Identification, Prevention and Treatment: A Review of Individual-Focused Strategies to Reduce Problematic Alcohol Consumption by College Students*
MARY E. LARIMER, Ph.D. AND JESSICA M. CRONCE,
Department of Psychiatry and Behavioral Sciences, Box 356560, University
of Washington, Seattle, Washington 98195
ABSTRACT. Objective: The purpose of this article is to review
and assess the existing body of literature on individually focused prevention
and treatment approaches for college student drinking. Method: Studies
that evaluate the overall efficacy of an approach by measuring behavioral outcomes
such as reductions in alcohol use and associated negative consequences were
included. All studies discussed utilized at least one outcome measure focused
on behavioral change and included a control or comparison condition; however,
not all trials were randomized. Results: Consistent with the results
of previous reviews, little evidence exists for the utility of educational or
awareness programs. Cognitive-behavioral skills-based interventions and brief
motivational feedback (including mailed graphic feedback) have consistently
yielded greater support for their efficacy than have informational interventions.
Conclusions: There is mixed support for values clarification and normative
reeducation approaches. Much of the research suffers from serious methodological
limitations. The evidence from this review suggests that campuses would best
serve the student population by implementing brief, motivational or skills-based
interventions, targeting high-risk students identified either through brief
screening in health care centers or other campus settings or through membership
in an identified risk group (e.g., freshmen, Greek organization members, athletes,
mandated students). More research is needed to determine effective strategies
for identifying, recruiting and retaining students in efficacious individually
focused prevention services, and research on mandated student prevention services
is an urgent priority. Integration between campus policies and individually
oriented prevention approaches is recommended. (J. Stud. Alcohol, Supplement
No. 14: 148-163, 2002)
THIS ARTICLE presents a review of the literature on individually focused prevention
(including universal, indicated and selective prevention targets) and treatment
approaches for college student drinking. Also included is a review of strategies
for identifying individuals in need of prevention or treatment services and
enhancing recruitment and retention of students in these services. Studies that
evaluate overall efficacy of prevention and treatment approaches are included,
as well as the available research on the effectiveness of these approaches with
identified subgroups of students who are at high risk for problematic alcohol
use (including children of alcoholics, fraternity/sorority members, freshmen,
judicially mandated students and athletes). The behavioral outcomes used to
evaluate program efficacy include reductions in alcohol use (including quantity,
frequency and intensity of use), reductions in the negative consequences of
use (in conjunction with or independent of use reduction) and/or increased rates
of alcohol abstinence.
The relevant literature was identified through online searches of electronic
databases, including MEDLINE, PsychInfo and ETOH as well as examining reference
sections from previous reviews of prevention literature (Hingson et al., 1997;
Maddock, 1999; Moskowitz, 1989; Walters, 2000; Wood, 1998) and the outcome studies
identified through these searches. Studies from the 15-year period of 1984-1999
are included. In addition, the Promising Practices: Campus Alcohol Strategies
sourcebook (Anderson and Milgram, 1997, 1998) was reviewed, and several sources
were identified and contacted for information about outcome evaluations of their
programs. Finally, authors who were identified through these searches and/or
through other contacts within the field (including Fund for the Improvement
of Postsecondary Education grant recipients) who are known to conduct research
in this area were contacted to request reprints or preprints of their work relevant
to this topic. The resulting review thus contains both published and unpublished
It should be noted that, although there is a growing body
of literature on prevention of problem drinking among college
students, and the majority of approaches have been
individually focused, there are still relatively few randomized,
controlled trials of these approaches in the published
literature. Therefore, although these few trials are heavily
weighted in the review, nonrandomized trials were also included.
Inclusion criteria were that, at a minimum, studies
must have a control or comparison condition, and studies
must include at least one outcome measure focused on behavioral
change in drinking or consequences (instead of or
in addition to typical attitudinal or knowledge-based outcomes
alone). Finally, in general, nonrandomized studies
were included only if they employed pre- and postassessments,
allowing for statistical control or evaluation
of baseline differences between groups. These criteria are
similar to those employed by Wood (1998) in his review of
Prevention and Treatment Strategies
A variety of prevention and treatment approaches have
been employed with college student drinkers. Although
many of these are multicomponent strategies, for the purposes
of this review, prevention programs have been divided,
based on content and theory of the approach, into
three major categories: (1) educational/awareness, (2)
cognitive-behavioral and (3) motivational enhancement techniques.
Table 1 lists the prevention programs covered in
this review, including design and outcome information.
In his 1989 review of the literature on effectiveness of
alcohol prevention strategies for adolescents, Moskowitz
concluded that the majority of prevention approaches utilized
with college students were based on weak or nonexistent
theory and had virtually no empirical support for their
efficacy. At that time, the most common approaches were
informational in nature. They were primarily based on the
assumption that students misused alcohol or other substances
due to a lack of knowledge or awareness of health risks
and that an increase in knowledge regarding the negative
effects of these substances would lead to a decrease in use.
Research evaluations of these approaches have tended to
suffer from a number of methodological limitations, particularly
small sample sizes, nonrandom samples and often
lack of or noncomparability of control or comparison conditions.
Despite these weaknesses, informational/educational
approaches are still the most commonly utilized techniques
for individually focused prevention on college campuses
Three relatively distinct types of educational programs
have been evaluated with college students: (1) traditional
information or knowledge-based programs; (2) values clarification
programs, designed to help students evaluate their
goals and incorporate responsible decision making about
alcohol into these goals or values; and (3) provision of
accurate normative information to students about peer drinking
rates and problems as well as modifying students' attitudes
about the acceptability to peers and parents of
excessive alcohol consumption.
Information/knowledge programs. Seven studies (Darkes
and Goldman, 1993; Flynn and Brown, 1991; Garvin et al.,
1990; Kivlahan et al., 1990; Meier, 1988; Roush and
DeBlassie, 1989; Schall et al., 1991) identified in the literature
evaluated informational or knowledge-based approaches
and met minimum inclusion criteria. The majority
of these studies suffered from methodological limitations,
such as high rates of attrition, noncomparability of the control
group and nonspecific reporting of methodology and
results, which made it difficult to draw meaningful conclusions.
