BACKGROUND. Alcohol risk and harm reduction is a public health approach that goes beyond specialized treatments for alcoholism. The greatest potential for reducing alcohol risk and harm in a population depends on the extent to which health care practitioners use secondary prevention programmes. OBJECTIVE. We aim to assess the factors that affect the prospects of disseminating comprehensive, secondary prevention programmes into mainstream practice. METHOD. A decision balance was used to assess the prospects of practitioners implementing comprehensive programmes systematically. The stages-of-change model provides perspectives about behaviour change with regard to patients, practitioners and practice settings. RESULTS AND CONCLUSIONS. Programme implementation is extremely unlikely given the current organization of health care settings. To maintain the use of such programmes, we need to change the "unit of leverage" in the system: from the clinical encounter--that is, practitioners working with individual patients in a case-finding manner--to an organizational level--that is, the appropriate use of managerial and information systems supporting health care settings to identify at-risk patients systematically as they enter primary care and hospital settings. With appropriate infrastructure support, practitioners will be able to fulfil the potential for as well as maintain the use of comprehensive, secondary prevention programmes to reduce alcohol risk and harm in the population.