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Characteristics of prospectively identified negative alcohol-related events among college students
Addictive Behaviors 78 (2018) 138–144
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Addictive Behaviors journal homepage: www.elsevier.com/locate/addictbeh
Characteristics of prospectively identified negative alcohol-related events among college students
T
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Matthew K. Meisela, , Shannon R. Kenneyb, Nancy P. Barnetta a b
Center for Alcohol and Addiction Studies, Brown University, USA Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, USA
H I G H L I G H T S of participants experienced the event at either their own or a friend's residence. • Majority of participants were with peers when the event happened. • 87.1% indicated that their closest friend knew about their event. • 85.0% • Overall, students' reactions to the event were mild.
A R T I C L E I N F O
A B S T R A C T
Keywords: Alcohol-related consequences College Same-age peers
Background: Throughout the first two years of college, the majority of drinkers experience one or more alcoholrelated consequences. Research that examines the characteristics surrounding negative consequences typically utilizes global retrospective survey methods. The objective of the current study was to apply an event-based methodology to describe the circumstances of a recent drinking episode that resulted in one or more alcoholrelated consequences among first- and second-year college students. Methods: We used a prospective web-based survey method to identify participants (N = 296) who had one or more alcohol-related consequences in the past week. Shortly after reporting the consequence(s), participants attended an in-person interview during which they described the circumstances that preceded and followed the consequence(s), including the use of alcohol and other substances, proximal contextual factors including peer drinking, the characteristics of the negative alcohol-related consequence(s), and the reaction of others to the event. Results: The majority of participants reported experiencing the event at either their own (32.4%) or a friend's (32.8%) residence, and 87.1% of participants were with peers when the event happened. Most (85.0%) of the sample indicated that their closest friend knew about their event. Conclusion: The high peer involvement at all stages of the event suggest the potential for training college students to help each other avoid or prevent consequences.
This research was supported in part by grant numbers R01AA13970 and T32AA007459-32 from the National Institute on Alcohol Abuse and Alcoholism, and T32DA016184 from the National Institute on Drug Abuse. 1. Introduction Heavy alcohol use is a well-documented problem among college students (Dowdall & Wechsler, 2002), particularly in the first year after matriculating into college (Barnett et al., 2014). College students
frequently drink heavily (Blanco et al., 2008; Dawson, Grant, Stinson, & Chou, 2004; Paschall, 2003; Slutske, 2005), and accordingly, they experience a variety of alcohol-related consequences (Hingson, Heeren, Winter, & Wechsler, 2005; Hingson, Heeren, Zakocs, Kopstein, & Wechsler, 2002; Hingson, Zha, & Weitzman, 2009; A. White & Hingson, 2014). Throughout the first two years of college, the majority of drinkers report at least one negative alcohol-related consequence (e.g., vomiting, blackout, and regretting something said; Mallett, Marzell, & Turrisi, 2011; Mallett et al., 2011). When measuring alcohol consequences, global retrospective surveys which collect counts or scores
⁎ Corresponding author at: Center for Alcohol and Addiction Studies, Department of Behavioral & Social Sciences, Brown University School of Public Health, Box G-S121-4, Providence, RI 02903, USA. E-mail address: [email protected] (M.K. Meisel).
https://doi.org/10.1016/j.addbeh.2017.11.025 Received 7 June 2017; Received in revised form 13 October 2017; Accepted 13 November 2017 Available online 14 November 2017 0306-4603/ © 2017 Elsevier Ltd. All rights reserved.
Addictive Behaviors 78 (2018) 138–144
M.K. Meisel et al.
with event characteristics. We also examined gender differences in the characteristics of drinking and the drinking setting on the event day and the reactions to the event. Understanding the circumstances under which students experience negative alcohol-related consequences when they drink can be informative for optimal prevention efforts.