Despite these problems, and although several of the
studies did demonstrate changes in knowledge or attitudes
following these interventions, overall they provide little support
for the efficacy of these approaches. Only one
(Kivlahan et al., 1990) of the seven studies reported significant
reductions in either drinking or negative
Kivlahan et al. (1990) evaluated an 8-week informational curriculum based on
Alcohol Information School (AIS) for DWI offenders compared with an eight-session
skills-training curriculum and an assessment-only control group. Results indicated
participants in both the AIS and the Alcohol Skills Training Program (ASTP)
intervention groups reduced their consumption over time. Participants who received
the AIS program reduced their consumption from 19.4 drinks to 12.7 drinks per
week at the 12-month follow-up compared with control group participants, who
reported a slight increase from 15.6 to 16.8 drinks per week. However,
neither the participants in the AIS group nor the control group fared as well
as the ASTP group (who experienced a reduction from 14.8 to 6.6 drinks per week
at the 12-month follow-up).
Values clarification programs. Five studies (Barnett et
al., 1996; Meacci, 1990; Sammon et al., 1991; Schroeder
and Prentice, 1998; Thompson, 1996) included a values
clarification condition or included values clarification activities
as part of a broader informational approach. Although,
of the five studies, twoOn Campus Talking About
Alcohol (Sammon et al., 1991) and Delts Talking About
Alcohol (Thompson, 1996)reported reductions in drinking
rates between baseline and follow-up assessments, insufficient
information about the samples, procedures and
the comparability of participants in the intervention and
control conditions limits the strength of the conclusions
drawn from these data. The remaining three studies were
constrained by methodological limitations, such as problems
with recruitment and retention of participants and
noncomparability of control and experimental groups, and
provided little support for the efficacy of the programs.
Normative reeducation programs. Two studies (Barnett et al., 1996; Schroeder
and Prentice, 1998) incorporated a normative reeducation group in their evaluation.
Barnett et al. (1996) utilized peers to provide normative reeducation, either
alone or in combination with values clarification information, to students in
residence halls and fraternities/sororities. Although there were no differential
effects of the interventions on drinking behavior over time, participants who
received either of the normative reeducation interventions reported significantly
greater changes in their perception of the norms than did participants in the
values clarification-only and control groups. Regression analyses indicated
changes in norms from baseline to postintervention predicted subsequent reductions
in alcohol consumption regardless of prevention condition.
Schroeder and Prentice (1998), in contrast, reported that
participants who received a 1-hour peer-delivered normative
reeducation program (similar to that utilized in the
Barnett et al. 1996 study) did report significant reductions
in drinking compared with the alternative values clarification
program, but there were no differences in increased
accuracy of normative perceptions. Their data suggest that
the change in drinking following the normative reeducation
intervention was the result of weakened proscriptive strength
of the norm (perceiving the norm as less universally adhered
to, therefore less powerful), rather than a change in
perceptions reflecting a more moderate norm. Participants
in the Schroeder and Prentice (1998) study were freshmen
residence hall members, as compared with a mixed-age
population of residence hall and Greek system members in
the Barnett et al. (1996) report, which may be one factor in
the discrepancy between the findings of these two studies.
It is possible that freshmen students may be more amenable
to normative interventions, given that they have had
less exposure to the influences of campus norms. Other
explanations for the discrepancy in findings may involve
differences in the measurement of both norms and drinking
behavior between the two studies, as well as attrition in the
study conducted by Barnett et al.
In summary, although several outcome studies evaluating
traditional informational programs with college students
have been conducted in the past 15 years, the majority of
these studies have found no effect of the interventions on
alcohol use and/or alcohol-related negative consequences.
In his recent meta-analysis of the college alcohol prevention
literature from 1983-1998, including only those trials
with random assignment to condition, Maddock (1999) concluded
that typical education/awareness-based programs (including
values clarification approaches) produce on average
only small effects on behavior (d = .17). These findings
suggest that continuing to pursue approaches based solely
on informative or awareness models is a poor use of resources
on college campuses. Values clarification approaches
such as On Campus Talking About Alcohol may
be efficacious, but have not been evaluated in randomized
trials and are time and resource intensive. Educational programs
based on normative reeducation approaches are less
costly and may hold more promise, but have yet to be widely
Cognitive-behavioral skills-based programs
Cognitive-behavioral skills-training programs are a relatively
newer addition to the college drinking prevention
repertoire than are educational or awareness approaches.
Many cognitive-behavioral programs also incorporate information,
values clarification and/or normative reeducation
components, but do so within the context of teaching
skills to modify beliefs or behaviors associated with highrisk
drinking. 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). The majority of programs are multimodal, including
both specific alcohol-focused skills as well as general
Specific alcohol-focused skills training. Three studies of expectancy
challenge procedures that met inclusion criteria, two of which (Darkes and Goldman,
1993, 1998) showed statistically significant positive effects at short-term
follow-up. The third (Jones et al., 1995) demonstrated trends in drinking supportive
of the expectancy challenge interventions, but did not achieve statistical significance.
Darkes and Goldman (1993) randomly assigned heavy-drinking male participants
to receive either alcohol or a placebo. Participants consumed beverages in a
social setting that included activities with a social or sexual component and
then attempted to guess which participants (including themselves) had consumed
alcohol or placebo based on their behavior. In addition, participants received
information about placebo effects of alcohol and monitored expectancy-relevant
events in their environment throughout the course of the 4-week study. Expectancy
challenge procedures were conducted during three 45-minute sessions. In contrast
to participants who received traditional alcohol education and to an assessment-only
control group, participants in the expectancy challenge group reported a significant
decrease in their alcohol use at 2-week follow-up.
Similarly, Darkes and Goldman (1998) randomly assigned 54 heavy-drinking male
participants to an assessment-only control condition or one of two expectancy
challenge conditions, targeting either sociability or arousal, using the procedures
described above to challenge social expectancies, whereas arousal expectancies
were challenged during tasks involving either sedating cues or problem-solving
tasks. The study also included a 15-minute passive "booster" session
4 weeks after completion of the expectancy challenge procedures, with an additional
follow-up 2 weeks later (6 weeks after the challenge procedure). Results indicated
participants in both expectancy challenge conditions significantly reduced their
alcohol consumption by 2 weeks posttreatment as compared with participants in
the control group, who demonstrated an increase in consumption. Participants
in all three conditions indicated a subsequent decrease in drinking by the 6-week
follow-up, with the expectancy conditions demonstrating the largest reductions.
