Key Results: Binge Drinking on College Campuses and in Communities
Citations Listed in Key Results
- Individuals who binge drink experience a wide range of problems.
Among adults (age 18 and older) in the U.S., young adults have the highest rates of binge drinking, and, among them, college students drink more heavily than their non-college attending peers (Slutske et al., 2004; OMalley & Johnston, 2002). While most binge drinkers are not alcoholics or dependent on alcohol, they are at higher risk for experiencing problems due to their alcohol use than those who do not drink at those levels. Those who engage in binge drinking are more likely to progress to meet criteria for alcohol use disorders, such as alcohol abuse or alcohol dependence (Knight et al., 2002; Wechsler & Nelson, 2006).
Heavy drinking causes a broad range of serious negative consequences for drinkers (Perkins, 2002b). These problems include poor school and work performance; engaging in risky sexual behaviors such as unplanned and unprotected sex; physical assault; sexual assault; vandalism; legal problems; and various intentional and unintentional injuries such as those resulting from motor vehicles crashes, falls, burns, firearms and domestic violence, and alcohol overdose (Dawson et al., 2005; Hingson et al., 2009; NIAAA, 2000). Binge drinking also contributes to chronic health conditions such as liver disease, high blood pressure, stroke, cardiovascular disease, and uncontrolled diabetes, and can lead to neurologic damage (Babor et al., 2003; NIAAA, 2000). Heavy drinking among women who are pregnant poses risks for poor birth outcomes and fetal alcohol syndrome (Alati et al., 2006; Kodituwakku et al., 2006).
Many college students are likely to experience consequences related to their alcohol use because of high levels of drinking. Each year, more than a half a million students are unintentionally injured under the influence of alcohol; approximately 30,000 students require medical treatment after overdosing on alcohol; and 1,700 die under the influence of alcohol (Hingson et al., 2005a; 2009). Driving a motor vehicle is a particularly risky context for heavy alcohol consumption. The majority of the college student deaths from alcohol-related unintentional injuries result from motor vehicle crashes. Among college students, 29% reported driving after drinking and 11% reported driving after binge drinking. Additionally 23% of students said that they rode with a driver who was high or intoxicated (Wechsler et al., 2003). Women face particular risks associated with alcohol. Three-fourths of female students who reported being sexually assaulted were under the influence of alcohol at the time of the assault (Mohler-Kuo et al., 2004).
- Binge drinking contributes to problems experienced by others.
The consequences of binge drinking are experienced by other people in addition to the drinkers themselves. Similarly to the concept of "secondhand smoke" from tobacco, the behavior of drinkers directly and indirectly impacts the health and well-being of those around them. Secondhand effects of binge drinking include disruption of sleep or study; property damage; verbal, physical, sexual and domestic violence; and motor vehicle crashes (NIAAA, 2000; Wechsler et al., 1995b; 2001b).
Secondhand effects of binge drinking are common on college campuses. A strong relationship exists between rates of binge drinking on campus and rates of problems experienced by students that are caused by other students drinking. Alcohol-related problems resulting from student binge drinking also frequently spill into communities surrounding campuses, resulting in problems such as noise disturbances, vandalism, and frequent police calls (Wechsler et al., 2002a; 1995b).
- Effective programs have been identified to address the needs of binge drinkers and other high-risk alcohol users, but these programs need to be implemented population-wide to reduce societal costs.
College campuses in particular need systems to address high-risk drinkers, and most colleges have not implemented such systems. Some individuals who binge drink meet the diagnostic criteria for alcohol abuse and dependence. Others who drink alcohol heavily on a regular basis but do not meet the clinical definition of alcohol abuse or dependence may also need intervention services.
Nearly one third of college students qualify for a diagnosis of alcohol abuse, and one in 17 qualifies for a diagnosis of alcohol dependence (one in five frequent heavy drinkers; Knight et al., 2002). However, the gap between those students who may need treatment and those who actually receive it may be as large as 1.1 million college students nationally (Weitzman et al., 2005).
