Research Article

Why underage College students drink in excess: qualitative research findings

Virginia Dodd, Tavis Glassman, Ashley Arthur, Monica Webb, and Maureen Miller

ABSTRACT

Background: Excessive consumption by underage students is a serious and persistent problem facing most U.S. colleges and universities. Purpose: This qualitative study explores why underage students engage in high-risk drink- ing and examines motivational cues that may serve as behavioral deterrents. Methods: Focus groups were conducted with college students under the age of 21 years (N=59) attending a large university in the southeast. All participants reported consuming five or more drinks in one sitting within the last two weeks (four or more for a female).Results: Participants attach positive expectancies to alcohol use, including peer influence/support and reduction of social anxiety. Negative social consequences such as embarrassment and relationship issues, including perceived sexual opportuni- ties, were cited as disincentives for excessive drinking. Gender distinctions were present among the referenced costs and benefits of excessive alcohol consumption. Discussion: Overall, the negative consequences associated with excess drinking by underage college students are outweighed by positive expectancies such as social approval and acceptance by their peers. Translation to Health Education Practice: Understanding the language, motives and expectancies young people attach to alcohol use can enhance the efficacy of health education and prevention efforts.

Dodd VJ, Glassman T, Arthur A, Webb M, Miller M. Why underage college students drink in excess: Qualitative research findings.Am J Health Educ. 2010;41(2):93-101. This paper was submitted to the Journal on July 23, 2009, revised and accepted for publication on Sep- tember 30, 2009.

BaCKground Previous studies also reveal that high-risk negative consequences for college students The practice of high-risk drinking may be drinking rates among college students are including unintentional injuries, risky sexual regarded as the most serious health problem greater than rates among their same-age behavior, violence, academic difficulties and faced by U.S. colleges and universities.1,2 peers not attending college.1,5,6 This pat- trouble with the law.1,8 Further, based on the Recent findings by Hingson and colleagues tern of high-risk drinking results in serious Diagnostic and Statistical Manual of Mental indicate a lack of overall progress in attempts to reduce alcohol-related mortality and morbidity rates among 18-to-24-year-old Virginia Dodd is an associate professor in at the National Center for Chronic Disease and college students.1 National College Health the Department of Health Education and Prevention and Health Promotion, Office on Assessment data collected in the fall of 2006 Behavior, Room 5 FLG, University of Florida, Smoking and Health/Epidemiology Branch, indicate that approximately 32% of female Gainesville, FL 32608; E-mail: [email protected]. Atlanta, GA 30333. Monica Webb is a Doctoral and 47% of male college students engage edu. Tavis Glassman is an assistant professor in candidate, University of Florida, Gainesville, in high-risk drinking,3 defined as the con- the Department of Health Education & Reha- FL 32611. Maureen Miller is an alcohol & other sumption of at least five or more drinks for bilitative Services, University of Toledo, Toledo, drug prevention specialist at the Student Health men or four or more drinks for women on OH 43606. Ashley Arthur is a health research Care Center, GatorWell Health Promotion Ser- at least one occasion in the past two weeks.4 analyst, Northrop Grumman Contract Support vices, Gainesville, FL 32611.

American Journal of Health Education — March/April 2010, Volume 41, No. 2 93 Virginia Dodd, Tavis Glassman, Ashley Arthur, Monica Webb, and Maureen Miller