of consequences along with information about alcohol use over roughly the same timeframe are primarily used. These more traditional methods can result in inaccurate responses and recall bias (Shiffman et al., 1997). In contrast, event-level methods (e.g., ecological momentary assessment, daily surveys) can identify a specific drinking event and its outcomes with the purpose of identifying precursors and correlates of the event. In the current event-level study combined with intensive interviewing, we aimed to provide a deeper understanding of the characteristics of alcohol-related events that are associated with consequences reported by college students. Volume of alcohol use is related to the setting in which it is consumed. The drinking setting not only refers to where alcohol is consumed, but it also refers to why, when, where, and with whom alcohol is consumed. When college students drink, they most often do so with their friends, on weekends, and at parties or other social occasions (Beets et al., 2009; Clapp, Shillington, & Segars, 2000). At the aggregate level, heavy drinking episodes among college students tend to equally occur at public contexts, such as bars or restaurants, and private contexts, such as residences (Clapp et al., 2000) although college students under the age of 21 predominately drink in private contexts (Clapp, Reed, Holmes, Lange, & Voas, 2006). The current study expands on this line of research by examining the settings of alcohol-related consequences. Studies that utilize global retrospective methods consistently find that individuals who drink heavily also tend to use other substances and that using multiple substance use is associated with more alcohol-related consequences (Haas & Smith, 2012; Reed, Wang, Shillington, Clapp, & Lange, 2007; Shillington & Clapp, 2006). For example, individuals who use both alcohol and marijuana are more likely to experience alcohol-related and non-alcohol-related problems than those who only drink (Hammer & Pape, 1997; Shillington & Clapp, 2001; Simons & Carey, 2006). The one event-level study to date that has examined the relationship between simultaneous substance use and alcohol-related problems among college students found that on occasions when students used more than one substance, more consequences were reported than when students only used alcohol (Mallett et al., 2017). However, this study only included individuals who reported both alcohol use and use of another substance on the event occasion; hence, the sample is higher risk and lacks generalizability. Students diverge in how they perceive alcohol-related consequences, resulting in differential effects on subsequent drinking and alcohol-related consequences. For example, when alcohol-related consequences are perceived as aversive, students are more motivated to reduce their alcohol use and show subsequent declines in use (Barnett, Goldstein, Murphy, Colby, & Monti, 2006; Merrill, Read, & Barnett, 2013). Despite the importance of friends and family in college students' drinking-related perceptions and behaviors (Kenney, Ott, Meisel, & Barnett, 2017; Meisel, Clifton, MacKillop, & Goodie, 2015; Walls, Fairlie, & Wood, 2009; H. R. White et al., 2006), no study to date has examined how friends' and family members' awareness of and reactions toward the consequence are associated with the event circumstances and to the student's own reaction toward the consequence(s) experienced. The current study utilized a combination of event-based methods and in-person interviews to describe the circumstances of a recent drinking episode that resulted in one or more alcohol-related consequences among first- and second-year college students at three different universities under the age of 21 and to examine: 1) proximal contextual factors related to drinking and the number of consequences experienced, 2) whether using alcohol with other substances was related to consequences, 3) whether alcohol use in the event was different from alcohol use in the prior month, and 4) students' reaction to the event, including the extent to which perceptions of aversiveness of alcohol-related consequences were related to the characteristics of the alcohol-related consequences, whether close others were aware of the event, and whether parents' and close friends' reactions were associated
2. Method 2.1. Participants The sample for this study (N = 296) was derived from a larger longitudinal study of college student alcohol use (Barnett et al., 2014). The parent study was conducted with three cohorts of incoming college students at three mid-sized universities/colleges in the northeast. To be eligible for the parent study, students had to be under the age of 21, an incoming freshman enrolled full-time at one of the three colleges, residing on-campus during their first year, and not an international student. The parent sample was stratified based on gender, and students with a racial-ethnic identity other than exclusively non-Hispanic white were oversampled. Individuals under the age of 18 were required to provide parent consent and the study was approved by the Institutional Review Boards at the three college locations. 2.2. Procedures for the parent study Participants were surveyed prior to their first year of college and were subsequently randomly assigned to one of two survey groups. Each group was surveyed every other week (on alternate weeks) for the first two years of college, except during winter and summer breaks. These online biweekly surveys assessed participants' alcohol use and alcohol consequences over the past seven days. Each semester was 16 weeks, so participants were asked to complete eight surveys each semester. Participants were compensated $2 for each completed survey and had a (randomly determined) opportunity to win $100 after each survey. If participants completed seven or eight of the eight surveys each semester, they received a bonus of $20. 2.2.1. Procedures for the present study Immediately following the end of each survey, participants who had reported one or more alcohol-related consequences were identified (n = 522). To ensure lower frequency consequences were captured, 50% of participants who reported a school or work problem, trouble with police, a physical fight, or accidentally hurting someone were selected; the rest of the 13 consequences (see Table 1) were sampled at a 25% rate. Selected participants were then randomly assigned at a 3:2 ratio to an assessment group (n = 326) or a no-assessment group (n = 196). Participants could only be selected once. Participants received $25 for completing the assessment. The no-assessment group was not relevant for the current analysis so is not further described. 2.2.2. Event identification interview In the week they were selected, participants were invited to attend an in-person on-campus interview. A research assistant (RA) informed participants that they were randomly selected to be interviewed about a recent alcohol-related consequence. During the interview, participants were presented with their responses from the survey and using a calendar were asked to identify the day(s) on which they experienced the reported negative consequences. If consequences were experienced on more than one day in the week, participants were asked to select the day on which the consequence(s) were the most important or meaningful; thereafter these alcohol-related circumstances were called “the event.” When more than one consequence was reported on the event day, participants were asked to select the consequence on the event day that was “the most meaningful or important when you think about your drinking now.” The RA then asked the participant to describe the drinking and social details that led up to and followed the event. 139
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bar, club, or restaurant; sporting event; party; fraternity or sorority function; car; other on-campus location; other off-campus location. They used the same list to indicate where they were when the event happened. Participants were asked about the drinking of others: “How were most of the people around you drinking compared to you?” with the response options of: more than you were; less than you were, about the same as you were, you were alone. Participants were asked “Who were you with when the event happened?” and could indicate any of the answers that applied: no one – you were alone; male friend(s); female friend(s); strangers; significant other; relatives; acquaintances. Participants also reported on the total number of people they were with when the event happened.