Effective systems in college settings should include systematic and routine alcohol screening at standard points of student contact (e.g., appointments at physical and mental health clinics; following alcohol-related incidents; Larimer & Cronce, 2002) using standardized and appropriate instruments. Once high-risk students are identified, they should be referred to and given access to comprehensive and age- and culturally-appropriate services, such as treatment programs for those who are alcohol dependent (NRC & IOM, 2003; Winters et al., 2002) or intervention services for those who regularly drink heavily but do not meet the clinical definition of alcohol dependence (SAMHSA, 2009; Wechsler & Nelson, 2006). In NIAAAs 2002 Task Force on College Student Drinking report (NIAAA, 2002), three programmatic approaches for heavy alcohol users were identified as effective with college students: (1) changing students views about the effects of alcohol, including documentation of daily alcohol consumption; (2) providing personalized feedback to students about their alcohol use either individually or in small groups, either in-person, or via mail or computer (Collins et al., 2002; Larimer & Cronce, 2002; Saunders et al., 2004); and (3) changing students beliefs about outcomes of alcohol use (e.g., belief they will be more sexually attractive following alcohol use). Recent research suggests that the effects of brief motivational interventions may be longer lasting than effects of programs that challenge "alcohol expectancies," which refers to students expectations about the effects of alcohol (Wood et al., 2007).
To decrease rates of alcohol use and related problems among the highest-risk drinkers, screening, treatment, and intervention programs that have been identified as most effective need to be implemented broadly. Effective programs often are not disseminated widely enough to create sustained reductions in problems (Hallfors & Godette, 2002). For example, although standardized alcohol screening instruments are available for minimal or no cost and have been evaluated as appropriate to use with college students (Larimer & Cronce, 2002; 2007; Knight et al., 2002), only a small percentage of campuses use these screening tools (Foote et al., 2004). Policies and systems are required to train individuals to implement the programs, to monitor the programs to ensure that they are implemented as intended (in terms of focus, length, specific components, etc.), and to ensure that adequate resources are available. Additionally, more cost-effective ways to deliver screening, intervention and treatment are needed. Some computer-based or e-interventions, which are less expensive to administer, have shown some promise and are more likely to reduce alcohol use than doing nothing (Elliott et al., 2008); however, more research is needed to assess their long-term effects.
Programs that focus on the highest-risk individuals need to be complemented by changes in the broader school, community, and state environments that promote binge drinking and other risky patterns of alcohol use (Wagenaar & Perry, 1994). Strongly enforced policies can help create changes in the environment related to alcohol use by placing controls on the availability of alcohol through restriction on its distribution, marketing, and use (Babor et al., 2003). By encouraging responsible alcohol use through limiting availability, we can increase the likelihood of sustaining the effects of treatment and intervention programs for high-risk alcohol users as well as decreasing binge drinking among individuals who do not meet diagnostic criteria for alcohol abuse or dependence but who still are at risk for alcohol-related problems.
- Only treating or intervening with those at highest risk is not enough to significantly reduce alcohol-related problems and costs on campuses or in communities and for states.
The more alcohol a person tends to consume and the more frequently that person binge drinks, the greater the likelihood that person will experience problems resulting from alcohol use (Babor et al., 2003; Wechsler et al., 2002b; Wechsler & Nelson, 2006). However, most individuals who binge drink do not need intervention or treatment. These individuals may have a lower individual-level risk of problems than those who are addicted or abusing alcohol, but there are many more of these types of binge drinkers (Weitzman & Nelson, 2004). As a result, the majority of alcohol-related harms in a community occur among those who consume lower levels of alcohol - not among those who are the heaviest drinkers.
This counterintuitive phenomenon is known as the Prevention Paradox and it has important implications for intervention (Rose, 1992). The paradox is that the "highest-risk" or heaviest drinkers account for only a small percentage of the overall harms in a population while the majority of harms that arise in the population occur among people who drink at comparatively lower levels. For example, nearly half (48%) of college students who reported falling behind in school as a result of their alcohol use usually consumed four or fewer drinks when drinking, and 38% of students who were hurt or injured as a result of their drinking usually consumed four or fewer drinks (Weitzman & Nelson, 2004). Strategies targeting only high-risk drinkers miss the source of a large proportion of most alcohol-related problems in a community (Weitzman & Nelson, 2004).
The most common prevention and intervention approaches target individuals at "high-risk" for alcohol-related problems through education, counseling, treatment, and punitive measures for those who come to the attention of authorities. These approaches often have short-term effects when implemented alone and are unlikely to affect the drinking behavior among the part of the population that contributes a larger proportion of the alcohol-related problems (Larimer & Cronce, 2002; 2007; Wechsler & Nelson, 2006, Weitzman & Nelson, 2004).