Disorders, 4th Edition, nearly one-third of is understanding what motivates underage between the age of 18 and 20 years, and to college students meet the criteria for a for- students to engage in excess drinking and have consumed five or more drinks in one mal diagnosis of , and one in identifying factors that might serve as deter- sitting within the last two weeks (four or 17 can be classified as alcohol dependent.4 rents to the behavior. Previous research us- more drinks for a female).Volunteers were In order to address this problem, the U.S. ing a qualitative approach revealed complex prescreened prior to being appointed to a fo- Surgeon General established a national perspectives regarding alcohol use among cus group. Focus groups were conducted in health goal aimed at reducing high-risk Hispanic college students and provided the early afternoon and were approximately drinking among college students by 50% evidence that individual perspectives vary 60 minutes in length; a light lunch was by the year 2010; 6,7 a goal that is unlikely to according to context and outcomes. 6 included. As an incentive for participating be achieved. in the focus groups, students received a $20 A specific problem for senior administra- PurPose university book store gift card. Prior to the tors at colleges and universities involves the The purpose of this study was to gain start of each group, participants read and high percentage of underage students who greater insight into issues associated with signed the IRb-approved consent form. engage in drinking. Wechsler and colleagues excess drinking among underage college The initial male focus group served as a estimate that underage alcohol consumption students. More specifically, our goal was pilot group for testing the content and flow by college students represents about half to identify benefits and barriers relating to of questions. based on suggestions received of the overall alcohol consumption among excessive drinking as perceived by underage from the group, minor changes to the college students.9 However, of particular college students. The overarching goal of discussion guide were made and the script concern are estimates indicating that 90% of this study was to gain a personally relevant and format revised. Each male focus group underage alcohol consumption occurs under perspective of excess drinking among un- was moderated/co-moderated by trained conditions meeting the criteria for “binge” or derage college students for the purpose of male graduate students who were part of high-risk drinking.10 As a result, institutions designing highly targeted health messages the research team. The four focus groups of higher education are an important setting to discourage the behavior and reduce as- (N=35) consisted of male students ages 18 for reaching young people and improving sociated negative consequences. to 20 years. because the main purpose of their health status. our study was to gain personally relevant, The increased national attention focusing MetHods perspectives of excess drinking demographic on high-risk college drinking has prompted based on their ability to add depth to data other than gender was not collected. At universities to initiate or increase their pre- research findings, focus groups were con- the time of this study many students on cam- vention efforts.4 Yet, several national studies ducted to better understand college stu- pus held a common misperception that the indicate little or no change in the high-risk dents’ attitudes and expectations regarding current administration intended to make the drinking rate among college students.1,4,10-12 excessive drinking (consuming five or more campus “dry.” Therefore, our intent was to Given the continued pervasiveness of high- drinks in one sitting for a male and four or avoid collecting any information that would risk drinking among college students, recent more drinks in one sitting for a female). make students suspicious of our motives, efforts have focused on understanding the Prior to implementation, the protocol for especially since each focus group was audio- nature of problem drinking.13 However, cur- this study was approved by the University’s recorded, students were underage, and asked rent research on college drinking is dominat- Institutional Review board (IRb). Focus to complete the Alcohol Use Disorders Iden- ed by large-scale survey-based (quantitative) group questions were designed to: (1) deter- tification Test (AUDIT) 14 immediately prior studies such as the Monitoring the Future mine student motives for drinking in excess, to the start of the focus group Survey and the CORE Alcohol and Drug (2) identify deterrents to mitigate alcohol The AUDIT is a 10-item criterion vali- Survey.5,6,14 These studies have played an im- consumption, (3) explore the psycho-social dated measure with good construct validity portant role in directing , differences between male and female drink- designed to measure the frequency, intensity prevention and promotion efforts through ing patterns, and (4) determine how and and alcohol-related consequences associated identification of the many social and cultural where students acquire alcohol-related with excessive drinking, as well as assessing factors influencing excess alcohol consump- information. one’s risk for alcohol abuse and depen- tion among college students. However, the Focus groups (4 male and 3 female) were dence.15 Validity of the AUDIT is similar to unremitting rate of excess drinking among conducted during the 2006 fall semester. that of other self-reported screening tests college students suggests that other forms of Participants were recruited for the study (e.g., CAGE) and is appropriate for both data, such as qualitative data, may be useful through a classified ad in the school news- males and females and has high sensitivity in augmenting present health education paper and flyers distributed on-campus. and specificity relative to alcohol use dis- and prevention efforts.6 A major challenge Inclusion data required participants to be orders for youth.16 A cut-off score of 8 has facing health education efforts in this arena currently enrolled in university classes, been cited as demonstrating sensitivity and

94 American Journal of Health Education — March/April 2010, Volume 41, No. 2 Virginia Dodd, Tavis Glassman, Ashley Arthur, Monica Webb, and Maureen Miller specificity for detecting high-risk drinking on-campus conference room which was expressed in response to each question. Due among college students.17, 18 A score of 8 to 18 conducive for privacy and audio recording to the high involvement of all research team indicates a participant may be experiencing of focus group discussions. Focus group members and general agreement regarding negative health consequences due to their moderators used a semi-structured focus expressed themes, inter-rater reliability was drinking and a score of 19 or above signifies group guide with fixed discussion items not quantified. both research assistants possible . 4 (Table 2) and identical sequences for each reviewed the transcripts utilizing the final On average, male participants reported focus group. Questions were designed to coding scheme to extract pertinent subject consuming five to six drinks on a typical augment university-specific quantitative matter and supporting quotes. Throughout drinking occasion, and drinking two to findings from annual administration of the the process coding discrepancies were re- three times per week. The overall mean Core Institute’s Alcohol and Drug Survey viewed and resolved by discussion among AUDIT score for the male groups was 23.69 (http://www.core.siuc.edu). At the conclu- the principal investigators. (SD=4.05). sion of each focus group, the co-moderator Each female focus group was moderated/ synthesized and paraphrased participant results co-moderated by trained female graduate responses to each discussion item to ensure AUDIT scores for both the male and students who were part of the research team. the absence of misunderstandings or gaps female groups indicate the presence of high- The three focus groups (N=24) consisted of in the discussion themes. The audio tapes risk drinking and the concomitant risk for women ages 18 to 20. On average, females were transcribed verbatim by a professional experiencing issues related to alcohol abuse reported consuming three to four drinks on transcriber and reviewed by three research and/or dependence. In addition to the im- a typical drinking occasion and drinking team members for accuracy. Two trained re- plication of the AUDIT scores, two multi- approximately two to four times per month. search assistants, familiar with the published faceted themes emerged from the qualitative The overall mean AUDIT score for the fe- literature in alcohol use among young adults analysis of focus group transcripts. The first male groups was 19.17 (SD=3.54). and current research goals and objectives, theme relates to college students’ motiva- The focus groups were conducted in an developed an initial list of common themes tions for drinking, while the second theme

