Challenging Dogma - Fall 2009

Tuesday, December 15, 2009

The Failures of College Drinking Interventions: Learning from the Past and Moving Forward – Nick McNeill

Introduction

Misuse of alcohol has been documented to be a critical public health issue for many years. Problematic drinking has specifically been seen to occur in young adulthood (1), with the highest prevalence rates of abuse and dependence arising in individuals ages 18-29 (2). Given 90% of college students fall between those ages (3) - and that national surveys have shown 40% of college students report heavy-episode drinking (usually defined as four or five drinks in one sitting for women and men, respectively) (4) and 18% suffer from clinically significant alcohol-related problems (5) – alcohol use among college students represents a serious public health threat.

College drinking’s salience as an emerging public health crisis is exemplified in the numbers, as approximately 1,700 unintentional deaths, 97,000 sexual assaults, and 500,000 injuries that occur each year to college students can be attributed to alcohol use (6). Furthermore, problematic drinking among college students is also associated with a myriad of other direct and indirect consequences, such as unplanned sexual activity, vandalism, blackouts, suicide attempts, poor class attendance, stealing, trouble with authorities, physical illness, and relationship issues (7). Most disconcerting, however, is that alcohol-related deaths, heavy drinking episodes and drunk driving have all been on the rise on college campuses over the past decade (8).

Drinking-related accidental deaths among 18- to 24-year-old students have increased from 1,440 in 1998 to 1,825 in 2005. In addition, the proportion of students who reported recent heavy episodic drinking rose from roughly 42% to 45%. Finally, the proportion who admitted to drinking and driving in the past year increased from 26.5 % to 29%. So, given college drinking is not going away, but actually getting worse, the question remains: why are interventions aimed at decreasing college drinking failing? While there are a number of different explanations as to why these public health interventions have been unsuccessful, I will discuss what I believe are three of the most critical mistakes these interventions have committed.

First, the majority of alcohol education programs for students have been individually focused and abstinence-based “browbeating” sessions, which ignore the idea that harm reduction exists on a continuum that begins with abstinence and ranges to practices that minimize the likelihood of negative consequences, such as moderating the amount of alcohol consumed. Second, many schools have focused their efforts primarily on the students, largely ignoring the broader environmental context in which college drinking occurs. Finally, although research has found social norms to be among the best predictors of college drinking (9), public health interventions have not done enough to correct inaccurate perceptions of norms and attitudes regarding college drinking, leading to the reinforcement and perpetuation of abusive drinking patterns. In turn, I will propose a comprehensive intervention that I believe can address these three errors and succeed where others in the past have failed.

The Folly of Promoting Alcohol Abstinence Programs

Though the minimum drinking age in the U.S. stands at twenty-one, its common knowledge that many adolescents and young adults who are underage consume alcohol, including those who are in college. Yet, many drinking prevention strategies - such as those in high school or college - virtually ignore this fact, unrealistically and irresponsibly setting out to achieve zero tolerance via the stigmatization of alcohol (10). In addition, by attempting to scare college students into alcohol abstinence, we run the risk of causing the very thing we’re trying to prevent – the misuse of alcohol.

The phenomenon of the “boomerang effect” in public health interventions has been well documented (11) and has principally come out of psychological reactance theory (PRT) (12-14). Developed by a psychologist by the name of Brehm, PRT basically espouses the concept of reverse psychology, which argues that people react against threats to their freedom of choice by experiencing and yielding to pressure to reestablish that freedom, including pressure to engage in the prohibited behavior. The argument follows that college students who are exposed to anti-drinking messages may react against them by not only expressing pro-drinking sentiments, but also more dangerously, by engaging in problematic drinking behavior.

In addition to looking at the possible consequences of “boomerang effects,” research studies have also examined the effectiveness of college alcohol education programs, comparing those that present an abstinence-only message with those that present drinking in moderation as an option. The results are clear: programs accepting responsible use of alcohol are demonstrably more successful than are abstinence programs (15). Despite good intentions and the spending of massive amounts of money and energy, the best research shows that our current abstinence-oriented alcohol education is ineffective. Therefore, http://www2.potsdam.edu/hansondj/references/UnderageDrinking.html - 27instead of stigmatizing alcohol and trying to scare people into abstinence, we need to recognize that it is not alcohol itself but rather the abuse of alcohol (i.e. binge drinking) that is the problem.

Clearly, the most effective way to avoid negative consequences is not to drink. However, despite the minimum legal drinking age of twenty-one, that's not the reality for the overwhelming majority of college students. Therefore, harm-reduction approaches logically opine that it's ultimately more realistic and effective to try and meet someone where their currently at and work together to reduce risks and negative consequences rather than to recommend complete abstinence from alcohol.