Importantly, in both of the Darkes and Goldman (1993, 1998) studies, heavy drinkers
showed the largest impact of the expectancy challenge procedures, in contrast
to other interventions demonstrating better effects for moderate or light-drinking
In contrast to the Darkes and Goldman studies, Jones et
al. (1995) evaluated an expectancy challenge procedure incorporating
didactic information and discussion about alcohol
expectancies, including self-monitoring of expectancies,
with or without an expectancy self-challenge procedure (randomly
assigned), but without the experiential component
of alcohol administration. Twenty-four-day follow-up indicated
drinking overall was reduced over time, but changes
in drinking over time were not found to vary significantly
by condition. However, post hoc analyses indicated only
those participants in the expectancy with self-challenge condition
significantly decreased their drinking from pretesting
Findings from these three studies suggest that expectancy
challenge procedures may have considerable utility
for decreasing alcohol use among college males. These findings
also suggest that increasing the personalization and
experiential component of expectancy information and providing
practice in challenging expectancies may be necessary
for these programs to be effective. Studies that replicate
these findings on a larger scale, with women as well as
men, and with a longer-term follow-up are needed to evaluate
this prevention approach more fully. In addition, further
evaluation of the relative impact of expectancy
challenge procedures with and without an alcohol administration
component is needed.
Three studies (Cronin, 1996; Garvin et al., 1990; Miller,
1999) evaluating self-monitoring or self-assessment of alcohol
use as an intervention were reviewed, all of which
indicated significant positive effects of this strategy on either
consumption, negative consequences or both.
Cronin (1996) compared student drinking rates and problems assessed at the
end of spring break between students who were randomly assigned to complete
a diary anticipating alcohol consumption and problems for the upcoming spring
break week and those who were assigned to a no-treatment control group. Results
indicated those students who completed the diary prior to spring break reported
fewer negative consequences at the end of spring break than did those students
in the control group.
In their study of fraternity pledge class members, Garvin et al. (1990) trained
participants in a self-monitoring-only group to record their daily alcohol consumption
during a 7-week period. Participants in this condition received no other intervention.
It is interesting to note that, at the 5-month follow-up, participants in the
self-monitoring group reported statistically lower alcohol consumption than
did participants in both the no-treatment control group and the alcohol education
Miller (1999) compared students who participated in three computerized assessments
of their drinking (with no additional intervention during their freshman year)
with participants who also received a two-session peer-delivered alcohol skills-training
program or a two-session peer-facilitated interactive CD-ROM skills group (the
Alcohol 101 CD-ROM, Reis et al., 2000). Participants were 547 students at varying
levels of risk for alcohol-related problems, randomly assigned to one of these
three conditions or a single-assessment-only control group, who completed the
alcohol assessment only at the end of their freshman year. Although some outcome
measures favored the two intervention groups as compared with the repeated assessment
condition, on average students in the repeated assessment group reported decreases
in drinking and consequences at the 6-month follow-up similar to those in the
two experimental conditions. Importantly, participants in the single-assessment-only
group were drinking more and experiencing more problems than those in any of
the other three groups by the end of the freshman year, despite having been
randomly assigned to condition at the beginning of the year. These results suggest
that the opportunity to respond to questions about drinking and negative consequences
in the absence of any additional feedback served as an intervention for those
participants in the repeated assessment group. One limitation of this study
is that there was a low initial response rate to recruitment efforts (approximately
25%), and all conditions included a fairly high percentage of abstainers and
light drinkers (41% and 32%, respectively).
Despite limitations, each of these three studies not only
provides support for the role of assessment in promoting
change, but also has implications for the conclusions drawn
from other longitudinal studies including repeated assessment
control groups. Inclusion of single-assessment control
groups in randomized longitudinal designs may be
necessary to assess program outcome more accurately.
Multicomponent alcohol skills training. The majority of
studies evaluating cognitive-behavioral prevention approaches
include a multicomponent skills-training condition. Seven studies
(Ametrano, 1992; Baer et al., 1992; Garvin et al., 1990;
Jack, 1989; Kivlahan et al., 1990; Marcello et al., 1989; Miller,
1999) evaluating a total of 10 multicomponent skills-based
interventions were identified in the literature. Of these, three
interventions (Ametrano, 1992; Jack, 1989; Marcello et al.,
1989) indicated no positive effect on alcohol use or consequences,
whereas seven interventions (Baer et al., 1992; Garvin
et al., 1990; Kivlahan et al., 1990; Miller, 1999) were found
to have at least some effects on alcohol consumption, problems
Baer et al. (1992) compared three formats of a similar ASTP to evaluate whether
intensity or format of the intervention would affect the magnitude of change.
Participants were heavy-drinking volunteers randomly assigned to receive either
a six-session version of the ASTP, a single individual session incorporating
risk feedback and advice to change or a self-help manual incorporating the ASTP
content. Results indicated participants in all three conditions who completed
the intervention showed significant change from baseline to follow-up in drinking
rates and problems. However, there was substantial attrition in the self-help
condition, such that this condition was eliminated from recruitment midway through
Garvin et al. (1990) included a skills-training group as
one condition in their study of fraternity pledge classes.
The program consisted of four 45-minute sessions designed
to teach moderate drinking skills, blood alcohol concentration
discrimination and assertiveness skills (including drink
refusal). Participants in this condition also self-monitored
their alcohol consumption for 7 weeks. Results indicated
significant reductions in average weekly alcohol consumption
for participants who received the skills-training intervention,
which appear comparable in magnitude with those
reported in the monitoring-only condition.
Kivlahan et al. (1990) evaluated an 8-week multicomponent ASTP, including assertive
drink refusal skills, relaxation and general lifestyle balance skills and alcohol-specific
skills such as drink pacing, limit setting and blood-alcohol discrimination
training. Results indicated that the participants who received the skills-training
intervention showed significant reductions in alcohol use and consequences throughout
a 2-year follow-up as compared with students who received the alcohol information
school program or assessment only.
Miller (1999) compared a two-session, peer-delivered ASTP with two-session
computerized information/skills-training via Alcohol 101 CD-ROM (Reis et al.,
2000) and with a repeated assessment-only control group and a single-assessment
control group. Both skills-based interventions included information on accurate
norms for alcohol consumption, blood alcohol concentration effects and blood
alcohol estimation as well as myths and placebo effects of alcohol. Differences
favoring the two skills-based interventions were noted within drinking subgroups
of participants, including increases in knowledge and motivation to change.