table 1. audit findings by gender (1)

AUDIT Item Male (n = 35) Female (n = 24)

Frequency of drinking 2-3 per week 2-4 per month

Number of drinks typically consumed 5-6 3-4

Frequency of high-risk drinking Weekly Less than Monthly

Inability to stop drinking once started (2) Never Never

Inability to do what was expected due to drinking (2) Less than Monthly Never

Had the need for a drink in the morning after a night of heavy drinking (2) Never Never

Felt guilty or remorseful after drinking (2) Never Never

Been unable to remember the night before due to drinking (2) Less than Monthly Never

Been injured as result of drinking (2) Never Never

Had a relative, friend, or health worker express concern about your drinking (2) Never Never

Notes: All Participants were college students ages 18-20. (1) All results reported represent the mode. (2) Responses indicate frequency within the past year.

American Journal of Health Education — March/April 2010, Volume 41, No. 2 95 Virginia Dodd, Tavis Glassman, Ashley Arthur, Monica Webb, and Maureen Miller

“I drink to reward myself if I have a hard week table 2. focus group discussion items of testing or classes” (female respondent). Though both genders agreed “drinking 1. Where do you get most of your information about the activities and events is a social thing. It loosens people up and it happening in the community? just seems to be what everyone does,” (male respondent) each had different reasons 2. It is ______for me to keep up with the drinking patterns of others. for doing so. Several female respondents 3. When you drink, what are your reasons for drinking? reported that, when it comes to drinking 4. What did you like best about having five or more drinks at one time? alcohol, ladies usually drink for free: “I don’t • What did you like least about having five or more drinks at one time? ever pay for anything. All the guys usually pay.” In addition, drink specials such as “2 5. How do your closest friends feel about you having five or more drinks in one sitting? for 1” and “ladies drink free” also compelled females to drink: “Sometimes you go out to 6. When you consume five or more drinks what specifically are you hoping will drink just because it is 2 for 1.” happen? Male respondents report drinking to 7. Name something that you would NOT want to happen when you have con- relieve boredom and to learn their alcohol sumed more than five drinks? limits. Several males described the impor- 8. To what extent, if any, do you think consuming five or more drinks makes you tance of knowing personal alcohol limits in more social? the business world. One male respondent 9. To what extent if any do you think consuming five or more drinks increases stated, “You are learning now what your limits your chances of hooking up? are so that you are not the drunk guy at the 10. To what extent does a severe hangover make you think twice about your company party. It’s like perfecting your golf drinking behavior? game before you get your job.” 11. To what extent are you concerned about the calories associated with alcohol Social lubricant consumption? Respondents also considered alcohol to be a social lubricant, providing them with 12. Take a few seconds and think back to your last drinking experience. What, if anything, could have happened to make you drink less? a greater ability to open up to and interact with others. Most respondents described • How about not drink at all? how alcohol helps them come “out of their 13. What are some things that might motivate a college student to cut back on shell” and feel more at ease in social situ- their drinking? ations. This liberation of social anxiety is 14. What is the best place to reach college students with health education mes- oftentimes described as “liquid courage” sages? because it increases confidence and boosts 15. What suggestions do you have to increase the effectiveness of responsible their ability to approach strangers and begin drinking campaigns? conversations. When asked to describe how alcohol helps them be more outgoing one male participant stated “I’m not a very good talker. If I don’t have a couple drinks to loosen delineates various deterrents for moderating because it releases them from the mundane me up, I won’t just randomly go up to people one’s drinking behavior; gender distinctions activities of everyday life. One male student and start a conversation.” are present in both themes. declared, “I like the stories that come from a Respondents also described alcohol as a night of drinking. If you have a sober night it facilitator of sexual opportunities and the WHy College students drinK is pretty dull. But the next morning when I term “hooking-up” was commonly used Alcohol expectancies wake up after drinking, there are always like to describe a spectrum of sexual activities. Focus group respondents described a va- 10 stories, craziness, fun stuff.” both males both male and female respondents felt that riety of expectancies associated with alcohol and females also described celebrations such alcohol increased their confidence in ap- consumption including an opportunity to as birthdays and college sporting events as proaching members of the opposite sex and have fun, celebrate, relieve stress and take a occasions to seek out alcohol. In addition, in seeking sexual opportunities. Interest- break from academics. They listed having fun respondents described drinking alcohol as a ingly, even though focus group participants as one of the primary reasons for drinking way to relax or take a break from academics: did not know one another, female students

