Epidemiology and Prevention Strategies

I. Learning Objectives

• A. Participants will increase their knowledge in the epidemiology of alcohol use and alcohol-related problems among college students.
• B. Participants will increase their knowledge of risk factors associated with student alcohol use.
• C. Participants will increase their knowledge of prevention strategies that work.

II. Chronology

• A. 10-to 40-minute large-group lecture, using a sub-sample of about 30 slides
.
• B. 10-to 20-minute large-group discussion on prevention of college drinking.

III. Training Materials

• A. Clinical Protocols to Reduce High-Risk Drinking in College Students—30 slides[HTML].
• B. Summary of the epidemiological data and evidence-based prevention strategies.

IV. Credits

The information included in the module is primarily derived from the position papers and publications associated with the National Advisory Council on Alcohol Abuse and Alcoholism Task Force on College Drinking of the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

A supplement to the Journal of Studies on Alcohol contains much of the original source data for this curriculum module. ( "College Drinking, What It Is, and What To Do About it: A Review of the State of the Science," Journal of Studies on Alcohol, Supplement No.14, March, 2002).

Introduction

The goal of this module is to provide staff and clinicians working in student health centers with information on prevention and treatment of alcohol problems among college students. The curriculum focuses on clinical methods directed at helping individual students reduce their level of alcohol use and the risks associated with heavy drinking. The curriculum is based on a harm reduction public health paradigm.

This model will review the epidemiology of alcohol use among college students, alcohol-related problems among this population, risk factors associated with alcohol use, and prevention strategies. The research presented in this module is intended to provide clinicians with new information to help in their work with students.

Epidemiology of Alcohol Use Among College Students

The epidemiological data presented in this module are derived from five sources: 1) College Alcohol Study conducted by the Harvard School of Public Health; 2) the Core Institute Alcohol and Drug Use Survey; 3) the National College Health Risk Behavior Study, conducted by the CDC; 4) the annual National Household Survey on Drug Abuse; and 5) the Monitoring the Future Study. The data are presented in Figures 1-3. These figures were obtained from O'Malley and Johnston (2002) and are reprinted with their permission.

The College Alcohol Study was conducted by the Harvard School of Public Health in 1993, 1997, 1999 and 2001 , Weschler, Lee, Kuo, Seibring, Nelson & Lee (2002); www.hsph.harvard.edu/cas. Longitudinal comparisons were made across 120 colleges that participated in the first three surveys. Over 10,000 students participated in the mailed surveys that focused on alcohol use, alcohol-related harm, attitudes, and beliefs.

A second study focused on college students is the Alcohol and Drug Use Survey by the Core Institute study of Southern Illinois University (Presley, Meilman & Cashin (1996); (www.siu.edu). The survey was conducted in those colleges funded by a Department of Education prevention grant program and represented a convenience sample. A study initiated in 2001 uses a representative sample of 300 colleges. The survey randomly selected over 142,500 students from these colleges. Like the Wechsler study, the Core Institute study focused on alcohol use, alcohol-related problems, attitudes and beliefs.

A third survey is the National College Health Risk Behavior Study (Center for Disease Control, 1997). The survey was conducted in 1995 at 136 two- and four-year colleges. A total of 4,838 students participated. The survey included questions on alcohol, tobacco, drugs, sexual behaviors, diet, and exercise.

The National Household Survey on Drug Abuse is the primary source of data used to estimate tobacco, alcohol, and illegal drug use in the U.S. (Gfroerer, Greenblatt & Wright (1997); www.samhsa.gov). The survey is conducted once a year utilizing an in-house interview procedure by researchers at the Research Triangle Institute in North Carolina. The survey focuses on civilian, non-hospitalized populations, including residents of student dormitories, shelters, and rooming houses. The study includes all age groups, including college-age students. One of the primary advantages of the survey is that it allows for comparison of college students and non-college peers.

The Monitoring the Future study is an annual survey of high school students (Johnston, O'Malley & Bachman (2002); www.monitoringthefuture.org). The survey began in 1976 and includes questions on alcohol, drugs, and substance-related adverse effects. Since 1980, the survey has also generated a longitudinal study that follows students into college and beyond graduation. This is the only national study that is following the same cohort over time. This survey is conducted by scientists at the University of Michigan.

Figure 1 estimates alcohol use among college students from the five data sources listed above. While the data are from different time sources, the 30-day prevalence for alcohol use was between 60-70%, with 30-40% reporting abstinence. Four of the five studies reported that 40% of students participated in heavy drinking at least once in the previous 2 weeks. Heavy drinking was defined as five or more drinks in a row.