In addition, light-moderate drinking students who received either of the skills-based
interventions reported significantly reduced negative consequences of drinking
as compared with those in the repeated assessment-only condition; abstainers
and heavy drinkers in the sample did not appear to differentially benefit from
the interventions as compared with repeated assessment only. Participant satisfaction
was significantly higher in the ASTP groups than in the CD-ROM group, suggesting
students on average preferred the more interactive ASTP approach.
General life skills training/lifestyle balance. Two studies
(Murphy et al., 1986; Rohsenow et al., 1985) in the
college student population evaluated the outcome on drinking
behavior of general lifestyle skills/lifestyle balance. Both
indicated at least short-term benefits on drinking rates.
Murphy et al. (1986) randomly assigned 60 heavy-drinking male students to 8
weeks of exercise, meditation or assessment only. Results indicated participants
in the exercise condition significantly reduced their mean weekly ethanol consumption
as compared with participants in the control group (60% reduction from baseline
to week 10), despite the fact that alcohol use reduction was not a specified
goal of the intervention. Reductions in use were largely maintained in the exercise
group (6 weeks) even after cessation of the active intervention. Participants
in the meditation condition were less likely to have been compliant with meditating;
however, those who did meditate showed reductions in drinking similar to those
in the exercise group.
Rohsenow et al. (1985) randomly assigned 36 heavy-drinking students to a general
stress-management course or an assessment-only control condition. Results indicated
participants who received the intervention reported decreased alcohol consumption
at 2.5-month follow-up as compared with participants in the control group. However,
by 5-month follow-up, these results were no longer significant.
In summary, several cognitive-behavioral interventions
including specific, global or multicomponent skills-training
approaches have been associated with behavioral changes
in drinking. The magnitude of these effects varies depending
on the interventions and the populations studied, but
generally support the efficacy of these approaches for universal,
indicated and selective prevention. Research designs
evaluating these approaches have generally been stronger
than those utilized with educational programs, but methodological
limitations are still evident in this research primarily
due to small sample sizes and relatively high attrition
rates in some samples.
Brief motivational interventions. Eight studies (Aubrey,
1998; Baer et al., 1992; Borsari and Carey, 2000; D'Amico
and Fromme, 2000; Dimeff, 1997; Larimer et al., 2001;
Marlatt et al., 1998; Monti et al., 1999) were reviewed that
met inclusion criteria and evaluated the efficacy of brief
(one or two session) individual or group motivational enhancement
approaches, typically incorporating alcohol information,
skills-training information and personalized
feedback designed to increase motivation to change drinking.
Of these, four were conducted with college student
samples (Baer et al., 1992; Borsari and Carey, 2000; Larimer
et al., 2001; Marlatt et al., 1998), three were conducted
with college-age samples in medical/mental health settings
(Aubrey, 1998; Dimeff, 1997; Monti et al., 1999) and one
was conducted with high school students but was directly
relevant to the topic of this article due to similar age groups
and similar prevention materials (D'Amico and Fromme,
2000). Each of these interventions demonstrated significant
effects on drinking behavior, consequences or both.
As mentioned, Baer et al. (1992) compared three formats
of the ASTP and found a single session of brief advice
was comparable to a 6-session ASTP group and a
6-session correspondence course in reducing alcohol use.
Marlatt et al. (1998) extended these findings through randomly
assigning 348 high-risk freshman students to receive
or not receive a brief (45-minute) in-person motivational
feedback session. Feedback included personal drinking behavior
and negative consequences, accurate normative information
and comparison of personal drinking to the actual
campus norms and advice/information regarding drinking
reduction techniques (Dimeff et al., 1999). This approach
is thus a hybrid of skills training, information, normative
reeducation and brief motivational enhancement. Results
indicated participants in the intervention group reduced their
consumption and negative consequences significantly and
maintained those reductions through a 2-year follow-up.
Borsari and Carey (2000) replicated the Baer et al. (1992) and Marlatt et al.
(1998) studies at a large northeastern university utilizing a student population
screened from an introductory psychology course. Sixty participants who reported
having consumed five or more drinks (four or more drinks for women) two or more
times in the previous month were recruited. Students were randomized into a
brief motivational interview condition (n = 29) that was modeled after
the intervention described in Dimeff et al. (1999) or into an assessment-only
control group (n = 31). At 6-week follow-up, participants in the brief
motivational interview condition demonstrated significant reductions in both
quantity and frequency of alcohol consumption as well as a decline in the number
of reported heavy episodic drinking events as compared with control participants.
However, neither intervention nor control participants showed reductions in
alcohol-related consequences, as measured by the Rutgers Alcohol Problem Index
(White and Labouvie, 1989). Interestingly, changes in perceived norms mediated
the relationship between intervention and drinking reductions, suggesting that
the normative feedback component of the Dimeff et al. intervention is a critical
Larimer and colleagues (Anderson et al., 1998; Larimer et al., 2001) also replicated
the Marlatt et al. (1998) study, implemented with first-year members of intact
fraternities and sororities. Participants were 296 members of 12 fraternities
and 6 sororities randomly assigned by house to either the brief individualized
feedback program or an assessment-only control condition. At 1-year follow-up,
fraternity members who received the intervention reported a decrease in consumption
from 15.5 to 12 standard drinks per week compared with an increase in the control
group from 14.5 to 17 drinks per week. Participants in the intervention group
also reported a decrease in estimated peak blood alcohol concentration from
.12% to .08% as compared with participants in the control group, who reported
no change in peak blood alcohol concentration over time. Sorority women did
not differ in alcohol use over time as a function of condition, although this
result may be attributable to a smaller than expected original sample.
Aubrey (1998) utilized brief motivational interventions with 77 adolescents
(ages 14-20, with a mean age of 17) presenting for outpatient substance abuse
treatment. Following intake assessment, youth participants were randomly assigned
to standard care (n = 39) or to receive two brief motivational feedback
interviews utilizing the assessment results (n = 38). Results at 3-month
follow-up indicated participants who received the intervention reported a greater
percentage of days abstinent (70% vs 43%), as well as increased treatment attendance
(17 vs 6 sessions attended) and decreased negative consequences of alcohol.