96 American Journal of Health Education — March/April 2010, Volume 41, No. 2 Virginia Dodd, Tavis Glassman, Ashley Arthur, Monica Webb, and Maureen Miller were guarded when discussing issues relat- keep up with the drinking of others. How- as a major concern. Additionally, females ing to “hooking up” and/or opportunities ever, upon reflection and further discussion, articulated high levels of concern regard- for sexual encounters. Audio recordings of the question for females should have been ing the appearance of embarrassing photos the female focus groups demonstrate only a expanded upon with a probe relating to the taken of them while intoxicated on Facebook superficial discussion of this topic. Male re- competition among females to see who re- or other social networking sites. spondents were more open in their willing- ceives the most free drinks during the course The majority of female respondents ex- ness to discuss issues relating to hooking up. of an evening. pressed a great deal of concern over “making While male respondents believed high-risk All respondents reported the percep- a scene,” appearing “stupid,” and/or fight- drinking (5 or more drinks in one sitting) tion that their friends participate in high- ing with friends while intoxicated. Several increased their chances of hooking-up, they risk drinking and that high-risk drinking females expressed anxiety over becoming also acknowledged that excessive drinking typically takes place with friends in social “that girl,” which they described as the girl can lead to embarrassing behavior that can situations. As one male participant stated, “I who embarrasses herself and her friends. As ultimately thwart one’s chances of hooking- think most of the time whenever I am drinking one female stated, “I don’t want to be that girl. up. One male stated, “If you get to 12, 15, 18 more than 5 beers, it’s with friends. There’s You know, the girl who’s totally passed out or drinks, your chances go down dramatically never a time when I’m doing it by myself.” barfing on everyone or needs her friends to because you are retarded and physiologically While drinking is usually encouraged by pick her up and bring her home.” Another things don’t work.” Female participants did peers, several respondents discussed the participant described “that girl” as the “walk- not express much concern associated with actions of their “sober friends” who would ing down the street with only one shoe on, the amount of alcohol they consumed, but encourage limiting the amount of alcohol and crying with mascara smeared all over her instead focused on their level of confidence consumed in order to prevent any problems face.” According to the female respondents (or lack of inhibition) toward the opposite from occurring. concern for avoiding the role of “that girl” is sex. One female participant stated, “I just Rite of Passage so great that girlfriends watch out for each other and “babysit” their drunken friends. know that if I am drinking I will be more likely An emerging theme in each focus group As one female participant stated, “My friends to hook up with someone.” Several respon- was the common belief that alcohol con- have to take care of me when I’m drunk and dents agreed that it was helpful to have both sumption is a rite of passage granted upon that is a pain for them.” This sentiment was people drinking to “level the sexual playing entering college. A common thread among echoed by another female participant who field.” One male stated,“If you are drunk and the male groups was “People have been tell- said, “You kind of ruin their night because they the girl is not, it is like trying to beat a football ing me what to do for 18 years and it’s over.” have to take care of you.” team when they have your playbook. So I think When asked what suggestions they had for Males also expressed concern with alco- that if you are wasted and the girl is not then increasing the effectiveness of responsible hol-related social consequences. However, you really hurt your chances of getting with drinking campaigns many students said their main focus revolved around feelings her.” Female participants report relying on the word “sober” should be avoided. One of regret associated with sexual experiences their friends to “watch out for them” if they student succinctly described his attitude and the negative impressions their alcohol- consume alcohol in excess; this includes to prevention messages, “If it says anything influenced actions made on females. Males making sure they are “safe” at the end of about sober I don’t look at it.” conveyed apprehension over their sexual the evening. performance while under the influence of deterrents to drinKing in exCess Peer influence alcohol; one male stated, “When you can’t In order to gauge the influence of peers, Social consequences get it up, it is not good.” In addition, males do participants were asked to complete the All respondents described feelings of not want to be viewed as a “sketchy drunk following statement: “It is _____ for me to concern relating to the social consequences guy.” Analogous to the female “that girl” keep up with the drinking patterns of oth- of excess drinking such as embarrassing concept, males worry about what others, ers.” There was a distinction between the behavior, annoying friends with drunken particularly females, think of them when answers given by males and females. The behaviors, being loud and obnoxious, or they are intoxicated. Male participants majority of male respondents felt it was ruining the night for others. both males describe “sketchy drunk guy” behavior as normal to keep up with the drinking habits and females expressed concerns relating standing very close to a girl while talking to of others. One male stated “For me and to saying/doing things while intoxicated her, uninvited touching, and being overly my friends, it’s like a competition” to see that they would later regret. A majority of forward. Males appear highly aware that this who can drink the most. However, among the respondents specified “drunk dialing,” behavior makes females feel uncomfortable. the female respondents there was a general defined as calling a former or current love As one male stated, “There are a couple of consensus that it is unimportant for them to interest while under the influence of alcohol, sketchy drunk guys in our fraternity. They get

