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How To Reduce High-Risk College Drinking: Use Proven Strategies, Fill Research Gaps

Promoting Healthy Behaviors Through Individual- and Group-Focused Approaches

Individual- and group-focused prevention and treatment approaches include a number of tested strategies. Prevention-oriented strategies include motivational enhancement techniques, cognitive-behavioral interventions, including expectancy challenges, and educational/awareness programs. Treatment-oriented strategies also include brief intervention, in addition to more intensive traditional treatment approaches. Accessible screening and recruitment programs are essential for service delivery. Hybrid approaches may combine elements of both prevention and treatment strategies to respond to the special needs of campus-based college students.

Summary of Relevant Research

There is a larger body of research on individual- and group-focused approaches in college populations than there is for environmental strategies. Collectively, individual- and group-focused interventions have proven valuable in both preventing and treating alcohol problems.

Prevention

Effective college drinking prevention programs frequently employ a multicomponent approach. For example, one study randomly assigned 348 high-risk freshman students to receive or not receive a 45-minute, in-person session that included feedback on students’ personal drinking behavior and negative consequences; accurate information about alcohol-related norms on campus and comparison of their personal drinking habits to actual campus norms; and advice or information regarding drinking reduction techniques (Marlatt et al., 1998). This approach combined brief motivational enhancement with normative reeducation, skills training, and information.

Brief Motivational Enhancement
The Panel reviewed a series of related studies that provide strong support for the efficacy of brief motivational enhancement (Anderson et al., 1998; Aubrey, 1998; D’Amico and Fromme, 2000; Dimeff et al., 2000; Marlatt et al., 1998; Monti et al., 1999). Motivational enhancement is based on the theory that individuals alone are responsible for changing their drinking behavior and complying with that decision (Miller et al., 1992). Interviewers assess student alcohol consumption using a formal screening instrument. Results are scored, and students receive nonjudgmental feedback on their drinking behavior and its negative consequences. Students also receive suggestions to support their decision to change (Miller et al., 1992). Studies on motivational enhancement report significant reductions in alcohol consumption and negative consequences such as driving after drinking, riding with an intoxicated driver, traffic violations, and injuries. In addition, brief motivational enhancement techniques work in a variety of contexts, including emergency rooms, outpatient counseling centers, fraternity organizations, and with randomly selected high-risk college freshmen. Brief interventions are described in more detail below under “Treatment.”

The research also suggests that in-person feedback and interpersonal interaction may not be essential to the success of brief motivational enhancement. One researcher provided computerized self-assessment and feedback with good results (Dimeff et al., 2000), and three other studies (Agostinelli et al., 1995; Walters, 2000; Walters et al., 1999) showed positive results with mailed feedback, although larger-scale studies of this approach are warranted.

Cognitive-Behavioral Skills Training
Cognitive-behavioral skills-training programs are a relatively new addition to the college drinking prevention repertoire. These programs teach skills to modify beliefs or behaviors associated with high-risk drinking, although many also incorporate information, values clarification, and/or normative reeducation components within the skills-teaching context (Garvin at al., 1990; Marcello et al., 1989). Cognitive-behavioral programs range from specific alcohol-focused skills training (including expectancy challenge procedures, blood alcohol discrimination training, or self-monitoring/self-assessment of alcohol use or problems) to general life skills training with little or no direct relationship to alcohol (such as stress-management training, time-management training, or general assertiveness skills) (Garvin et al., 1990; Murphy et al., 1986; Rohsenow et al., 1985).

Expectancy challenge programs show students that their expectations about how they and their peers will behave after drinking alcohol can affect that behavior. This strategy may include either direct experience, including the use of placebo beverages that students believe contain alcohol, or education on and discussion of expectancy issues.

One study randomly assigned heavy-drinking male students to consume beverages in a social setting and participate in activities including a social or sexual component (Darkes and Goldman, 1993). The students then attempted to guess which participants (including themselves) had consumed alcohol based on their behavior. Performance on the task was no better than chance. In addition, participants received information about how expectations of alcohol’s effects can influence behavior and monitored expectancy-relevant events in their environment throughout the course of the 4-week study. The intervention comprised three 45-minute sessions.

The Panel reviewed three studies, including the one just summarized (Darkes and Goldman, 1993, 1998; Jones et al., 1995), that indicated that this technique may have considerable utility for decreasing alcohol use among college males. Of particular note is the finding that the greatest effects occurred among those who drank more heavily. Evidence suggests that the direct experience component may be important to success, but more research is needed to confirm it. More studies are also needed to replicate these findings on a larger scale and evaluate the utility of this approach with women.