Figure 1: Prevalence of Annual, 30-day, and Heavy Alcohol Use Among College Students

Figure 2 illustrates trends in alcohol use among college students between 1980 and 1999. These data were obtained from the Monitoring the Future Study. As one can see, there is little change in alcohol use during these years.

Figure 2: Trends in Annual, 30-day, Heavy, and Daily Alcohol Use Among College Students 1980 - 1999

There is a slight downward trend in the rate of heavy drinking over the last two decades. Unfortunately, there are no data prior to 1980 that can be used for direct comparison.

Figure 3 compares college students and non-college peers* of the same age. These data were again derived from the Monitoring the Future Study. College students appear more likely to use alcohol and to drink more heavily than their non-college peers. The only difference is daily alcohol use, which may be higher in young adults who do not attend college. Longitudinal data from the annual survey suggest little change in this difference over the last 20 years. College students drink more than their peers who do not attend college.

* "Non-college peers" does not include military personnel.

Figure 3: Prevalence of Annual, 30-day, Heavy, and Daily Alcohol Use Among College Students and Non-College Peers

As expected, all national surveys reported variation in alcohol use by gender, race and geographical region. The studies found that men drink at higher levels than women. The difference, however, is not as dramatic as might be expected. Four of the surveys found 50-60% of college men in the samples reported heavy drinking episodes, with 34-40% of women reporting heavy drinking. Trends over time suggest fewer differences between men and women.

There are marked racial differences among student groups (Wechsler, Fulop, Padilla, Lee & Patrick, 1997). White students reported nearly three times as much heavy high-risk drinking as black students. Hispanic students reported approximately 25% less heavy drinking than white students.

Finally, regional variations were found. Alcohol use was less prevalent in Western colleges than in Northeastern or North Central colleges.

In summary, the frequency of heavy alcohol use on college campuses is high. The pattern and level of use have changed little over the past 20 years on most college campuses. College students are more likely to engage in high-risk drinking than their peers who do not attend college.

Frequency of Alcohol-Related Problems Among College Students

Using a number of national data sets, Hingson, Heeren, Zakos, Kopstein & Wechsler (2002) estimated that 1,400 U.S. college students aged 18-24 died from alcohol-related unintentional injuries in 1998. Of the 1,400 deaths, 307 were unintentional non-traffic deaths. These deaths were related to falls, burns, drowning, alcohol poisoning, and other accidents. Mortality rates due to suicide or other related medical problems are not available. College student status is not included on death certificates or other fatality data sets.

Hingson et al. (2002) also estimated that 600,000 students were assaulted by other students who were drinking alcohol, and 500,000 students were injured as a result of their drinking. Estimates suggest that one in four college students (approximately two million students) drove a car under the influence of alcohol in the previous 12 months. One in three students reported getting in a car driven by someone who had been drinking alcohol.

Self-report surveys provide additional evidence of the multiple adverse effects of alcohol use among college students. Blackouts are one of the most common effects of heavy alcohol use, with a number of surveys finding that 25% of students report memory loss on at least one occasion after drinking (Perkins, 2002). Alcohol-related personal injuries are reported by 9-15% of students in the College Alcohol Study (Wechsler, 1998) and the Core Survey (Presley et al., 1996). Nearly 50% of college students who use alcohol report hangovers, abdominal pain, and vomiting during heavy drinking episodes (Presley et al., 1996).

Unintended and unprotected sexual activity are of great concern. HIV infection continues to occur at an alarming rate among various U.S. populations, including college students. While more effective treatment is available, HIV infection is a serious life- threatening illness. The social stigma associated with HIV infection, as well as its possible effect on future children, are other components that impact affected individuals. Self-report surveys (Weschler, 1999; Anderson, 1996) have found that as many as 10% of students report having unprotected sex as a result of alcohol use. These surveys also suggest that 20-40% of women report unintended sex associated with alcohol use (Mielman, 1993; Wechsler, 1998; Gross & Billingham, 1998; Fisher, Cullen & Turner, 2000).

The effect of high-risk alcohol use on roommates and other members of a college community is another aspect of alcohol use on college campuses (Fisher, Sloan, Cullen & Lu, 1998). Nearly 30% of students report being involved in a fight or argument while drinking in the previous 12 months. Data collected from the College Drinking Survey (Wechsler, 1998) found that 13 to 27% of students reported being assaulted, hit or pushed by another student who was drinking. In the same study, 8% reported damaging university property or setting off a fire alarm. Five to ten percent of the students reported being involved with campus or community police for incidents involving alcohol.