American Journal of Health Education — March/April 2010, Volume 41, No. 2 97 Virginia Dodd, Tavis Glassman, Ashley Arthur, Monica Webb, and Maureen Miller

pretty drunk and creep girls out.” other value-added alcohol-related items.19 her friends by drinking too much. Males When students were asked what could Among college students social anxiety is express a similar social milieu know as the be done to decrease the high-risk drink- cited as one of the strongest motivators for “sketchy drunk guy,” which they describe as ing on campus, both genders claimed little underage drinking and most students report an intoxicated male whose aggressive and would motivate them to cut back on their using alcohol as a social crutch when inter- unwanted social advances makes women feel drinking. However, they felt other students acting with one another, particularly when uncomfortable. Males overwhelmingly agree may be motivated by testimonials and scare pursuing intimate relationships. While males that a “sketchy drunk guy” is the antithesis tactics. Students also suggested using social were willing to openly discuss the role of al- of cool or popular. networking sites such as MySpace and cohol in “hooking-up,” female respondents’ In addition to the previously noted gen- Facebook as channels for message distribu- discussions in this area were limited. While der differences, males seem more prone than tion. One male participant proposed use it is likely that the need to provide socially females to peer influence. Males describe of Facebook as an outlet for prevention desirable responses during the audio-taped their perception of drinking as a competi- messages since “almost every student has an discussion influenced their unwillingness tion where individuals monitor (and strive account.” Furthermore, a female participant to elaborate on this topic, post focus group to exceed) one another’s alcohol consump- said “I know there are tons of Facebook groups comments by some participants reasoned tion. In direct contrast, women believe that it now that if you join they email you regularly.” that while they did not currently know the is unimportant to keep up with the drinking both males and females encouraged health other girls in the group right then, they may of others. However, this response should be educators to communicate with students in have them in a class later on, or see them out considered in the context of its “social desir- non-traditional venues. at the bars. The women stated that they did ability” in the focus group setting especially not trust anyone to keep their comments since females report keeping track of “free disCussion private, even though prior to the start of drinks” received during the evening. Inter- The literature focusing on alcohol con- the discussion, all participants were asked estingly, females seem not to perceive this sumption among college students offers to agree to keep the information discussed behavior as competitive “drinking behavior” extensive quantitative research, but find- in the groups confidential. based on this but more as a competition for affirmation ings from qualitative studies are scant. The information, when topics include questions of their physical appeal. However, in general, persistent and complex nature of excessive relating to sexual behaviors, individual in- both males and females describe high-risk drinking among underage college students terviews with female college students may drinking in social settings mirroring that requires continued inquiry especially via be more productive. of their friends. While both genders report qualitative methods which can increase our Males were quite forthcoming with their drinking, their motivations differ as do their understanding of the attached behavioral responses to this discussion topic. Males alcohol-related expectancies. motivations and expectancies attached to perceive increased chances of “hooking up” Gender differences are evident in the alcohol use. This information is critical when their social acquaintance drinks along number of high-risk drinking occasions. for crafting prevention messages which are with them. Males also report a curvilinear In this sample, females report drinking in relevant to this audience, and most notably, relationship between alcohol consump- excess of two to three times per month ver- what might deter students from engaging in tion and perceived sexual opportunity. For sus two to three times per week for males. this high-risk behavior. instance, males believe that if they (males) This discrepancy may be a reflection of the Regardless of gender, students have a drink too much, or considerably more than gender disparities present in excessive drink- variety of positive expectancies concern- their potential partner, their chances of ing among college students, but could also ing alcohol use. Consistent with Quintero engaging in an intimate social experience reflect the surfacing of social desirability and colleagues6 findings, college students in will drastically decrease; therefore, males within the groups. It should be noted that the present study report drinking for fun, report trying to closely mirror the drink- the AUDIT was used to quantify the num- relaxation and to facilitate and/or maintain ing of their partner. This behavior tends to ber of excessive drinking occasions, and as social interactions. Students offered a variety result in lower levels of intoxication among a result, this information was not shared of reasons for consuming alcohol including males who are drinking from a “couples with the group or researchers at the time of celebrations such as birthdays or sporting perspective;” conversely, females report us- the focus group. The validity of this infor- events, stress relief or a break from academ- ing alcohol to increase their confidence and mation is not known and further research ics, as well as to forget problems in general lower inhibitions. in this area is warranted. It is important and escape reality for a while. In addition, both genders appear keenly aware of for researchers to consider the amount of drinking behaviors are strongly influenced the social drawbacks of over consumption. distortion social desirability can place on by the cost of alcohol, as is evidenced by the Females do not want to be known as “that participant’s responses. Additionally, the widespread availability of drink specials and girl;” the one who embarrasses herself and high degree of pressure students’ feel to be