Another fairly simple cognitive-behavioral intervention asks students to document their current or anticipated alcohol consumption in writing or on the computer. In one study, students recorded their daily alcohol consumption for 7 weeks (Garvin et al., 1990), while another asked students to complete a diary anticipating alcohol consumption and problems for an upcoming spring break week (Cronin, 1996). The third asked students to assess their drinking via computer three times during their freshman year (Miller, 1999). All three studies support the potential of this approach for controlling consumption and reducing negative consequences (Cronin, 1996; Garvin et al., 1990; Miller, 1999). However, due to methodological limitations, additional research is needed to confirm findings.

Ineffective Approaches Used in Isolation
For the past two decades, educational approaches have been most commonly used to combat high-risk college student drinking (Moskowitz, 1989; Ziemelis, 1998). These traditional approaches are based on the assumption that students primarily abuse alcohol because they are unaware of its health risks. The theory is that increasing knowledge about negative effects will lead to decreased use. However, there is very little evidence to suggest that knowledge deficits are related to high-risk alcohol use in this population or that a change in knowledge leads to a change in behavior (Moskowitz, 1989).

Several outcome studies evaluating traditional informational programs with college students have been conducted in the past 15 years. Most found no effect on either alcohol use or negative consequences. Although many of these outcome studies suffer from serious methodological limitations (Larimer and Cronce, 2002), a recent meta-analysis of the college alcohol prevention literature from 1983 to 1998 concluded that typical education- and awareness-based programs (including values clarification approaches) produce, on average, only small effects on behavior (Maddock, 1999). These findings suggest that although education may be an essential component in skills training, brief motivational enhancement programs, and expectancy challenge, pursuing informational approaches in the absence of other integrated comprehensive programs is a poor use of resources on college campuses.

Treatment

Time-limited, patient-centered counseling strategies that focus on changing alcohol-related behavior have proven effective in treating college students with diagnosed alcohol problems. As with the prevention programs described previously, brief intervention techniques are also used and can be efficiently delivered in a variety of settings including student health clinics, counseling centers, and peer counseling programs. Easy to teach and easy to learn, most techniques can be effectively passed on in 1- or 2-day training programs.

Elements of Brief Intervention
The clinical elements of brief treatment intervention include the following steps:

  1. Conduct an assessment: “Tell me about your drinking.” “What do you think about your drinking?” “What do your parents or friends think about your drinking?” “Have you had any problems related to your alcohol use?” “Have you ever been concerned about how much you drink?”
     
  2. Provide direct and clear feedback: “As your doctor/therapist, I am concerned about how much you drink and how it is affecting your health.” “The car accident/injury/emergency room visit is a direct result of your alcohol use.”
     
  3. Establish a treatment contract through negotiation and goal setting: “You need to reduce your drinking. What do you think about cutting down to three to four drinks, two to three times per week?” “I would like you to use these diary cards to keep track of your drinking over the next two weeks. We will review them at your next visit.”
     
  4. Apply behavioral modification techniques: “Here is a list of situations when college students drink and sometimes lose control of their drinking. Let’s talk about ways you can avoid these situations.”
     
  5. Ask patients to review a self-help booklet and complete a drinking diary: “I would like you to review this booklet and bring it with you at your next visit. It would be very helpful if you could complete some of the exercises in the book.”
     
  6. Set up a continuing care plan for reinforcement phone calls and clinic visits. “I would like you to schedule a followup appointment in one month so we can review your diary cards and I can answer any questions you might have. I will call you in two weeks. When is a good time to call?”

In studies testing brief intervention, the number and duration of sessions varied by trial and setting. The classic brief intervention performed by a physician or nurse usually lasted for 5 to 10 minutes and was repeated one to three times over a 6- to 8-week period. Other trials that used therapists or psychologists as the interventionist usually had 30- to 60-minute counseling sessions for one to six visits. Trials in which therapists conducted the interventions used motivational interviewing techniques extensively. Some trials developed manuals or scripted workbooks. In others, the interventionist decided how to conduct the intervention based on a training program. Some studies used the FRAMES mnemonic as a guide for the intervention (Miller and Sanchez, 1994).

Effects of Brief Intervention
Brief intervention talk therapy delivered by primary care providers, nurses, counselors, and research staff can decrease alcohol use for at least 1 year in nondependent drinkers in primary care clinics, managed care settings, hospitals, and research settings (Bien et al., 1993; Fleming et al., 1997, 1999; Gentilello et al., 1999; Kahan et al., 1995; Marlatt et al., 1998; Ockene et al., 1999; WHO, 1996; Wilk et al., 1997). In trials with positive outcomes, reductions in alcohol use varied from 10 to 30 percent between the experimental and control groups. One trial followed patients for 48 months and found a sustained reduction in use (Fleming et al., 2000).