Environmental Context: Looking Past the Individual

Many schools have primarily focused their efforts on students - for example, offering counseling to those who've been found to have a potential drinking problem. While it’s clear that I don’t ascribe to interventions that emphasize an abstinence approach to alcohol, I do believe there is merit in having programs and policies in place that are geared towards students. With that being said, another problem with most college drinking interventions is that they have solely emphasized the individual student, and by doing so, have largely ignored the broader environmental context in which college drinking occurs (16). This is a critical failure for a number of reasons.

The idea that individual beliefs, attitudes, and behaviors occur in a social context has been a staple of a number of social sciences theories, most notably the Behavioral Ecological Model (BEM), a multi-faceted expansion of social cognitive theories (17). The BEM states that health promotion, such as curbing the prevalence of college drinking, can be more successfully accomplished through changing one’s social environment (18). As a result, it emphasizes the importance of considering multiple levels of influence and the role of the environment on behavior (19, 20). The five levels of influence which make up the BEM are: intrapersonal or individual factors; interpersonal factors; institutional or organizational factors; community factors; and public policy factors (21). What the majority of college drinking interventions most lack is a broader focus on communal and institutional factors.

Community factors, such as social networks, can have a detrimental impact on students and their drinking habits. A social network that doesn’t deem college drinking to be an issue (i.e. the school, the student’s peers, and people in the community) will probably lead to the student themselves also not seeing their drinking or others drinking as a problem (22). Similarly, the mass media can also harmfully contribute to college drinking, via beer or liquor commercials that glamorize partying or anti-drinking commercials which stigmatize the use of alcohol, which in turn unintentionally cause students to misuse alcohol. Finally, the availability and accessibility of bars and liquor stores can also have a significant effect on students’ drinking habits, as increased alcohol availability is associated with increased alcohol consumption (23).

Institutional factors - such as a school’s policies, culture, or living arrangements - can also have a significant effect on students’ drinking habits. Studies have shown that heavy drinking behavior of students is more common in college environments that have: a strong drinking culture; few alcohol control policies on campus or in the surrounding community; and weak enforcement of existing policies (24). In addition, students’ drinking behaviors also differ as a function of living arrangement (25). On-campus living is usually associated with heavier drinking than off-campus living, especially if a student lives with their parents (26). Finally, among on-campus living types, students living in Greek houses (fraternities/sororities) have a greater level of alcohol use and misuse as compared to those living in dorms (27).

Given that drinking, and specifically binge drinking, among college students has been tied to conditions in the environment, current and future interventions must re-think their approaches to the problem. Rather than narrowly focused on the individual student, interventions will have to be aware of and account for the many different influences on college students’ drinking behavior.

Inaccurate Social Norms & Unrealistic Optimism: A Recipe for Disaster

Though many college interventions incorrectly focus on abstinence education and for the most part disregard the influence a student’s environment has on their drinking, perhaps the biggest failure of these public health interventions is their inability to correct inaccurate perceptions of social norms and attitudes regarding college drinking. In turn, this leads to the reinforcement and perpetuation of abusive drinking patterns.

Social norms can be categorized into two main categories: descriptive norms (perceptions of what others do) and injunctive norms (perceived opinions of relevant others) (28). Perceived descriptive drinking norms refer to the perceived prevalence of drinking, such as the perceived quantity and frequency of alcohol consumption (29). Studies have shown that college students have a generalized tendency to overestimate descriptive norms (30). Furthermore, students who reported higher perceived descriptive norms for alcohol use of their peers have also been shown to report heavier drinking themselves.

Perceived injunctive norms refer to the perceptions of how much others approve of a particular behavior, and are tantamount with subjective norms, a crucial aspect of both the Theory of Reasoned Action (TRA) (31) and the Theory of Planned Behavior (TPB) (32). Similar to research on descriptive norms, studies have shown that college students usually perceive their student peers as more approving of drinking behavior than they actually are (33). In addition, students who reported higher perceived injunctive norms, such as overestimating their student peers’ approval of their drinking, was also associated with heavier alcohol use (34). Misconceptions regarding both descriptive and injunctive norms must be corrected if we hope to reduce alcohol use among students, especially given they lead to college student drinkers being overly optimistic about the likelihood of experiencing future problems with alcohol.

Unrealistic optimism or optimistic bias about future life events has also been well documented in the literature (35-37). Optimism bias refers to the demonstrated systematic tendency for people to be over-optimistic about the outcome of planned actions, i.e. more optimistic that good things will happen to them and more optimistic that bad things are less likely to happen to them. This includes over-estimating the likelihood of positive events, such as owning your own home, living past 80, and traveling to Europe, and under-estimating the likelihood of negative events, such as having a drinking problem, attempting suicide, and being injured in a car accident. It is one kind of positive illusion – people’s beliefs about themselves, the world, and the future which are more positive than reality can sustain - to which people are susceptible.