98 American Journal of Health Education — March/April 2010, Volume 41, No. 2 Virginia Dodd, Tavis Glassman, Ashley Arthur, Monica Webb, and Maureen Miller socially desirable provides ample fodder for this study. Second, students voluntarily translation to HealtH use when designing prevention messages. agreed to participate in the focus groups; eduCation PraCtiCe Lastly, it is important to make certain that thus, the answers they provided may differ A recent article in The Atlantic Online participants understand the definition of from those students who were unwilling or described our societal approach to underage drinking “excessively” and are using a stan- unable to participate in this study. Third, drinking as “about effective as a parachute dard reference for the term a “drink.” the criteria for participation in the focus that opens on the second bounce.”21 The When asked what could be done to pre- groups were all based on self-report. It is writer alludes to the ineffectiveness of laws vent or minimize excessive drinking among possible that some participants may have regulating underage drinking and his be- college students, participants were extremely misrepresented their ages or drinking status lief that legislation crafted to address this pessimistic that any intervention would to be eligible for the focus groups; although, problem has stifled creativity in other areas influence their personal choice to imbibe. every effort was made to discourage this of alcohol-related health prevention/promo- However, they did concede others may be behavior. Students were prescreened via tion practice. While the MLDA (minimum more susceptible to intervention attempts. e-mail and again immediately prior to the ) constitutes effective Students suggested health-promotion ef- start of the focus group. Participants who health policy, the stable rate of alcohol use forts most likely to change behavior would showed up for their designated focus group among underage college students indicates use scare tactics and peer-testimonials to but did not meet the inclusion criteria were the need for health educators to be more highlight the harsh consequences associated still given the promised incentive. This was creative in their approach to this problem. with excessive drinking. While this response determined as the best way to avoid having Ultimately, policy approaches and individual is common among college students, past use ineligible students misrepresent their age based interventions are complementary not of these tactics has proven less than success- in order to participate in the focus groups competing strategies. ful. In general, suggestions for changing and receive the promised incentive, albeit Another critical component of behavior alcohol-consumption behavior were sparse. a small one. Lastly, the focus groups were change is possessing a clear understanding However, this result should be expected and comprised of students who consume higher of the target audience’s perceived benefits should not be viewed as an indication that levels of alcohol than their peers, therefore and barriers to the desired behavior22 since the behavior cannot be changed. Upon con- their opinions and insights most likely developing personally relevant messages sideration, it seems plausible that students differ as well. is dependent upon an in-depth under- who drink heavily and have no interest in In spite of these limitations, these find- standing of the behavior from the target changing their behavior would find it diffi- ings contribute to the limited body of quali- audience’s perspective; a perspective that cult to offer suggestions for behavior change, tative research on the motivations and deter- can only be gained from members of the especially in a focus group discussion which rents related to high-risk drinking among target audience. Understanding underage probably provided inadequate time for in- underage college students. The information college students’ motivations for drinking dividuals to reflect on the question. Future presented here can assist practitioners’ ef- in excess are necessary for development research with college students who do not forts when designing health messages which of effective health promotion messages drink or who do so moderately may yield discourage excessive drinking. Among this and strategies. The ineffectiveness of past more information relating to intervention sample of college students the primary mo- health behavior change efforts in this designs. Students suggested using technol- tivation for restraining their alcohol intake area are somewhat attributable to health ogy as a method of communicating with involves avoidance of embarrassment and messages that students perceived as irrel- large numbers of students. They encouraged fear of being socially ostracized. While males evant; as a result, they did not attend to health educators and others to communicate and females have very distinct reasons for or believe the information as presented. prevention messages through web-based drinking, both genders report anxiety sur- Students reported their disbelief of the venues such MySpace, Facebook and/or rounding social interactions; neither gender statistic that “7 out of 10 students drank other electronic forums. wants to be perceived as annoying or out of 0 to 4 drinks when they partied,” and This study contains several limitations. favor for excessive alcohol use. More research described the “sober is sexy” campaign as First, focus group participants were ob- in the area of alcohol-related psychosocial inaccurate.When asked to explain further tained from a large school in the southeast; phenomena is needed. A better understand- students overwhelmingly reported that if consequently, their motivations for drink- ing of these issues can guide sophisticated the word “sober” is used in a message they ing may not be representative of other and more effective interventions which will immediately disregard the information. In university students. Research demonstrates strengthen future efforts to achieve goals fact, for some students, until alcohol low- that quantitative drinking patterns differ such as the Healthy Campus 2010 goal of ers their inhibitions they are sure they are by region;20 the same could be expected reducing the high-risk drinking rate to less not sexy. Therefore, from their perspective with the qualitative findings reported in than 20%. sober is not sexy.