The effect size for men and women is similar (Fleming et al., 1997; Manwell et al., 1998; Ockene et al., 1999; Wallace et al., 1988; WHO, 1996). The effect size for persons over the age of 18 is similar for all other age groups including older adults (Fleming et al., 1997, 1999; Marlatt et al., 1998; Monti et al., 1999; Ockene et al., 1999; Wallace et al., 1988; WHO, 1996). Brief intervention appears to work in young adults and students under the age of 25 who are not alcohol dependent (Fleming et al., 2000; Marlatt et al., 1998).

Brief intervention can also reduce health care utilization in the general population (Fleming et al., 1997; Gentilello et al., 1999; Israel et al., 1996; Kristenson et al., 1983). Studies including Project TrEAT (Trial for Early Alcohol Treatment) found reductions in emergency room visits, hospital days, hospital readmissions, and physician office visits (Fleming et al., 1997; Gentilello et al., 1999; Israel et al., 1996; Kristenson et al., 1983). Brief intervention can also reduce alcohol-related harm. For example, a number of studies have found a reduction in blood levels of gamma-glutamyltransferase (GGT), an index of liver damage (Israel et al., 1996; Kristenson et al., 1983; Nilssen, 1991; Wallace et al., 1988), sick days (Chick et al., 1985; Kristenson et al., 1983), drinking and driving (Fleming et al., 2000; Gentilello et al., 1999; Monti et al., 1999), and emergency room and trauma center injury admissions (Gentilello et al., 1999).

Promising Approaches for Increasing Student Recruitment and Retention in Prevention and Treatment Programs

Despite the advances made in developing and testing efficacious prevention approaches, many students do not participate in these programs. Those who need them most appear to be least likely to use them. In fact, one study found that 46.2 percent of male drinkers and 39.57 percent of female drinkers had no interest in participating in even a minimal intervention involving informational brochures and flyers (Black and Coster, 1996).

Two approaches have been identified that may be effective in increasing student recruitment and retention:

  • Using social marketing techniques to construct and advertise programs (Black and Coster, 1996; Black and Smith, 1994; Gries et al., 1995).
  • Incorporating screening for and, in some cases, the intervention itself into standard practice at campus health centers and emergency rooms (Dimeff et al., 2000; Monti et al., 1999).

Panel Recommendations: What Colleges and Universities Can Do Now

The Panel recommends that colleges and universities:

  • Use brief motivational interventions, such as providing feedback on students’ personal drinking behavior and negative consequences, comparing individual drinking habits to actual campus norms, and teaching drinking reduction skills. Strong evidence of effectiveness supports these relatively low-cost interventions.
  • Increase screening and outreach programs to identify students who could benefit from alcohol-related services.
  • Train those who regularly interact with students, such as resident advisors, coaches, peers, and faculty, to identify problems and link students with intervention services and/or provide brief motivational interventions. This allows colleges and universities to improve services without adding new staff.
  • Use educational interventions that provide new information such as describing alcohol-related programs and policies, informing students about drinking-and-driving laws, and explaining how to care for peers who show signs of alcohol poisoning. Use alcohol education in concert with other approaches, such as skills training or social norms.
  • Avoid using educational efforts focused primarily on facts about alcohol and associated harm as a sole programmatic response to student drinking. They have proven to be ineffective.
  • Be inclusive of varied student subpopulations. Determine and address the special needs of groups such as racial/ethnic minorities, women, athletes, Greeks, students of different ages, and gay and lesbian* students.

Panel Recommendations: What Researchers Can Do To Address Gaps in Knowledge

The Panel recommends that researchers address the following questions to fill key gaps in knowledge:

  • What are the campuswide effects of implementing individual- and group-focused interventions?
  • How well do these interventions work with different campus populations, including Greeks, incoming students, mandated students, adult children of alcoholics, athletes, students at various risk levels based on current alcohol practices, students living on and off campus, and members of different ethnic, religious, and cultural groups?
  • How effective are student-to-student interventions?
  • What are the most effective uses of computer-based technologies in college alcohol initiatives?
  • Should approaches be tailored to the needs and situations of underage students versus those age 21 and older?
  • What are the most effective and cost-effective ways to conduct outreach for alcohol services?
  • What criteria are appropriate for diagnosing college student alcohol problems? Do they differ from the general population criteria used in currently available instruments?
  • How well do pilot programs work when taken to scale on different campuses?

* Term used in broad sense; includes students who are bisexual, transgendered, and questioning as well as gay and lesbian.

 

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Historical document
Last reviewed: 9/23/2005


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