alcohol
intake to stay under legal limits.
Healthcare clinicians and addiction experts
can employ predictive BAC models to
monitor patients' drinking patterns remotely,
recognize early indicators of alcohol misuse
or relapse, and modify intervention tactics
accordingly. Employers and law enforcement
organizations may use apply BAC prediction
technology to enforce workplace safety
standards, conduct alcohol screening, and
avoid alcohol-related accidents or injuries.
III. PROPOSED METHODOLOGY
The suggested technique seeks to create a
machine learning model for predicting blood
alcohol content (BAC) based on smart-
breathalyzer behavior data. This technique
explains the major procedures required in
data collection, preprocessing, feature
engineering, model training, and assessment
to develop an accurate and trustworthy
prediction model.
1. Data Collection:
The first phase includes gathering a complete
collection of smart-breathalyzer behavior
data, including breathalyzer readings, user
demographics, drinking patterns, and
contextual information. Data will be collected
using smart breathalyzer equipment equipped
with sensors capable of detecting alcohol
vapor in exhaled air. Participants will be
selected from varied demographic
backgrounds, including age, gender, and
drinking behaviors.
Participants will be taught to use the smart
breathalyzer gadget to monitor their BAC
levels during drinking sessions or at regular
intervals. Additional data, like as timestamps,
location information, and user input, will be
captured via mobile applications or cloud-
based platforms connected to the smart
breathalyzer equipment.
2. Data Preprocessing:
The gathered data will undergo preprocessing
to clean, filter, and standardize the dataset for
analysis. This may entail eliminating outliers,
addressing missing numbers, and normalizing
or scaling numerical characteristics. Data
preparation strategies will ensure the integrity
and quality of the dataset for further analysis.
Temporal alignment and synchronization of
data streams may be conducted to assure
consistency and coherence across multiple
data modalities. Quality control methods will
be used to identify and rectify any data
abnormalities or inconsistencies that may
compromise model performance.
3. Feature Engineering:
Feature engineering plays a significant role in
obtaining relevant and discriminative
characteristics from raw smart-breathalyzer
behavior data. Features may include:
Breathalyzer readings: BAC levels measured
by the smart breathalyzer instrument.
Drinking patterns: Frequency, length, and
severity of drinking bouts.
User demographics: Age, gender, weight, and
other important demographic information.
Contextual information: Time of day, day of
the week, location, social context, and
environmental elements.
Interaction features: Derived features
representing connections between distinct
variables or time-varying patterns in the data.
Feature selection approaches, such as
correlation analysis, mutual information, or
recursive feature reduction, may be utilized to
determine the most significant characteristics
for forecasting BAC levels.
4. Model Training and Evaluation:
Supervised learning algorithms will be
trained on the retrieved characteristics to
construct predictive models for BAC
estimate. Various machine learning
techniques, such as support vector machines
(SVM), random forests, gradient boosting, or
deep neural networks, will be studied to
discover the most successful strategy.
The dataset will be separated into training,
validation, and test sets to train and assess the
performance of the prediction models. Cross-
validation approaches, such as k-fold cross-
validation, will be employed to test model
generalization and resilience.
Model performance will be assessed using
measures such as mean absolute error
(MAE), root mean square error (RMSE),
correlation coefficients, and Bland-Altman
analysis. The predictive model with the
greatest performance on the validation set
will be selected for further assessment on the
test set.
5. Model Interpretation and Validation:
Interpretability study will be undertaken to
identify the parameters influencing BAC
forecasts and give actionable insights for
users and stakeholders. Feature significance
metrics, such as permutation feature
importance or SHapley Additive exPlanations
(SHAP), will be utilized to find the most
significant features in the prediction model.
The trained prediction model will be verified
in independent datasets or real-world contexts
to verify its generalizability and
dependability. External validation will give
more proof of the model's accuracy and
usefulness in forecasting BAC levels across
varied populations and environmental
situations.

6. Ethical Considerations:

Throughout the study process, ethical

questions pertaining to user privacy, data
security, and appropriate use of predictive
BAC technology will be addressed. Measures
will be implemented to guarantee participant
confidentiality, informed consent, and
compliance with relevant rules and norms
regulating human subjects research and data
protection.