American Journal of Health Education — March/April 2010, Volume 41, No. 2 99 Virginia Dodd, Tavis Glassman, Ashley Arthur, Monica Webb, and Maureen Miller

Future Directions respectful relationships with students is of 4. Wechsler H, Lee JE, Kuo M, et al. Trends based on findings from this study, health utmost importance, as is the importance in college during a period of messages targeting excessive drinking among of treating them as respected members of increased prevention efforts: Findings from 4 college students are more likely to be noticed the research effort. Initial efforts designed Harvard School of Public Health college alcohol if messages do not directly condemn alco- to gain the target audience’s perspectives study surveys, 1993-2001. J Am Coll Health. 2002; hol consumption, even among underage relating to the relevance and impact of 50:203-217. students. In addition, using students’ words alcohol consumption in their lives cannot 5. O’Malley PM, Johnston LD. Epidemiology when providing information on moderating be overemphasized. Health educators who of alcohol and other drug use among American alcohol consumption to avoid becoming respect the autonomy of the target audi- college students. J Stud Alcohol. 2002; 14:23-39. the “sketchy drunk guy” or “that girl” are ence and speak their “language of behavior 6. Quintero GA, Young KJ, Mier N, et al. Per- less likely to be ignored. While past efforts change” will enhance the effectiveness of ceptions of drinking among Hispanic students: have focused on the legal and academic their efforts. How qualitative research can inform the devel- costs associated with underage alcohol use, Lastly, it is important that prevention opment of collegiate alcohol abuse prevention a shift in focus to the social costs of excessive efforts are not thwarted by the legions of programs. J Drug Edu. 2005; 34:291-304. underage drinking appear more relevant to individuals loudly proclaiming their own 7. Wechsler H, Nelson TF. binge drinking and today’s college students. Thombs and col- personal experiences with alcohol as an the American college student: What’s five drinks? leagues report using student volunteers to “innocent rite of passage” and base their Psychol Addict Behav. 2001; 15:287-291. collect field data and breath-alcohol levels of worldview of this issue on a narrow per- 8. Johnston LD, O’Malley PM, bachman patrons exiting bars at closing.23,24 Student spective. Public ignorance or denial of the JG, et al. Monitoring the Future national survey research volunteers have described the expo- vast and often serious nature of the con- results on drug use, 1975-2005: Volume II, College sure to intoxicated peers while they are sober sequences associated with binge drinking students and adults ages 19-45. 2006. bethesda, as an effective deterrent to binge drinking among college students does not mean that MD: National Institute on Drug Abuse. NIH (personal communication). Additionally, the problem is not worthy of continued Publication No. 06-5884. students who have been required to work vigilance. Successful behavioral change can 9. Wechsler H, Lee JE, Nelson TF, et al. Under- in aid stations for impaired/intoxicated stu- occur if researchers determine intervention age college students’ drinking behavior, access to dents exiting bars repeatedly report how the strategies that address students’ motivations, alcohol, and the influence of deterrence policies. experience changes the way they view alco- opportunities, and abilities to binge drink. J Am Coll Health. 2002; 50:223-236. hol consumption. Providing novel ways for Ultimately, successful behavioral change ef- 10. Glassman, TJ. Framing analysis: “Drink students to observe “up-close and personal” forts are expected to require a combination specials especially controversial.” The Health the negative social consequences discussed of educational, social marketing, legislative, Education Monograph Series.2008; 25:7-13. in health promotion messages appears to and environmental approaches 25 11. Werch CE, Pappas DM, Carlson JM, et al. have promise as an intervention. Results of a social norm intervention to prevent Health educators who understand the aCKnoWledgeMent binge drinking among first-year residential col- media preferences of their target groups can This work was funded in part by a grant lege students. J Am Coll Health. 2000; 49:85-92. place relevant messages promoting behavior from the U.S. Department of Education. 12. Perkins HW. Social norms and the pre- change in venues that are sure to be accessed vention of alcohol misuse in collegiate contexts. by the appropriate population. Today’s col- referenCes J Stud Alcohol. 2002; 14:164-172. lege students are connected through Face- 1. Hingson RW, Zha W, Weitzman ER. Mag- 13. Reboussin bA, Song E, Shrestha A, et book, MySpace and other social networking nitude of and trends in alcohol-related mortality al. A latent class analysis of underage problem sites. Our ability to use these communication and morbidity among U.S. college students ages drinking: Evidence from a community sample channels to “be there at the point of deci- 18-24, 1998-2005. J Stud Alcohol Drugs. 2009; of 16-20 year olds. Drug Alcohol Depend. 2006; sion making” is largely untapped. However, S16:12-20. 83:199-209. while the reach and impact of these venues 2. Nelson TF, Wechsler H. School spirits: 14. babor TF, Higgins-biddle JC, Saunders enhance our ability to successfully motivate Alcohol and collegiate sports fans. Addict Behav. Jb, et al. AUDIT: The Alcohol Use Disorders behavior change, they also require research- 2002; 28:1-11. Identification Test: guidelines for use in primary ers to work diligently to stay abreast, or 3. American College Health Association. care. World Health Organization. 2001. Avail- ideally ahead, of rapidly changing electronic American College Health Association - National able at: http://whqlibdoc.who.int/hq/2001/ communication options; use of these venues College Health Assessment (ACHA-NCHA) WHO_MSD_MSb_01.6a.pdf. Accessed Sep- while they are still unique can do much to Web Summary. Updated April 2006. Available at: tember 22, 2006. gain the students’ attention. http://www.acha.org/projects_programs/ncha_ 15. babor TF, Grant M. From clinical research The importance of forming collaborative, sampledata.cfm. 2006 Accessed July 21, 2007. to secondary prevention. International collabora-