In summary, alcohol problems among college students are common. These problems are serious and can result in death and serious injury. The study conducted by Hingson and colleagues suggests that 14,000 students have died in the past 10 years as a result of their drinking. Interpersonal violence and high-risk sexual behavior are strongly associated with alcohol use. Alcohol use is also strongly associated with tobacco and other drug use.

Risk Factors Associated With High-Risk Drinking

Clinicians may want to consider a number of factors that contribute to high-risk alcohol use and alcohol-related adverse events. Some of these factors can be modified or changed. Others are more resistant to prevention efforts.

Clinicians may want to use these individual risk factors to screen, assess, and develop a plan for each student they encounter at the student health center. For example, students who have a strong family history of alcohol problems, a history of impulsive or deviant behavior, or chronic depression should be counseled to be abstinent from alcohol use. Others with less immediately threatening risk factors should be informed about low-risk drinking limits and how to avoid alcohol use in high-risk situations.

Modules 2, 3 and 4 are designed to provide clinicians with methods to screen, assess, and intervene with individual students.

What follows is a list of interventions that have been tested and evaluated in research studies. While many of these interventions are beyond the immediate scope of work of clinic-based health care professionals, providers may want to volunteer time and expertise to work with campus and community groups who are involved in broader-based efforts.

Some strategies have been shown in research studies to be ineffective. Health care professionals need to be aware of them in order to insure that time, energy, and funding are directed to more promising approaches.

One strategy that is within the scope of work of most student health clinicians is to promote healthy behaviors through individual and group interventions. Module 2 of this curriculum describes the role of the college health clinic in screening students for at- risk and problem drinking in order to discern who needs what type of health message and to identify the small percentage of students who should be referred to an addiction treatment program. Modules 3 and 4 focus on the skills needed to deliver effective office-based brief interventions for those students who would benefit from reducing their drinking.

It is important to have screening and outreach programs on campus that identify those students who may not seek care in student health centers. Opportunities include dormitories, the Greek system, student unions, or student health fairs. Having incoming students complete a health habit survey that includes alcohol use is a system-wide screening method that has worked in some campus settings (Marlatt et al., 1998). Another option is National Alcohol Screening Day, an annual event sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Substance Abuse and Mental Health Services Administration (SAMHSA). The program provides free, anonymous screening, alcohol and health information, and the opportunity to speak with a health professional about alcohol concerns. It takes place every April on college campuses and in community and private practice settings around the country. (For more information go to www.niaaa.nih.gov.)

Summary

High-risk alcohol use among college students is a major problem. There are many adverse effects with high levels of mortality and serious morbidity. While we need additional research, there are a number of proven prevention strategies that can be implemented immediately. In addition to implementing screening and intervention protocols in student health centers, clinicians have the opportunity to participate in a variety of campus and community intervention activities. The key is to base all interventions on proven and tested strategies

References

Anderson, P.B. & Mathieu, D.A. (1996); "College Students' High-Risk Sexual Behavior Following Alcohol Consumption;" Journal of Sex & Marital Therapy, 22: 259-264.

Baer, J.S. (2002); "Student Factors: Understanding Individual Variation in College Drinking;" Journal of Studies on Alcohol, Supplement No. 14, 40-54.

Centers for Disease Control and Prevention, (1997); Youth Risk Behavior Surveillance: National College Health Risk Behavior Survey - United States. MMWR 46 (SS-6): 1-56.

Clapper, R.L., Martin, C.S. & Clifford, P.R. (1994); "Personality, Social Environment, and Past Behavior as Predictors of Late Adolescent Alcohol Use;" Journal of Substance Abuse 6, 305-313.

Corbin, W.R., McNair, L.D. & Carter, J. (1996); "Self-Esteem and Problem Drinking Among Male and Female College Students;" Journal of Alcohol and Drug Education, 42, 1-14.

Dowdall. G.W., Wechsler, H. (2002); "Studying College Alcohol Use: Widening the Lens, Sharpening the Focus;" Journal of Studies on Alcohol, Supplement No. 14, 14-22.

Fisher B.S., Sloan J.J., Cullen, F.T. & Lu, C. (1998); "Crime in the Ivory Tower: The Level and Sources of Student Victimization;" Criminology 36, 671-710.

Fisher, B.S., Cullen, F.T& Turner, M.G. (200); The Sexual Victimization of College Women, NCJ 182369, Washington: Bureau of Justice Statistics, National Institute of Justice, Department of Justice.