This distorted perception of risk has important implications for public health interventions aimed at decreasing the prevalence of college drinking. If students don’t perceive themselves or their peers to have a drinking problem, and they actually do, such unrealistic optimism about their future can prompt risky behaviors and unfortunate consequences (38). As a result, we must come up with strategies and interventions that can help to curb unrealistically optimistic perceptions and ultimately reduce risky health behaviors.

Proposed Intervention: Harm Reduction, Environmental Context, and Correcting Social Norms

A comprehensive intervention that I will propose has the ability to address these three flaws of public health interventions aimed at reducing the prevalence of college drinking. First, my alternative intervention will move away from ineffective alcohol abstinence education programs for students and instead emphasize a more realistic and effective harm reduction strategy that will account for possible boomerang effects. Second, this alternative intervention will not only focus on the individual student, but also incorporate the broader environmental context in which college drinking occurs, including communal and institutional strategies to help reduce the prevalence of college drinking. Finally, this proposal will include strategies to correct inaccurate perceptions of social norms and unrealistic optimism regarding college drinking.

A Harm Reduction Continuum: Combating Reactance via BMI

Rather than employing an abstinence-based program towards reducing college drinking that stigmatizes the use of alcohol, I would instead opt for a program utilizing Brief Motivational Interventions (BMI). Studies have shown that students are particularly receptive to BMI, responding favorably to the concept of harm reduction rather than abstinence (39). For example, at the University of Central Florida, researchers found that BMI were effective in reducing alcohol consumption and drinking-related problems (40), which suggests that providing an opportunity to discuss alcohol-related information in a non-judgmental format can influence drinking behaviors (41). Furthermore, research has shown that BMI-based interventions have been more successful than alternative interventions at reducing alcohol use and problems, such as alcohol-education (AE) classes which promote abstinence (42).

BMI approaches generally work well in college populations and especially work well with students mandated to go for alcohol counseling for a number of reasons (43, 44). First, harm reduction through BMI exists on a continuum that starts with abstinence and ranges to practices which diminish the likelihood of harmful consequences, such as moderating consumption or using designated drivers. This is a much more realistic way of attempting to reduce drinking compared to abstinence.

Second, BMI is a collaborative, non-confrontational way of addressing behaviors like drinking. It is quite suitable for use with college students who consider themselves “emerging adults,” as they are a group very likely to resist authoritarian figures, because students’ peers are often the ones who conduct the sessions. The importance of using trained peer facilitators is especially relevant given our discussion of PRT earlier. PRT states that similarity is the most important factor one can use to decrease reactance (and in turn, possible boomerang effects) and increase compliance regarding a certain behavior. Therefore, using peers to conduct BMI sessions to reduce college drinking ensures a less threatening and more similar message to the student, as compared to using individuals who are older or more aggressive.

Third, BMI approaches also make a point of seeing where a student is currently at motivationally and trying to modify the intervention accordingly. In a BMI session, for example, if there is a student who is drinking heavily and experiencing negative consequences as a result of their behavior, but has given little thought to changing this behavior, the intervention would focus on increasing awareness of these negative consequences and both current and future risks related to those results.

Finally, BMI is cost effective, can be implemented by trained peer facilitators, and may lead to an increase in the likelihood of additional help seeking. These benefits are especially important when you consider mandated students, as they are far more likely to enter alcohol sessions more hesitantly.

No matter what we do, some college students are still likely to drink. The quicker we realize this fact the better the chance we have at mitigating the problem. As a result, we must make use of interventions such as BMI that utilize harm-reduction approaches, as not only are they more realistic than recommending complete abstinence from alcohol, but they are also more effective, particularly when they make use of trained peer facilitators who can decrease student reactance to such programs.

Broadening Our Perspective

College drinking doesn’t occur within a vacuum and is in fact influenced by a number of factors, such as environmental context. Recent studies have shown that there are effective ways to curb college drinking via changing students’ social environment. For example, two studies at the Universities of Rhode Island and Washington found that programs in which colleges worked with surrounding communities to target student drinking were effective in reducing heavy drinking and off-campus alcohol-related incidents (45). Therefore, one effective strategy to reduce college drinking seems to be getting the wider community at large to collaborate more with colleges, which can be done in a few different ways.

First, college environments that have a number of liquor stores and bars where students can buy alcohol, and may be influenced to do so by heavy marketing, low prices and special promotions, create conditions for not only college drinking, but more seriously, binge drinking. To change these types of conditions, colleges and local communities must work hand-in-hand and attempt to include more controls on the supply of alcohol, such as limiting the numbers of liquor stores and bars surrounding the college campus (46). Second, colleges must ensure that they work with the community to better enforce laws against underage drinking, fake identification (ID) cards, and alcohol-related violations, such as drinking and driving.