Table 1 Most salient negative consequence experienced and the percent of negative consequences endorsed for interview. Negative consequence
Percent reported
Most salient negative consequence
Got physically sick (e.g. vomited, stomach cramps) Couldn't remember some part of the day or night Felt sad or depressed Said something that I wish I hadn't Had problems with school work Disappointed others who are close to me Had a romantic or sexual activity that I now regret Was physically injured Drove after drinking and realized I should not have Got into trouble with my school authorities or police Accidentally physically hurt someone Got into a physical fight Passed out
32.9
20.4
36.3
19.3
22.0 24.1 12.2 17.6
13.9 10.8 8.1 7.8
12.2
6.1
9.2 3.1
3.7 3.1
4.1
2.0
4.1
1.7
2.7 8.1
1.7 1.4
2.3.4. Substance Use Participants were asked whether on the day of the event they had used any drugs other than alcohol including marijuana, cocaine, designer drugs, and other drugs not prescribed to them. Participants also reported if they used any of the above substances in the month before the event. 2.3.5. Reactions to event Participant attributions about the event and aversiveness of the event were adapted from Longabaugh et al. (1995). The three attribution items (e.g., “To what extent do you believe your alcohol consumption was responsible for this event?; α = .71) measured the extent to which the individual believed alcohol and their own behavior were responsible for the event. The three aversiveness items (e.g., “To what extent has this event upset you?”; α = 0.91) measured the extent to which the individual was disturbed about the event. Items are scored ranging from 1 (not at all) to 7 (extremely or totally). Total scores were calculated. In addition, participants were asked “To what do you attribute the event?” and were allowed to indicate one or more of the following: pressure from others, just having fun, too intoxicated to think clearly, carelessness, poor judgment, stupid rules, bad luck, fate, someone's overreaction, and other. Parents, friends and campus administrators' responses to the event were collected by asking: “Does your mother/father/closest friend/campus entity (police, emergency medical services, college infirmary or hospital, resident advisor or peer counselor, campus official) know about your event?” and “How upset was your mother/father/closest friend when he/she heard?” Responses to the second question ranged from 1 (not at all) to 5 (very). For those who did not tell either their mother or father about the event, participants were asked “How concerned are you about this person finding out about the event?” on a scale ranging from 1 (not at all) to 5 (very). Finally, participants responded to the question “How much did you change your drinking as a result of this experience?” Response options were 1) I did not change anything, 2) I did not change how much I drink, but now I am more careful about how I drink and what I do when I drink, 3) Now I drink very little or not at all, and 4) Other.
Note. The total number of negative consequences ranged from zero to eight with a mean of 1.88 (SD = 1.27).
Following this event identification interview, the RA administered the Timeline Followback (see 2.3.2 below), after which participants selfadministered the rest of the measures. 2.3. Measures Gender, year in school, and race/ethnicity were collected in the baseline survey of the parent study. The Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, De la Fuente, & Grant, 1993) was collected at the same time and was used to compare participants in the current study to students who were not selected. 2.3.1. Biweekly Surveys On each biweekly survey, participants provided the number of drinks consumed on each day for the past week. Participants who reported drinking in the past week were asked to indicate whether they had experienced any of 13 negative alcohol-related consequences in the past week derived from common measures of alcohol-related consequences (Table 1). Cronbach's alphas for these items ranged from 0.79–0.83 each week. 2.3.2. Timeline followback (Sobell & Sobell, 1995) This structured, calendar-aided assessment of alcohol use on each of the thirty days prior to the event was administered by the RA. Participants reported the number of drinks consumed on each day and the length of time spent drinking. Number of drinking days and number of heavy drinking days (4 or more drinks for women, 5 or more for men) in the month were calculated. For each drinking day, an estimate of BAC was calculated (eBAC; Matthews & Miller, 1979), from which average and peak eBAC were derived. Event day number of drinks and eBAC were also calculated.
2.4. Data Analysis Chi-square analyses were used to compare participants who were and were not selected, and among those who were selected, between those who did and did not complete the interviews. Correlations and independent samples t-tests were conducted to examine the three aims. Furthermore, chi-square analyses were also conducted to examine gender differences. All analyses were conducted in SPSS.
2.3.3. Event Characteristics Participants were asked specific questions about the circumstances surrounding their drinking event, including intoxication: “Did you feel drunk at the time of the event?” and intoxication intentions: “That day, before you started drinking, or at some point during your drinking, did you decide to get intoxicated?” The measure of drinking location was: “Where were you when you were drinking?” and participants could answer one or more of the following: own residence; friend residence;
3. Results The method we used intentionally sampled earlier occurrences of alcohol-related events, by allowing each participant to be eligible for selection on any week he/she reported a negative alcohol consequence. Further, because consequences tend to be higher earlier in the school year (Hoeppner et al., 2012), more participants were eligible in the 140
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drinking day, and 15.9% of the sample reported using a drug besides alcohol on the day of the event, with the most common drug being marijuana (84.6%). As shown in Table 1, the most frequently endorsed negative consequences on the event day were blacking out (36.1%), getting sick (32.8%), and saying something regretted (24.0%). The average total number of consequences experienced in the event was 1.88 (Mdn = 1.0, SD = 1.26), ranging from one to eight. Total number of consequences was positively associated with the number of drinks (r (295) = 0.20, p < 0.001) and eBAC (r(295) = 0.31, p = 0.001) on that day. The difference in the number of negative consequences experienced among those who used both alcohol and marijuana (M = 1.95, SD = 1.20) and those who only consumed alcohol (M = 1.87, SD = 1.28) on event day was not significant, t(293) = −0.40, p = 0.69.