Gfroerer, J.C., Greenblatt, J.C. & Wright, D.A. (1997); "Substance Use in the U.S. College-Age Population: Differences According to Educational Status and Living Arrangement;" American. Journal of Public Health, 87, 62-65.

Gross, W.C. & Billingham. (1998); "Alcohol Consumption and Sexual Victimization Among College Women;" Psychology Report, 82, 80-82.

Haines, M. & Spear, S.F. (1996); "Changing the Perception of the Norm: A Strategy to Decrease Binge Drinking Among College Students;" Journal of American College Health, 45 134-140, 1996.

Haines, M.P. (1996); A Social Norms Approach to Preventing Binge Drinking at Colleges and Universities; Newton, MA: Higher Education Center for Alcohol and Other Drug Prevention, Department of Education.

Hingson. R.W., Heeren, T., Zakocs, R.C., Kopstein, A., & Wechsler, H. (2002); "Magnitude of Alcohol Related Mortality and Morbidity Among U.S. College Students Ages 18-24;" Journal of Studies on Alcohol, 63, 136-144.

Johnston, L.D., O'Malley, P.M. & Bachman, J.G. (2000); National Survey Results on Drug Use From the Monitoring the Future Study, 1975-1999, Vol. 2. NIH Publication No. 00-4803, Bethesda, MD: Department of Health and Human Services.

Marlatt, G.A., Baer, J.S., Kivlahan, D.R., Dimeff, L.A., Larimer, M.E., Quigley, L.A., Somers, J.M, & Williams, E. (1998); "Screening and Brief Intervention for High Risk College Student Drinkers: Results From a 2 Year Follow Up Assessment;" Journal Consult Clinical Psychology, 66, 604 615.

Meilman, P.W. (1993); "Alcohol-Induced Sexual Behavior on Campus;" Journal of American college health, 42, 27-31.

O' Malley, P.M., & Johnston, L.D. (2000); "Epidemiology of Alcohol and Other Drug Use Among American College Students;" Journal of Studies on Alcohol, Supplement 14, 14-23.

Perkins, H.W. (2002); "Surveying the Damage: A Review of Research on Consequences of Alcohol Misuse in College Populations;" Journal of Studies on Alcohol, Supplement No. 14, 91-101.

Presley, C.A. Meilman, P.W. & Cashin J.R. (1996); Alcohol and Drugs on American College Campuses: Use, Consequences, and Perceptions of the Campus Environment, Volume IV: 1992-94; Carbondale, IL: Core Institute, Southern Illinois University.

Substance Abuse and Mental Health Services Administration. (1999); National Household Survey on Drug Abuse Main Findings 1997; DHHS Publication No. (SMA) 99-3295, Rockville, MD: Office of Applied Studies.

Wechsler, H. & Austin, S.B. (1998); "Binge Drinking: The Five/Four Measure;" Journal of Studies on Alcohol, 59,122-4.

Wechlser, H., Dowdall, G.W., Maenner, G., Gledhill-Hoyt, J., & Lee, H. (1998); "Changes in Binge Drinking and Related Problems Among American College Students Between 1993 and 1997. Results of the Harvard School of Public Health College Alcohol Study;" Journal of American College Health, 47: 57-68.

Wechsler, H., Lee, J.E., Kuo, M., & Lee, H. (2000); College Binge Drinking in the 1990s: A Continuing Problem: Results of the Harvard School of Public Health 1999 College Alcohol Study;" Journal of American College Health, 48, 199-210.

Wechsler, H., Moeykens, B., Davenport, A., Castillo, S., & Hansen, J. (1995); "The Adverse Impact of Heavy Episodic Drinkers on Other College Students;" Journal of Studies on Alcohol, 56, 628-634.

Wechsler, H. (2001); Binge Drinking on America's College Campuses: Findings From the Harvard School of Public Health College Alcohol Study (monograph), Boston, MA: Harvard School of Public Health.

Wechsler, H., Davenport, A., Dowdall, G., Moeykens, B., & Castillo, S. (1994); "Health and Behavioral Consequences of Binge Drinking in College. A National Survey of Students at 140 Campuses;" Journal of the American Medical Association, 272, 1672- 1677.

Wechsler, H., Fulop, M., Padilla, A., Lee, H., & Patrick, K. (1997); "Binge Drinking Among College Students: A Comparison of California With Other States;" Journal of American College Health, 45, 273-277.

Historical document
Last reviewed: 9/23/2005