Dimeff (1997) conducted a computerized assessment of alcohol use and problems
in a college health center waiting room and randomly assigned high-risk participants
to receive the assessment only (n = 24) or a computerized, personalized
graphic feedback regarding alcohol risks and suggestions for reduced risk, which
was reviewed with their primary care provider (n = 17). Although limited
by small sample size, moderate-to-large treatment effects for both drinking
(d = .81) and consequences (d = .54) were observed in the intervention
group. These findings suggest that use of computer-generated feedback in a health
care setting may be a viable option for prevention of alcohol misuse.
Monti et al. (1999) utilized a brief motivational intervention
to reduce alcohol use and consequences among 94
adolescents ages 18-19 who were seen in the emergency
room following an alcohol-related event. Participants were
randomized to receive the intervention or the usual emergency
room care. Results at 3-month follow-up indicated
participants who received the intervention had significantly
lower incidence of drinking and driving, traffic violations,
injuries and alcohol-related problems than did patients who
received the usual care intervention. However, participants
in both conditions reported reductions in consumption.
D'Amico and Fromme (2000) randomly assigned 300 high school students to participate
in a Risk Skills Training Group (n = 73), including both skills training
and personalized motivational feedback; a brief version of the DARE program
(n = 77); or a no-treatment control group (n = 150). Results indicated
that, at posttreatment assessment, participants in the Risk Skills Training
Group significantly reduced the frequency with which they drank heavily, drove
after drinking, rode with an intoxicated driver and used drugs.
Taken together, these studies provide strong support for
the efficacy of brief, personalized motivational enhancement
techniques, delivered individually or in combination
with risk skills-training information delivered in small
groups. In addition, studies of brief motivational enhancement
approaches have generally been methodologically superior
to earlier studies, including randomization to
condition, standardized assessment of outcome, manualized
and/or well-described interventions and relatively large
sample sizes. Longer-term follow-up of these interventions
Mailed feedback. Interestingly, three recent studies
(Agostinelli et al., 1995; Walters et al., 1999, 2000) suggest
the efficacy of brief motivational enhancement approaches
may not depend on the individual or interpersonal
component, but might instead be a result of the feedback
employed in these approaches.
Agostinelli et al. (1995) randomly assigned 24 heavy-drinking students identified
through a mass-testing procedure to either receive mailed graphic feedback or
no treatment. Results indicated that, at 6-week follow-up, participants who
received the mailed feedback reported reductions in consumption of nearly eight
drinks per week as compared with control participants, who remained unchanged.
Similarly, Walters (2000) described two trials (Walters et al., 1999, 2000)
of mailed graphic feedback as compared with a group skills plus feedback condition
and a no-treatment control group. In each case, mailed graphic feedback was
significantly more effective alone than in combination with skills-training
information. Participants in the first study (n = 37) were moderate-
to heavy-drinking students randomized to condition. At 6-week follow-up, feedback
participants indicated a reduction of nearly 14 drinks per week as compared
with 6 drinks per week among group participants and less than 1 drink in the
control group. In the second study (Walters et al., 1999), 34 participants were
assigned to feedback only, assessment only or a modified group consisting of
values clarification activities with a review of the feedback along with mailed
feedback. Results again favored the feedback-only condition (6.6 drinks per
week reduction compared with .35 drinks per week in group intervention and 2.75
drinks per week in the control group).
Each of these studies is limited by relatively short-term
follow-up and by the potential for selection bias due to the
relatively small sample sizes and lack of information about
the samples. Despite these limitations, findings regarding
the efficacy of direct-mail feedback are encouraging, and
larger-scale studies of this approach are warranted. In particular,
additional trials of the efficacy of motivational enhancement
approaches and personalized graphic feedback
alone and in combination may aid in identifying the effective
components of these interventions.
Intensive treatment and medication
No treatment studies were identified that met minimum
study inclusion criteria, primarily due to a lack of control
or comparison conditions in these studies. Two studies
(Bennett et al., 1996; Keller et al., 1994) reported pre- and
postoutcome results that compare very favorably with other
treatment outcome studies, suggesting incorporation of a
residential or intensive outpatient component into on-campus
treatment services may be an effective means of maintaining
academic connections for students with more serious
One study (Davidson et al., 1996) evaluated the impact of naltrexone as opposed
to placebo on latency to drink alcohol and overall amount of alcohol consumed
by social-drinking college students in a laboratory setting. Results indicated
naltrexone was effective in increasing latency to drink and in reducing overall
consumption. This finding suggests that opioid blockers may be a useful adjunct
to treatment for college students wishing to moderate consumption.
Intervening with High-Risk Subpopulations
Within the college student population some groups of
students have traditionally been viewed as being at increased
risk for alcohol-related problems. These include Adult Children
of Alcoholics, members of Greek letter organizations
(fraternities/sororities), student athletes, freshmen (Canterbury
et al., 1992; Dielman, 1990; Klein, 1989; Meilman et
al., 1990; Pope et al., 1990) and students referred for conduct
violations involving alcohol (mandated students).
Here we summarize the results of preventive interventions
that have been evaluated with these special populations.
Because each of the efficacious interventions is
described in more detail in the preceding sections, only
general conclusions and citations for relevant studies are
Adult Children of Alcoholics
Although descriptive studies abound (Bosworth and Burke, 1994; Havey and Dodd,
1993; Rodney, 1996; Sher and Descutner, 1986; Sher et al., 1991, 2001), only
one study identified between 1984 and 1999 specifically evaluated a prevention
program for Adult Children of Alcoholics in the college population (Roush and
DeBlassie, 1989). This study compared two informational/educational approaches
and found no effect of either intervention on behavior. However, Adult Children
of Alcoholics appear comparable with those without a parental family history
of alcoholism regarding response to interventions utilized with the general
college student population. Specifically, Marlatt et al. (1998) found students
with a parental family history of alcoholism showed similar response to a brief
motivational interview as did their peers without such a family history. In
addition, Sammon et al. (1991) and Jack (1989) both indicated a trend toward
students with parental family history responding more positively to their informational/values
clarification/risk-reduction interventions than did those students without a
parental family history of alcoholism. Although both the Sammon et al. and Jack
studies are limited due to nonrandom assignment to condition and small sample
size, these results warrant further investigation.
Programs for fraternity/sorority members
Several studies evaluated prevention programs for
fraternity/sorority members or included Greek members in
the evaluation of programs for general college student populations.