Table 2 Locations where alcohol was consumed and where the event happened.
Friend residence Your residence Party Fraternity/sorority function Other place off-campus Bar/club/restaurant Other place on-campus Car Sporting event
Locations where alcohol was consumed
Location where most salient event happened
61.9 32.7 27.9 14.3
32.8 32.4 7.8 6.8
12.9 9.2 6.5 1.4 0.3
6.5 5.1 6.1 2.4 0
Note. Participants could report multiple locations where alcohol was consumed, thus it sums to over 100. For 73.9% of the sample, the most salient event occurred at a location where alcohol was consumed.
3.2.2. Characteristics of drinking and the drinking setting on the event day On the event day, 70.8% of the sample had decided in advance to get intoxicated, and 88.4% of the sample reported feeling drunk at the time of the event. There was a significant difference in the number of negative consequences experienced between those who felt drunk at the time of event (M = 1.95, SD = 1.31) and those who did not (M = 1.35, SD = 0.65; t(1,75) = −4.37, p < 0.001). However, there was not a significant difference in the number of negative consequences experienced between those who decided to get intoxicated (M = 1.93, SD = 1.29) and those who did not (M = 1.75, SD = 1.17; t(1289) = −1.08, p = 0.28). As shown in Tables 2, 61.7% of participants reported consuming alcohol at a friend's residence, 32.5% at their own residence, and 27.8% at a party. Consumption was less likely to occur at a bar, club, or restaurant, sporting event, Greek function, car, and other on-campus/offcampus locations. A little over half (52.7%) of the participants consumed alcohol at only one location, with 32.3% consuming alcohol at two locations, 11.2% at three locations, and 3.8% at four or more locations. The number of negative consequences experienced was not associated with the total number of drinking locations (r(294) = −0.02, p = 0.74). Similarly, there was no difference in negative consequences between those who consumed alcohol at more than one location and those who consumed alcohol at only one location (t(292) = −0.33, p = 0.75). The majority of participants (63.7%) stated that most of the people around them were drinking at similar rates as they were, 23.5% reported that others were drinking more, 12.5% indicated that others were drinking less, and 0.3% of participants were drinking alone. As indicated in Table 2, the majority of participants reported experiencing the event at either their own (32.4%) or a friend's residence (32.8%), and 87.1% of participants were not alone when the event happened. Of those who were with others at the time of the event, participants reported being with: at least one same-sex friend (75.8%), at least one opposite-sex friend (67.2%), acquaintances (29.7%), strangers (22.7%), their significant other (17.6%), and relatives (2.3%). The majority of the sample (54.4%) indicated that they were with more than one of these categories when the event occurred. When participants estimated the number of people they were with when the event happened, they reported being with: one person (23.0%), two to five people (33.2%), six to ten people (20.3%), 11 to 99 people (18.0%), 100 people or more (3.1%). For 73.9% of the sample, the most salient event occurred at the same location type where alcohol was consumed. We also examined gender differences in the characteristics of drinking and the drinking setting on the event day. Regarding the drinking setting, men had a greater tendency to consume alcohol at a friends' residence (χ2(1) = 7.56, p < 0.01). When the event happened, men had a greater tendency to be with at least one male friend (χ2(1) = 13.75, p < 0.001) and to be with strangers (χ2(1) = 7.47, p < 0.01). Furthermore, when the event happened, men were more likely to be with more different types of groups (e.g., same-sex friend,
beginning of each year. By the end of two years of eligibility, 77.2% of the original sample who had at least one consequence was selected.1 Of the 326 participants selected for the assessment interview, 296 (90.8%) completed it.2One person was removed from the analysis due to providing inconsistent data. The sample was 78.0% freshman and 60.3% female. Of the sample, 59.0% were from College 1, 27.8% from College 2, and 13.2% from College 3. Most (74.9%) reported their race as White, 8.1% were Asian, 5.1% were Black, 6.4% reported more than one race, and 5.4% reported no race. Latino/Hispanic ethnicity was reported by 5.1% of the sample. An average of 16.6 days (Mdn = 16; SD = 5.4) elapsed between the day the event was experienced and the interview day. 3.1. Substance use before the event day In the month before the event, the average number of drinking days was 5.26 days (SD = 4.32) and the average number of heavy drinking days was 3.07 days (SD = 3.50). Participants reported an average eBAC of 0.09 (SD = 0.06) and a peak eBAC of 0.15 (SD = 0.09). Half (49.0%) of the sample reported using marijuana at least once in the month before the event, and 10.9% of the sample reported using a drug besides marijuana at least once in the month before the event. There was no difference in the number of negative consequences experienced on the event day between those who used only alcohol in the month before the event (M = 1.77, SD = 1.15) and those who use both alcohol and marijuana in the month before the event (M = 1.98, SD = 1.35; t(292) = − 1.41, p = 0.16). 3.2. Event-related Information 3.2.1. Substance use and consequences on event day On average, participants reported consuming 7.43 (SD = 4.57) standard drinks on the event day, resulting in an average eBAC of 0.15 (SD = 0.09). For 79.7% of the sample, the event day was a heavy 1 As reported by Magill, Kahler, Monti, and Barnett (2012), the participants who were and were not selected for interviews did not differ by gender, frequency of pre-college drinking or pre-college number of heavy drinking days, but they were more likely to identify as white or multi-race, (χ2 (5, 684) =30.69, p < 0.001) and showed higher AUDIT scores (5.2 [SD = 4.5] vs. 3.2 [SD = 3.6]; t(686) = 5.18, p < 0.001). Also as reported by Magill et al. (2012) there were no significant differences on substance use between participants assigned to the interview (N = 326) and those assigned to control (N = 196). 2 There was no difference in gender (χ2(1) = 0.15, p = 0.70), race (χ2(4) = 0.33, p = 0.99), maximum drinking quantity (t(316) = 0.26, p = 0.80), number of drinks per week (t(316) = − 0.43, p = 0.67), and number of heavy drinking days in the past month (t(311) = −0.87, p = 0.39) between those who attended the interview and those who were selected, but did not attend. These groups were compared on alcohol use from the parent dataset which included annual surveys. Sophomores were less likely to attend the interview compared to freshmen (χ2(1) = 4.86, p = 0.03).