In contrast, a population approach to prevention targets an entire community (e.g., all students on a college campus) by addressing the conditions that influence the drinking behavior of everyone in that community (e.g., policy changes that affect the price of alcohol or improve responsible service of alcohol). When distributed across a community, population interventions can positively impact overall harms by shifting everyones drinking behavior to a slightly lower level of risk, and such interventions are likely to result in community-wide benefits.
Population approaches such as policies to restrict alcohol availability and high-risk approaches such as treatment and intervention programs are often viewed as competing prevention strategies, but they are complementary. Communities, including college campuses, should engage in both types of approaches to create sustained reductions in binge drinking and related problems.
- Alcohol control policies can reduce binge drinking and related problems.
Population approaches can be effectively implemented through policy interventions (Babor et al., 2003) and many such interventions have documented efficacy for reducing binge drinking and related consequences (see Toomey & Wagenaar, 1999; 2002; Toomey et al., 2007). Based on the strength of the research evidence, the National Institute on Alcohol Abuse and Alcoholism (NIAAA, 2002), the Institute of Medicine (NRC & IOM, 2003), the Higher Education Center for Alcohol and Other Drug and Violence Prevention (www.edc.org/hec), the Substance Abuse and Mental Health Services Administration (SAMHSA, 2003), and the Centers for Disease Control and Prevention (http://www.thecommunityguide.org/alcohol/index.html) have recommended several alcohol control policies to affect alcohol-related problems among the general population, underage youth, and college students.
Below we provide a brief summary of the most well-researched alcohol control policies.
-Minimum Legal Drinking Age (MLDA)
Many studies using robust research designs show that an age-21 MLDA (currently policy in the U.S.) results in reductions in alcohol use and traffic crashes among 18- to 20-year-olds (Wagenaar & Toomey, 2002; http://www.saprp.org/KnowledgeAssets/Knowledge_Detail.cfm?KAID=19). However; most youth in the U.S. continue to drink, in part due to lax enforcement of existing laws, which allows underage youth to obtain alcohol from many different sources (Wagenaar and Wolfson, 1994; 1995; Paschall et al., 2007). A key MLDA enforcement strategy that has been shown to be effective in reducing illegal alcohol sales to underage youth is compliance checks, where an underage person attempts to purchase alcohol under supervision of law enforcement. If the sale is made, penalties may be applied to the server and/or the license holder (Grube, 1997; Lewis et al., 1996; Preusser et al., 1994; Wagenaar et al., 2005). Effective strategies for reducing underage access to alcohol for college students will likely require different interventions from those used for middle and high school students. For example, underage college students may be more likely to obtain alcohol from legal-aged college students or directly from a bar or liquor store while middle/high school students are more likely to obtain alcohol from parents (Fabian et al., 2008; Paschall et al., 2007).
Research indicates that as the price of alcohol goes up, alcohol consumption and, in turn, some alcohol-related problems decrease (Chaloupka et al., 2002; Wagenaar et al., 2009). This is true in the general population of alcohol users as well as among underage youth and college students (Chaloupka & Wechsler, 1996; Grossman et al., 1998; Kuo et al., 2003; OMara et al., 2009). An effective way to raise the unit price of alcohol is through raising alcohol excise taxes. Although some states in the U.S. have recently raised alcohol excise taxes, tax rates in most states have not kept up with inflation over the last several decades, resulting in lower alcohol prices over time (Alcohol Epidemiology Program, 2000).
Restrictions on Drink Specials
Several studies have found that reducing the price of alcohol through drink specials (e.g., 2-for-1 specials, ladies nights) is associated with higher consumption (Babor et al, 1978; 1980; Christie et al., 2001; Thombs et al., 2009), with one study specifically finding that colleges where students had access to low-priced alcohol had higher rates of binge drinking (Kuo et al., 2003). Studies show that policies that restrict drink specials are associated with reduced binge drinking among the general population and college students (Nelson et al., 2005; Smart & Adlaf, 1986; Williams et al., 2005).
Other State/Local-Level Alcohol Control Policies
Other state- and/or local-level policies that may reduce alcohol availability and subsequent problems include requiring the training of managers and servers/sellers of alcohol establishments (bars, restaurants, liquor stores, etc.) in responsible service practices (Toomey et al., 2008), reducing the hours that alcohol can be sold (Popova et al., 2009), and reducing the number of alcohol outlets in communities and near campuses (Williams et al., 2005). A review of policies affecting retail availability of alcohol is available at: http://www.saprp.org/KnowledgeAssets/Knowledge_Detail.cfm?KAID=9. Campus alcohol control policies, such as offering substance-free residence halls and banning alcohol throughout a campus, are associated with less binge drinking and other alcohol use (Wechsler et al., 2001a; 2001b; 2002c).