Five of these approaches indicated positive effects
on behavior of fraternity and/or sorority members. Of these,
two incorporated brief motivational feedback (Larimer et
al., 2001; Marlatt et al., 1998), two were skills-based (the
alcohol monitoring and behavioral skills-training conditions
evaluated by Garvin et al. ), and one involved information
in conjunction with values clarification and riskreduction
guidelines (Delts Talking About Alcohol;
Thompson, 1996). Only Marlatt et al. (1998) utilized a true
experimental design with randomization at the level of the
individual, and this study is also the only study that included
(sufficient) sorority women to assess effects of the
intervention on women's drinking. Of note, even after reducing
their drinking through participation in these efficacious
prevention programs, fraternity members, on the
average, continued to drink heavily and remained at substantial
(although reduced relative to baseline) risk for negative
consequences. Other prevention programs sponsored
by the National Inter-fraternity Conference or Panhellenic,
including such promising interventions as Our Chapter, Our
Choice, have yet to be rigorously evaluated.
Programs for athletes
Several articles describing drinking behavior of athletes
or evaluating the effectiveness of training programs for athletic
department personnel in the implementation of policies
and prevention programs targeting alcohol consumption
by college athletes are available in the literature (Grossman
and Smiley, 1999). In contrast, only one published prevention
outcome study with college student athletes meeting
minimum inclusion criteria was identified in this review
(Marcello et al., 1989). This study failed to find an effect
of a multicomponent skills-training intervention with student
athletes. Clearly, additional outcome research with this
population is needed.
Several outcome studies identified in this review focused exclusively or primarily
on freshmen students (Larimer et al., 2001; Marlatt et al., 1998; Miller, 1999;
Schroeder and Prentice, 1998). In general, brief motivational enhancement approaches,
skills-training approaches (including self-assessment of alcohol use) and peer-based
normative reeducation approaches have all been shown to be successful at reducing
alcohol use and/or negative consequences among freshmen. Although freshmen represent
a segment of the college population at increased risk for heavy drinking and
alcohol-related negative consequences (Pope et al., 1990), these studies suggest
that they are nonetheless quite responsive to alcohol prevention programs that
are nonjudgmental, include a normative reeducation component and emphasize skills
and personal responsibility for change.
Finally, only one study identified in this review specifically
evaluated a prevention program for judicially mandated
college students. Flynn and Brown (1991) failed to
find an effect of the Alcohol Information School curriculum
with this population. This lack of research on mandated
students is particularly problematic given that some
students may violate campus conduct policies in isolated
instances (being in the wrong place at the wrong time),
whereas other students may be exhibiting a more chronic
pattern of heavy drinking coupled with policy violations.
Clearly, evaluating the effectiveness of prevention programs
provided to mandated students is both an urgent research
priority and an ethical necessity.
Identification, Referral and Recruitment Strategies
In contrast to the state of the field when Moskowitz
(1989) published his discouraging review, there is now a
growing body of evidence that several types of prevention
approaches "work"; that is, students who (voluntarily) participate
in these interventions show reductions in alcohol
use and/or consequences. This literature also indicates some
types of interventions are associated with larger reductions
in use or consequences than are others (Maddock, 1999).
Despite the advances made in developing and testing
efficacious prevention approaches, another difficulty is often
present in the college setting, which limits the utility of
individually focused prevention efforts. Specifically, many
students do not participate in these programs, and those
students who most need them appear to be least likely to
utilize them (Black and Coster, 1996). For example, Black
and Coster (1996) found 46.2% of male drinkers and 39.6%
of female drinkers had no interest in participating in even a
minimal intervention involving informational brochures and
flyers. In this section, we review some suggestions (with
support from the literature) for increasing identification, recruitment
and retention of students into individually focused
Marketing and outreach efforts
One consideration in solving the problem of low attendance at alcohol prevention
services is to remember that students are consumers of these services.
Attending to the lessons learned in the advertising and marketing fields is
therefore an important step in designing and providing alcohol prevention services.
In particular, social marketing techniques have been utilized recently to promote
increased accuracy of normative perceptions and decreased alcohol consumption
on college campuses (Berkowitz, 1997; Haines, 1996; Haines and Spear, 1996).
Research suggests social marketing techniques might also increase recruitment
into campus alcohol prevention services (Black and Coster, 1996; Black and Smith,
1994; Gries et al., 1995).
Gries et al. (1995) conducted focus groups and interviews with residence hall
students to develop and revise marketing and recruitment materials for a 1-hour
alcohol education program. Results indicated significantly more students attended
the program in the intervention hall (n = 17) than in the control hall
(n = 0) or the combined average of the three historical halls (n
= 5). Although even the rates of attendance in the intervention hall are low
(i.e., more than 700 residents were eligible to attend), more than half of those
students who attended were moderate to heavy drinkers. Black and Smith (1994)
conducted survey research using Social Marketing Theory to evaluate factors
that might increase recruitment into alcohol prevention or education programs.
In both studies, students reported that convenience of the program (location,
timing and time commitment required), an emphasis on what students could gain
by participating (e.g., helping a friend, learning new information about alcohol)
and by reducing consumption and the use of incentives for participation (e.g.,
a refund of student fees, university credit for attendance, food, prizes) were
ranked as important factors for attendance. In addition, Black and Smith found
students were more likely to attend if their friends could participate at the
same time and that participants judged physicians and parents to be the most
influential sources for communicating risk-reduction messages.
Incorporating treatment outreach services or program reminder
contacts may also be effective in increasing recruitment
of heavier drinkers or those in need of treatment (Black
and Smith, 1994; Gottheil et al., 1997). Black and Smith
(1994) found heavy drinkers, compared with the general
population, rated reminder contacts as a more important
strategy for increasing attendance at programs. Similarly,
Gottheil et al. (1997) found that calling adult individuals
who missed their first scheduled outpatient substance abuse
treatment appointment resulted in increased treatment entry.
In addition, participants recruited through these outreach
efforts subsequently participated in and benefited from
the treatment program as much as did those participants
who had not missed their first appointment.
Use of standardized screening instruments
Routine screening of college students for alcohol misuse
or problems may be another mechanism for increasing
identification and referral of students to services. Identifying
students at risk for alcohol-related problems early in
their college career, and offering brief intervention to reduce
these risks, has been shown to be an effective indicated
prevention strategy (Marlatt et al., 1998). Incorporating
brief alcohol screening measures into other standard contacts
with undergraduates may minimize reactivity to these
questions and increase participation rates compared with
advertising voluntary "alcohol screening," which students
may view as pejorative. Despite these potential advantages
to routine screening, there are both practical and ethical
considerations in implementing this strategy that would need
to be addressed. These include choosing appropriate screening
instruments, cost and use of the information once collected.