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endorsed negative consequences were blacking out, vomiting, and saying something that was later regretted. These event-level findings are consistent with those using global retrospective surveys (Mallett et al., 2011; Mallett et al., 2011), suggesting that when summary measures covering a longer time-frame are used, the prevalence of consequences are quite similar to those found with much shorter retrospective surveys. Of note, we found that participants' estimated level of intoxication on the event day was not different from their peak eBAC in the month prior to the event, suggesting that our procedure of randomly selecting a day with consequences identified a drinking day that was not more extreme than the participant's most recent (prior) peak drinking day. The fact that the estimated intoxication on the event day was more extreme than the past-month typical intoxication suggests that consequences were more likely to occur (and therefore be selected for this study) on extreme drinking days than on typical drinking days. Co-use of alcohol and other substances in the month before the event or on the day of the event were not related to a higher number of alcohol consequences. This is contrary to previous findings using global retrospective survey methods and a recent event-level study that have demonstrated escalated risks associated with co-occurring use (Hammer & Pape, 1997; Mallett et al., 2017; Shillington & Clapp, 2001; Simons & Carey, 2006). In the current study the use of alcohol and other substances was measured at the day level, thus, we cannot be certain if participants used the substances simultaneously (i.e., at the same time). This may explain the discrepant finding from the other event-level study (Mallett et al., 2017). Furthermore, the current study examined these associations among individuals who reported at least one alcohol-related consequence; thus, our finding may not be generalizable to all drinkers. This study's findings reflect the importance of peers before, during, and after a drinking episode that resulted in at least one alcohol-related consequence. The vast majority of drinking events and the negative consequences of drinking occurred in the presence of same-age peers. Furthermore, the majority of the sample reported that their closest friend knew about the event, whereas campus administrators and parents were unlikely to know about the event. However, reactions of students and peers to the events were mild. Students expressed little concern about the consequences they experienced, and best friends were only mildly upset (as perceived by the participant). There was consistency between the participant's own aversiveness ratings and the perceived upset of friends and mothers, but the effect of the experience on future drinking was generally low; nearly half of participants reported that the event had no effect on their subsequent drinking behaviors, and another 41% of participants reported they would drink more carefully but not alter the amount they would drink. Interestingly, 70.8% of the sample had decided in advance to become intoxicated, and 88.4% of the sample reported feeling drunk at the time of the event. However, the decision whether or not to become intoxicated did not influence the number of consequences experienced, but those who felt drunk at the time of event experienced more consequences. Although ample research has highlighted predictors of drinking intention (e.g., health messaging, alcohol expectancies, and drinking refusal self-efficacy; e.g., (Glanton & Wulfert, 2013; Glock & Krolak-Schwerdt, 2013; Kim, Lee, & Macias, 2014) and prospectively linked drinking intentions with actual drinking behaviors in college students (Pedersen, LaBrie, & Hummer, 2009), there is a paucity of research examining the relationship between drinking intentions and alcohol consequences. One possible explanation for this finding is that students intending to become intoxicated may take precautions and/or use protective behaviors to avoid consequences. We found a few significant gender differences in the characteristics of drinking and the drinking setting on the event day and the reactions to the event. Men tended to consume alcohol at a friends' residence and when the event happened, they were also more likely to be with other men and strangers. In sum, the lack of results suggest that in a sample of individuals with at least one alcohol-related consequence, the drinking
opposite-sex friend, acquaintances) than women (M = 2.22, SD = 1.17 and M = 1.86, SD = 1.06, respectively; t(227) = 2.71, p < 0.01). No other significant differences were found. 3.2.3. Comparison of past-month and event day drinking eBAC on the event day was significantly greater than the past-month average eBAC (t(259) = 11.84, p < 0.001), but was not significantly different than the past-month peak eBAC (t(259) = 0.64, p = 0.52). 