100 American Journal of Health Education — March/April 2010, Volume 41, No. 2 Virginia Dodd, Tavis Glassman, Ashley Arthur, Monica Webb, and Maureen Miller tion in the development of the Alcohol Use Dis- Validity of Alcohol Use Disorders Identification Health Promot Pract.2007; 8:134-139. orders Identification Test (AUDIT). test in college students. Alcohol Clin Exp Res. 23. Thombs DL, Dodd V, Pokorny Sb, et al. and Health Research World. 1989; 13: 371-374. 2004; 41:914-920. Drink specials and the intoxication levels of 16. Cook RL, Chung T, Kelly TM, et al. Al- 19. O’Mara RJ, Thombs DL, Wagenaar AC, et patrons exiting college bars. Am J Health Behav. cohol screening in young persons attending a al. Alcohol price and intoxication in college bars. 2008: 32:411-419. sexually transmitted disease clinic: comparison Alcohol Clin Exp Res. 2009; 33:1-8. 24. Thombs DL, O’Mara R, Dodd VJ, et al. A of AUDIT, CRAFFT, and CAGE instruments. J 20. Presley CA, Meilman PW, Leichliter JS. field study of bar-sponsored drink specials and Gen Intern Med. 2005; 20:1-6. College factors that influence drinking.J Stud their associations with patron intoxication. J Stud 17. Martens MP, Cimini MD, barr AR, et al. Alcohol. 2002; 63(Suppl. 14):82–90. Alcohol Drugs.2009: 70:206-214. Implementing a screening and 21. McCardell, J. Teaching drinking. The 25. Rothschild M. Carrots, sticks, and Prom- for high-risk drinking in university-based health Atlantic Online. 2009. Available at: http://www. ises: A conceptual framework for the manage- and mental health care settings: Reductions in theatlantic.com/doc/by/john_mccardell. Ac- ment of public health and social issue behaviors. alcohol use and correlates of success. Addict cessed June 18, 2009. J Mark. 1999; 63:23-37. Behav. 2007; 32:2563-2572. 22. Wayman, JJC, beall, T, Thackeray, R, et al. 18. Kokotailo PK, Egan J, Gangon R, et al. Competition: A social marketer’s friend or foe?

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