Although choice of instruments is reviewed here, it
is important for campuses considering routine screening to
consider who will collect the information, what safeguards
there are to protect confidentiality of students, what procedures
are in place for referring students for services once a
need is identified and who (besides the referral source) will
have access to the information once it is collected.
Regarding choice of screening instruments, there are a
variety of screening and assessment tools available for evaluating
and diagnosing alcohol-related problems. Unfortunately,
many of these, such as the CAGE (Heck, 1991;
Heck and Williams, 1995; Nyström et al., 1993; O'Hare
and Tran, 1997; Smith et al., 1987; Werner and Greene,
1992; Werner et al., 1996) and the Michigan Alcoholism
Screening Test (Martin et al., 1990; Nyström et al., 1993;
Otto and Hall, 1988; Silber et al., 1985; Smith et al., 1987;
Svikis et al., 1991), were developed using adult conceptualizations
of alcohol-related problems, with a particular
emphasis on the disease model of alcoholism and
identification of chronic alcohol dependence. These instruments
are limited by the fact that they may not be adequately
sensitive to accurately identify individuals suffering
from short-term problems. They also may not be adequately
specific to separate those with short-term problems resulting
from heavy episodic drinking from those with more
serious alcohol-related problems. Some health centers or
other referral sources on campus may choose to utilize these
common adult screening measures despite limitations, as
their brevity and familiarity make them easy to use. In this
case, it is important for those using the measures to complete
more detailed assessment following screening to better
evaluate and meet the needs of the individual student.
In addition, diagnosis of alcohol dependence on the basis
of these assessments is not warranted.
An additional complication of screening and assessment with college students
is the fact that alcohol diagnoses, in-cluding the diagnosis of alcohol dependence,
tend to be relatively unstable during the adolescent and young adult years (Grant,
1997). Only about 30% of students with an alcohol misuse or dependence diagnosis
in college will continue to meet criteria into the later adult years (Fillmore
and Midanik, 1984; Grant, 1997; Kilbey et al., 1998; Temple and Fillmore, 1985).
Therefore, utilizing screening or diagnostic assessments in college to predict
later adult adjustment or problems is a difficult endeavor, and one best avoided.
In contrast to adult measures, there are several assessments
of alcohol use and alcohol-related negative consequences
that have been developed specifically for college
student populations. These include the Rutgers Alcohol
Problem Index (White and Labouvie, 1989), the Young
Adult Alcohol Problem Severity Test (Hurlbut and Sher,
1992) and the College Alcohol Problem Scale (O'Hare,
1997). Each of these is weighted toward identifying consequences
common to the adolescent or young adult experience,
thus increasing sensitivity to detect problems. The
measures vary regarding specificity, but each provides considerable
information regarding different types of negative
consequences, which is valuable for prevention or treatment
planning purposes. Assessment of quantity, frequency
and pattern of use is also important for adequate prevention
or treatment planning.
Health center and emergency room screening
One potential method for increasing participation in prevention
and treatment services on campus while minimizing
cost and increasing protections for individual students
may be to incorporate screening for and, in some cases, the
intervention itself into standard practice at campus health
centers and emergency rooms. Two outcome studies identified
in this review (Dimeff, 1997; Monti et al., 1999) incorporated
brief motivational enhancement procedures,
including assessment, into these health care settings. In both
cases, motivational interviews delivered in a health care
setting resulted in decreases in consumption and problems
for college-age participants. In the Dimeff (1997) study,
both assessment and feedback were generated using an interactive
computer program available in the clinic waiting
room, suggesting students with little to do while they wait
might access and complete the intervention on their own
with little staff involvement. Similarly, several computerized
versions of alcohol screening measures have been developed
for the college student population (Anderson, 1987;
Miller, 1999; Rathbun, 1993). Incorporating routine screening
of alcohol consumption and problems into standard health
care practices in college clinics and either training medical/
nursing/support staff to deliver motivational feedback or
providing for computer-generated feedback without staff intervention
may serve to increase participation in these programs.
Brief interventions to increase service entry and retention
In addition to utilizing brief motivational interventions
for risk reduction, these approaches might be effective in
increasing motivation for and retention in longer-term prevention
or intervention programs. Aubrey (1998) found motivational
feedback improved outcome for adolescents
presenting for outpatient treatment. It is possible that mailed
motivational feedback, such as that evaluated by Agostinelli
et al. (1995), may have similar effects on recruitment and
retention in more intensive services, but this has yet to be
evaluated. Evaluating low-cost mailed or large-group brief
interventions as universal prevention approaches designed
both to reduce risky behavior and to increase participation
in additional services may be a viable strategy.
Peer training for identification, referral and provision of services
The use of peers to deliver prevention services, as well
as to assist with identification and referral of students in
need of services, has a long history in the college student
setting (Caron, 1993; D'Andrea and Salovey, 1998; Ender
and Winston, 1984; Grossberg et al., 1993; Hatcher, 1995;
Sloane and Zimmer, 1993). However, few studies have systematically
evaluated the effectiveness of peers as either
providers of service or as referral sources.
In the current review, nine of the individually oriented prevention approaches
reviewed in the first section were delivered by peer providers (Barnett et al.,
1996; Larimer et al., 2001; Miller, 1999; Schall et al., 1991; Schroeder and
Prentice, 1998). Of these, only four demonstrated efficacy in reducing consumption
or reducing consequences, including a normative reeducation approach (Schroeder
and Prentice, 1998), a motivational feedback approach (Larimer et al., 2001)
and two skills-based approaches (Miller, 1999). Although these results have
led some to conclude that peers are not effective in delivering prevention services,
in fact peers have not typically been systematically compared with professional
providers. Therefore, lack of efficacy of the approaches evaluated cannot be
clearly determined to be the result of the program, the peer providers or some
combination of both. In one study that included random assignment of peer or
professional providers (Larimer et al., 2001), preliminary data suggest peers
are at least as effective at promoting change in drinking behavior among fraternity
pledges using a brief motivational intervention as professional-level staff.