3.2.4. Reactions to event Participants mainly attributed the event to: just having fun (58.7%), poor judgment (46.1%), carelessness (35.5%), and too intoxicated to think clearly (33.8%). On the extent to which participants thought their own alcohol or behavior was responsible for the event, the average was M = 4.73 (SD = 1.50) on a scale from 1 to 7, roughly equivalent to a response of “mostly”. Feeling personal responsibility for the event was positively associated with event day drinking (r(294) = 0.28, p < 0.001) and event eBAC (r(294) = 0.29, p < 0.001). Participants' average aversiveness rating of the event was 2.75 (SD = 1.43), equivalent to a response of “somewhat,” and aversiveness was positively related to number of negative consequences experienced (r(294) = 0.41, p < 0.001). Most participants (85.0%) indicated that their closest friend knew about their event, 14.7% reported that their mother knew about their event, and 7.6% reported that their father knew about the event. When asked how upset these people were on a scale ranging from 1 (not at all) to 5 (very), closest friend's upset mean score was 1.71 (SD = 1.06), mother's upset mean score was 2.28 (SD = 1.08), and father's upset mean score was 1.81 (SD = 1.08). For those who did not tell either their mother or father about the event, participants were asked how concerned they were about this person finding out about the event. On a scale ranging from 1 to 5, the mean concern of mother and father finding out about the event were 2.42 (SD = 1.42) and 2.50 (SD = 1.50), respectively, equivalent to responses of “somewhat”. Responsibility for the event was positively related to participant concern of both mother and father finding out about the event (r(246) = 0.19, p < 0.01, and r(256) = 0.18, p < 0.01), but not with friend upset (r(246) = − 0.12, p = 0.07), mother upset (r(43) = 0.15 p = 0.32), or father upset (r(21) = 0.21, p = 0.37). Aversiveness was positively related to concern about mother (r(246) = 0.20, p < 0.01) and father (r(256) = 0.24, p < 0.001) finding out, friend upset (r (246) = 0.39, p < 0.001), and mother upset (r(43) = 0.43, p < 0.01), but not father upset (r(21) = 0.04, p = 0.88). Lastly, 13.3% of the sample reported that a campus entity knew about the event. Of those who reported that a campus entity knew about the event, only 7.7% reported having to attend counseling or health education because of it. When asked to indicate how much this experience changed their drinking, 45.9% stated that it had no effect on their drinking, 41.2% stated that “it did not change how much they drank, but they are now careful about how much they drink and what they do when they drink”, 3.7% indicated that they “drink very little or not at all”, and 9.2% of the sample indicated “other”. Last, only one gender difference was found regarding reactions to the event. Although there was no difference in mom knowing about the event between men and women (χ2(1) = 2.88, p = 0.09), mothers of women tended to be more upset about the event than mothers of men (t(41) = −2.07, p = 0.04). 4. Discussion The main aim of this study was to describe randomly-selected alcohol-related negative consequences experienced by first- and secondyear college students at three universities, including the circumstances that preceded and followed these events, and associations between the event characteristics, the consequences, and post-event reactions of the participants and important others. We found that the most commonly 142
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college students. Taken together, the findings of the study suggest that the vast majority of alcohol consumption and alcohol-related consequences occur in the presence of other individuals. Future work could investigate methods to leverage peer relationships in an effort to reduce alcohol-related consequences in the context of existing harm reduction strategies such as interventions and social norms campaigns.
setting and the location of the event is largely the same among men and women. These results highlight two primary and intersecting directions for intervention development. First, the presence of peers during drinking and consequences put them squarely in the position to help others avoid these consequences. These findings point to the potential of bystander training for alcohol harm reduction. Same-age peers represent potential bystanders who can help their peers avoid or prevent consequences, deal with consequences that do occur, and engage in discussions about the consequences (Banyard, Moynihan, & Grossman, 2009; Banyard, Plante, & Moynihan, 2004). Thus, providing students with knowledge about how to intervene at various stages in a drinking event could be an effective strategy to reduce negative alcohol-related consequences in this population. Furthermore, because students' reactions were mild, overall, and that the majority of the sample decided to become intoxicated, providing education about the harms of drinking would also be useful. These findings also have important implications for intervention approaches that intervene shortly after adverse events (i.e., “teachable moments”; (Longabaugh et al., 1995) to stimulate one's engagement in behavior change and possible additional counseling (Carey, Scott-Sheldon, Garey, Elliott, & Carey, 2016).
Role of funding source This research was supported in part by grant numbers R01AA13970 and T32AA007459-32 from the National Institute on Alcohol Abuse and Alcoholism, and T32DA016184 from the National Institute on Drug Abuse. NIAAA and NIDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Contributors MKM analyzed the results of the study, and was the primary contributor to the composition of the manuscript. SRK and NB were the secondary contributors to the composition of the manuscript. NB contributed to the primary design and provided oversight of all aspects of the study.