Although a wide variety of alcohol policies have been identified and shown to be effective for reducing high-risk alcohol use and related problems, many institutions (including colleges), communities, and states have not implemented these policies (Wechsler et al., 2004; DeJong & Langford, 2002; http://alcoholpolicy.niaaa.nih.gov/). Additionally, although research has shown that most policies need to be systematically enforced to be optimally effective (Gibbs, 1975), several studies have found that alcohol control policies are often not adequately enforced (Wagenaar & Wolfson, 1994; Lenk et al., 2009).
- Multiple strategies are needed to create sustained reductions in binge drinking and related problems.
Alcohol control policies and strategies may need to be implemented in combination, rather than as individual policies or strategies, to produce observable changes in rates of binge drinking and alcohol-related problems among the general population, underage youth, and college students. Support for use of multiple strategies comes from studies conducted at the community, campus, and state levels (Hingson et al., 2005b; Shults et al., 2009).
The Community Prevention Trial found that following implementation of five strategies (community mobilization, responsible beverage service training at bars, compliance checks to prevent sales to underage youth, sobriety checkpoints to prevent drinking and driving, and media advocacy) in intervention communities, rates of alcohol consumption, alcohol sales to minors, and alcohol-involved traffic crashes were significantly lower compared to comparison communities (Holder et al., 2000). The Communities Mobilizing for Change on Alcohol project (CMCA) used a community organizing approach to implement multiple strategies to prevent underage individuals from obtaining alcohol to ultimately reduce alcohol use and related problems. A variety of strategies aimed at reducing access to alcohol were implemented across the intervention communities, such as alcohol compliance checks at bars and liquor stores, and stricter drinking policies at community events (Wagenaar et al., 2000a; 2000b). The evaluation of the project found that 18- to 20-year-olds in intervention communities were less likely than 18- to 20-year-olds in the control communities to try to buy alcohol, drink in a bar, consume alcohol, or be arrested for driving under the influence.
Several studies have assessed effects of multiple policy strategies on alcohol use and related problems among college students. The A Matter of Degree initiative (AMOD), funded by the Robert Wood Johnson Foundation, examined intervention campuses separated into low and high intervention groups based on the number of environmental change strategies they implemented compared with a group of colleges not in the program (Weitzman et al., 2004). Among the high implementation sites, significant decreases were observed for binge drinking as well as several other measures of alcohol use and alcohol-related harm.
Multiple environmental policies or strategies can also be implemented at the state level. In cross-sectional analyses, researchers found that states with more state alcohol control policies had lower rates of binge drinking, underage drinking, and drinking and driving among college students than states with fewer alcohol control policies (Nelson et al., 2005; Wechsler et al., 2002c; 2003).
There is need for caution in interpreting the results of each of the individual studies evaluating multiple strategies because of their methodological limitations. However, taken together, these studies provide evidence that use of multiple strategies may be effective in reducing heavy alcohol use and alcohol-related problems among the general population, underage youth, and college students (Shults et al., 2009).
- Campus-wide interventions aimed at individual behavior change have mixed effects on alcohol use.
Several types of campus-wide alcohol interventions aimed at individual behavior change are popular among colleges. These include social norms marketing campaigns, online intervention programs, and traditional education approaches.
Social norms marketing programs were developed based on findings that some college students overestimate the amount of alcohol that other students on their campus consume (Kypri & Langley, 2003; Perkins, 2002a; Perkins & Berkowitz, 1986). Social norms marketing campaigns communicate the actual rate of student alcohol use on campus, as measured by surveys conducted on a specific campus. According to this approach, correcting students misperceptions about other students alcohol use by providing accurate information will lead students to conform their own alcohol use to the prevailing norms.
Studies of the effectiveness of social norms campaigns have mixed findings with respect to reducing students misperceptions of peer alcohol use and student alcohol consumption.
Online intervention programs may also be implemented to change individual-level behaviors. Educational programs - administered online or through more traditional methods - that focus solely on providing information to increase knowledge are not effective in reducing alcohol use when used alone (Larimer & Cronce, 2002; 2007; NIAAA, 2002).