However, more research is needed to evaluate carefully the efficacy and cost
effectiveness of peer-delivered as compared with professionally delivered services.
Several programs also exist to train peers in identifying
and intervening with their peers to promote less risky behavior
as well as to increase utilization of available alcohol
prevention services. One area where data support this as a
useful intervention strategy involves studies of naturalistic
interventions in potential drunk driving incidents. Several
survey research projects have indicated that, when there is
intervention to stop an intoxicated individual from driving,
peers are most often the ones to intervene, and the majority
of these interventions are successful (Hernandez and Rabow,
1987; Newcomb et al., 1997).
The use of campus police and campus judicial officers
to increase referrals to and completion of substance abuse
prevention or treatment services is becoming a common
practice (Stone and Lucas, 1994). There is growing evidence
that students who violate campus alcohol or conduct
policies are on average at increased risk for heavy drinking
and related negative consequences (Flynn and Brown, 1991;
O'Hare, 1997). These findings suggest that campus police
and judicial officers may be valuable referral sources and
should be knowledgeable about campus services to facilitate
referral. Referral of policy violators to alcohol education,
prevention or treatment services instead of or in
addition to other legal sanctions is viewed as one means of
reducing recidivism and promoting individual behavior
change. Unfortunately, as described above, there are sparse
data available regarding the effectiveness of this strategy
on the college campus, either in terms of entry/retention of
mandated students into services or the outcome of such
services when provided. Research in the area of drunk driving
in the general population suggests "diversion" programs
are less effective when they are used in place of other sanctions
(Hingson, 1996; Wells-Parker et al., 1995), but can
be effective in combination with other swift and certain
consequences of drunk driving (like license revocation or
vehicle impoundment). In addition, the strength of the mandate
(i.e., the consequences for failure to complete the program)
is an important determinant of actual entry and
retention in mandated services. Considerably more research
is needed to evaluate whether, for whom and under what
circumstances referral to prevention or treatment programs
as a sanction strategy is effective on college campuses.
Conclusion and Summary of Research Priorities
This review of the literature covered individually focused prevention and treatment
strategies evaluated between 1984 and 1999. Conclusions regarding efficacy of
existing prevention and treatment programs are similar to those of previous
reviews, in that little evidence exists for the utility of educational or awareness
programs, including informational-based and values clarification approaches.
One exception to this may be the Prime for Life program (formerly called On
Campus Talking About Alcohol) (Sammon et al., 1991; Thompson, 1996), which has
some evidence of efficacy. The Prime for Life program includes risk-reduction
guidelines based on personal risk factors in addition to general information,
which may contribute to increased efficacy. However, evaluations of this program
available to date have been limited due to nonrandom assignment of participants
and/or lack of a comparison group. Peer-based normative reeducation programs
also show some support, but have similarly not been adequately tested. Therefore,
randomized trials of these interventions with sufficient methodological rigor
and adequate sample size to detect differences would be of value. To evaluate
relative efficacy and cost effectiveness, these approaches should be evaluated
in comparison to existing efficacious brief interventions.
Skills-based interventions have consistently yielded
greater support for their efficacy than have informational
interventions. Recently, several minimal skills-based interventions
have been shown to result in decreases in alcohol
consumption, including both self-monitoring/self-assessment
of alcohol consumption as well as expectancy-challenge procedures
involving alcohol/placebo administration. In addition,
brief motivational feedback interviews have been
demonstrated to be efficacious in a variety of contexts, including
emergency rooms, outpatient counseling centers,
fraternity organizations, high school classrooms and with
randomly selected high-risk college freshman. Finally,
mailed graphic feedback has been shown in three studies to
result in decreases in alcohol consumption equivalent to or
superior to skills-based groups combined with feedback.
Several research priorities emerge from reviews of these
studies. First, additional research is needed evaluating the
role of self-assessment in drinking reductions and methods
for facilitating this effect. Second, further research evaluating
the conditions under which expectancy challenge procedures
are effective is needed, particularly studies designed
to disentangle the informational and experiential components
of expectancy challenge procedures. Inclusion of
longer-term follow-up is also needed. Similarly, additional
studies that disentangle the effects of graphic feedback alone
from skills training alone and in combination with feedback
are needed. In general, replication of each of these
techniques in larger-scale studies by investigators not involved
in the development of the techniques is warranted.
In particular, larger samples allowing for evaluation of gender,
ethnicity, residence-type, athlete status and family history
effects on response to these interventions would yield
Studies evaluating on-campus treatment programs are
also lacking in the literature, as are studies evaluating the
effects of any of these interventions with students mandated
to comply. Given the ethical concerns inherent in
mandated treatment, evaluation of services for mandated
students is an urgent priority.
In addition to effectiveness or efficacy trials of interventions
already available on campus, this review suggests the
field could benefit from additional research regarding service
delivery systems, including the most effective means
for screening, identifying, recruiting, referring and retaining
students in alcohol prevention services. Systematic
evaluation of marketing and recruitment techniques, as well
as training for police, faculty, staff and medical/mental
health personnel, is needed.
The evidence from this review suggests campus personnel
searching for effective individually oriented practices
to implement on their campus right now would be best
served by implementing brief, motivational or skills-based
interventions, targeting high-risk students identified either
through brief screening in health care or other campus settings
(indicated prevention) or through membership in an
identified risk group. Careful attention to the marketing of
these services and the provision of incentives for participation
is also recommended. Focus groups with students on
each campus to develop materials and marketing strategies
may help maximize recruitment and retention of students.
Partnering with psychology, sociology, public policy, public
health, education or social work departments or institutional
research offices on campus to obtain technical
assistance in conducting and evaluating these efforts may
be one viable strategy for accomplishing these aims. Finally,
understanding that individually oriented prevention
and treatment services are only one piece of the puzzle is
important. Fostering a campus climate supportive of prevention
efforts through collaborations with policy-makers,
judicial and disciplinary officers, law enforcement personnel,
student affairs staff, health care staff and other stakeholders,
to best support prevention efforts, is necessary.
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*This article was prepared with support from the National
Institute on Alcohol Abuse and Alcoholism grants AA10772 and AA05591 awarded
to Mary E. Larimer.
Mary E. Larimer may be reached at the above address
or via email at: firstname.lastname@example.org. Jessica M. Cronce is with the Addictive
Behaviors Research Center, Department of Psychology, University of Washington.
Last reviewed: 9/23/2005