4.1. Strengths and limitations
Conflict of interest
One strength of the current study is that the initial biweekly assessment of alcohol-related consequences occurred close to the actual event, and the subsequent interview occurred within about two weeks. Prior investigations of drinking events do not typically assess participants soon after the event; for example evaluations of mandated students can occur months after the student violation (Morgan, White, & Mun, 2008). However, it is possible that even in those two weeks' time, participants' interpretations of events changed from their initial recall of the event. EMA methodology may be useful to better understand students' evaluation of negative consequences and their reactions to them, and potentially intervene with students as soon as possible after an adverse event has occurred (Wray, Merrill, & Monti, 2014). Another limitation of the study is that we only sampled those who had a negative consequence, which does not allow us to conduct a complete investigation of the characteristics of drinking events that do and do not lead to consequences. Another limitation is that eBAC estimates are prone to error (Clapp et al., 2009). However, the findings from the eBAC complement the other drinking findings. By the end of the participants' sophomore year, we had selected approximately 80% of those who had reported consequences, and our completion rate for the interviews was excellent. One artifact of our methodology was that participants who had repeated consequences were more likely to be sampled because they were eligible more often, and therefore although the events were sampled randomly, each participant did not have the same likelihood of being selected. Still, there were few differences between those who were selected and those who were not. It is also possible that participants who had consequences and were selected early in college had different experiences than those who were selected later; we did not investigate time of the consequence as a factor. Furthermore, even though we intentionally oversampled more serious consequences, we found in this sample that the consequences we thought were more serious (fights, injuries) were not perceived as such by participants (Barnett et al., 2014) which should reduce concern about the oversampling affecting our findings. Our sample included only first- and second-year college students from three New England colleges and the sample was primarily White, so our findings may not generalize to other settings and populations.
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Addictive Behaviors journal homepage: www.elsevier.com/locate/addictbeh
Characteristics of prospectively identified negative alcohol-related events among college students
T
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Matthew K. Meisela, , Shannon R. Kenneyb, Nancy P. Barnetta a b
Center for Alcohol and Addiction Studies, Brown University, USA Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, USA
H I G H L I G H T S of participants experienced the event at either their own or a friend's residence. • Majority of participants were with peers when the event happened. • 87.1% indicated that their closest friend knew about their event. • 85.0% • Overall, students' reactions to the event were mild.
A R T I C L E I N F O
A B S T R A C T
Keywords: Alcohol-related consequences College Same-age peers
Background: Throughout the first two years of college, the majority of drinkers experience one or more alcoholrelated consequences. Research that examines the characteristics surrounding negative consequences typically utilizes global retrospective survey methods. The objective of the current study was to apply an event-based methodology to describe the circumstances of a recent drinking episode that resulted in one or more alcoholrelated consequences among first- and second-year college students. Methods: We used a prospective web-based survey method to identify participants (N = 296) who had one or more alcohol-related consequences in the past week. Shortly after reporting the consequence(s), participants attended an in-person interview during which they described the circumstances that preceded and followed the consequence(s), including the use of alcohol and other substances, proximal contextual factors including peer drinking, the characteristics of the negative alcohol-related consequence(s), and the reaction of others to the event. Results: The majority of participants reported experiencing the event at either their own (32.4%) or a friend's (32.8%) residence, and 87.1% of participants were with peers when the event happened. Most (85.0%) of the sample indicated that their closest friend knew about their event. Conclusion: The high peer involvement at all stages of the event suggest the potential for training college students to help each other avoid or prevent consequences.
This research was supported in part by grant numbers R01AA13970 and T32AA007459-32 from the National Institute on Alcohol Abuse and Alcoholism, and T32DA016184 from the National Institute on Drug Abuse. 1. Introduction Heavy alcohol use is a well-documented problem among college students (Dowdall & Wechsler, 2002), particularly in the first year after matriculating into college (Barnett et al., 2014). College students
frequently drink heavily (Blanco et al., 2008; Dawson, Grant, Stinson, & Chou, 2004; Paschall, 2003; Slutske, 2005), and accordingly, they experience a variety of alcohol-related consequences (Hingson, Heeren, Winter, & Wechsler, 2005; Hingson, Heeren, Zakocs, Kopstein, & Wechsler, 2002; Hingson, Zha, & Weitzman, 2009; A. White & Hingson, 2014). Throughout the first two years of college, the majority of drinkers report at least one negative alcohol-related consequence (e.g., vomiting, blackout, and regretting something said; Mallett, Marzell, & Turrisi, 2011; Mallett et al., 2011). When measuring alcohol consequences, global retrospective surveys which collect counts or scores
⁎ Corresponding author at: Center for Alcohol and Addiction Studies, Department of Behavioral & Social Sciences, Brown University School of Public Health, Box G-S121-4, Providence, RI 02903, USA. E-mail address: [email protected] (M.K. Meisel).
https://doi.org/10.1016/j.addbeh.2017.11.025 Received 7 June 2017; Received in revised form 13 October 2017; Accepted 13 November 2017 Available online 14 November 2017 0306-4603/ © 2017 Elsevier Ltd. All rights reserved.