Third, colleges can collaborate with local media outlets (T.V., internet, radio) to put together more effective and realistic messages regarding college drinking. Finally, colleges can also work together with their local communities and implement measures like increased police patrols in problem neighborhoods and efforts to make students more aware of their responsibilities as community residents (47).

Another way in which colleges can reduce the prevalence of college drinking is by making changes to the actual institution. As we have seen, students’ drinking behaviors also differ as a function of living arrangement, i.e. on-campus living is usually associated with heavier drinking than off-campus living, students living in fraternities or sororities usually drink more than those living in dorms. In turn, creating alcohol-free or substance-free dormitories would be one possible intervention that could lessen the amount of college drinking.

Some research has already shown that substance-free college dorms can help to reduce heavy drinking (48). One study found that students who live in substance-free college dorms were 60% less likely to engage in heavy episodic drinking as compared to students living in unrestricted dorms. Furthermore, such students also experienced fewer alcohol-related problems. Finally, these students also experienced fewer secondhand effects of alcohol use by other students than students in unrestricted dorms, such as their property being vandalized or their possessions stolen.

Studies have also shown that college drinking, and specifically heavy drinking behavior of students, is more common in college environments that have few alcohol control policies on campus or in the surrounding community and weak enforcement of existing policies (49). As such, colleges must make a concerted effort to actually “walk the talk” and implement policies that no longer provide students with a simple slap on the wrist. Rather, institutions must deal with alcohol-related misconduct and incidents seriously and openly, appropriately punishing students for their transgressions but also giving them the counseling they need to get better.

Effective interventions must target multifaceted environments, including communal and institutional factors, if we are to reduce the prevalence of college drinking. By acknowledging that such alcohol use occurs in a broader context of influence, we have the ability to focus on multiple areas of need, giving us a better chance of succeeding where public health interventions have failed in the past.

Changing Normative Misperceptions

Social norms are among the best predictors of college student drinking, and given college students have a generalized tendency to overestimate both descriptive and injunctive norms, interventions must correct the disconnect between perception and reality (50). This can be specifically done by implementing interventions which take advantage of theories that espouse the power of group behavior, such as Social Network Theory (SNT) (51).

SNT is a group-level model which states that what determines behavior is social norms, and that these social norms are actually quite malleable if you understand the behavior that drives them. Specifically, the theory states that people within a respective network have the ability to directly influence and change each other’s behavior, i.e. the effect friends, family, co-workers, etc., can have on one another.

This theory has been shown to have validity, as research has shown that network phenomena are relevant to smoking behavior and obesity, as both have been shown to spread through close and distant social ties over time, described as “clusters” of behavior (52, 53). In addition, another study found that peers had an impact on grade point average and on decisions to join social groups such as fraternities, which is especially relevant given the topic of problematic college drinking (54). Furthermore, given our discussion earlier of how students’ unrealistic optimism regarding their future can prompt risky behaviors and unfortunate consequences, targeting the social network of students - especially those who have already gotten into trouble as a result of alcohol misuse - may be an effective strategy for changing drinking perceptions and behaviors.

Let’s take, for example, those college students who have been mandated to receive alcohol counseling, usually because of an alcohol-related transgression of a law or college policy. Evidence has shown that mandated students typically drink on average more than students who are not mandated (55). However, mandated students usually state that their friends drink as much, or even more, than they do. So, their perceptions about what constitutes normal drinking are clearly influenced by their peers, who also just so happen to drink heavily. Therefore, if we can effect changes in these perceptions as well as in the student's social network, by possibly offering an intervention to their peers who are binge drinkers, such as BMI, we might end up seeing better outcomes.

Conclusion

A significant proportion of college students are going to drink, despite whatever interventions or strategies we attempt to implement. In addition, problematic college drinking hasn’t gone away but has actually gotten worse, as alcohol-related deaths, heavy drinking episodes and drunk driving have all been on the rise on college campuses over the past decade.
As a result, an alternative strategy is needed to combat the misuse of alcohol among college students. First, ineffective alcohol abstinence education programs must be thrown by the wayside and instead be replaced by more realistic and effective harm reduction strategies, such as BMI, that increase compliance and learning among college students. Second, incorporating the broader environmental context in which college drinking occurs will also help to reduce the prevalence of college drinking. Finally, correcting inaccurate perceptions of the frequency of alcohol consumption, the approval of such activities, and unrealistic optimism regarding alcohol use, will be paramount to the success of new public health interventions regarding college drinking.

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