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with event characteristics. We also examined gender differences in the characteristics of drinking and the drinking setting on the event day and the reactions to the event. Understanding the circumstances under which students experience negative alcohol-related consequences when they drink can be informative for optimal prevention efforts.
of consequences along with information about alcohol use over roughly the same timeframe are primarily used. These more traditional methods can result in inaccurate responses and recall bias (Shiffman et al., 1997). In contrast, event-level methods (e.g., ecological momentary assessment, daily surveys) can identify a specific drinking event and its outcomes with the purpose of identifying precursors and correlates of the event. In the current event-level study combined with intensive interviewing, we aimed to provide a deeper understanding of the characteristics of alcohol-related events that are associated with consequences reported by college students. Volume of alcohol use is related to the setting in which it is consumed. The drinking setting not only refers to where alcohol is consumed, but it also refers to why, when, where, and with whom alcohol is consumed. When college students drink, they most often do so with their friends, on weekends, and at parties or other social occasions (Beets et al., 2009; Clapp, Shillington, & Segars, 2000). At the aggregate level, heavy drinking episodes among college students tend to equally occur at public contexts, such as bars or restaurants, and private contexts, such as residences (Clapp et al., 2000) although college students under the age of 21 predominately drink in private contexts (Clapp, Reed, Holmes, Lange, & Voas, 2006). The current study expands on this line of research by examining the settings of alcohol-related consequences. Studies that utilize global retrospective methods consistently find that individuals who drink heavily also tend to use other substances and that using multiple substance use is associated with more alcohol-related consequences (Haas & Smith, 2012; Reed, Wang, Shillington, Clapp, & Lange, 2007; Shillington & Clapp, 2006). For example, individuals who use both alcohol and marijuana are more likely to experience alcohol-related and non-alcohol-related problems than those who only drink (Hammer & Pape, 1997; Shillington & Clapp, 2001; Simons & Carey, 2006). The one event-level study to date that has examined the relationship between simultaneous substance use and alcohol-related problems among college students found that on occasions when students used more than one substance, more consequences were reported than when students only used alcohol (Mallett et al., 2017). However, this study only included individuals who reported both alcohol use and use of another substance on the event occasion; hence, the sample is higher risk and lacks generalizability. Students diverge in how they perceive alcohol-related consequences, resulting in differential effects on subsequent drinking and alcohol-related consequences. For example, when alcohol-related consequences are perceived as aversive, students are more motivated to reduce their alcohol use and show subsequent declines in use (Barnett, Goldstein, Murphy, Colby, & Monti, 2006; Merrill, Read, & Barnett, 2013). Despite the importance of friends and family in college students' drinking-related perceptions and behaviors (Kenney, Ott, Meisel, & Barnett, 2017; Meisel, Clifton, MacKillop, & Goodie, 2015; Walls, Fairlie, & Wood, 2009; H. R. White et al., 2006), no study to date has examined how friends' and family members' awareness of and reactions toward the consequence are associated with the event circumstances and to the student's own reaction toward the consequence(s) experienced. The current study utilized a combination of event-based methods and in-person interviews to describe the circumstances of a recent drinking episode that resulted in one or more alcohol-related consequences among first- and second-year college students at three different universities under the age of 21 and to examine: 1) proximal contextual factors related to drinking and the number of consequences experienced, 2) whether using alcohol with other substances was related to consequences, 3) whether alcohol use in the event was different from alcohol use in the prior month, and 4) students' reaction to the event, including the extent to which perceptions of aversiveness of alcohol-related consequences were related to the characteristics of the alcohol-related consequences, whether close others were aware of the event, and whether parents' and close friends' reactions were associated
2. Method 2.1. Participants The sample for this study (N = 296) was derived from a larger longitudinal study of college student alcohol use (Barnett et al., 2014). The parent study was conducted with three cohorts of incoming college students at three mid-sized universities/colleges in the northeast. To be eligible for the parent study, students had to be under the age of 21, an incoming freshman enrolled full-time at one of the three colleges, residing on-campus during their first year, and not an international student. The parent sample was stratified based on gender, and students with a racial-ethnic identity other than exclusively non-Hispanic white were oversampled. Individuals under the age of 18 were required to provide parent consent and the study was approved by the Institutional Review Boards at the three college locations. 2.2. Procedures for the parent study Participants were surveyed prior to their first year of college and were subsequently randomly assigned to one of two survey groups. Each group was surveyed every other week (on alternate weeks) for the first two years of college, except during winter and summer breaks. These online biweekly surveys assessed participants' alcohol use and alcohol consequences over the past seven days. Each semester was 16 weeks, so participants were asked to complete eight surveys each semester. Participants were compensated $2 for each completed survey and had a (randomly determined) opportunity to win $100 after each survey. If participants completed seven or eight of the eight surveys each semester, they received a bonus of $20. 2.2.1. Procedures for the present study Immediately following the end of each survey, participants who had reported one or more alcohol-related consequences were identified (n = 522). To ensure lower frequency consequences were captured, 50% of participants who reported a school or work problem, trouble with police, a physical fight, or accidentally hurting someone were selected; the rest of the 13 consequences (see Table 1) were sampled at a 25% rate. Selected participants were then randomly assigned at a 3:2 ratio to an assessment group (n = 326) or a no-assessment group (n = 196). Participants could only be selected once. Participants received $25 for completing the assessment. The no-assessment group was not relevant for the current analysis so is not further described. 2.2.2. Event identification interview In the week they were selected, participants were invited to attend an in-person on-campus interview. A research assistant (RA) informed participants that they were randomly selected to be interviewed about a recent alcohol-related consequence. During the interview, participants were presented with their responses from the survey and using a calendar were asked to identify the day(s) on which they experienced the reported negative consequences. If consequences were experienced on more than one day in the week, participants were asked to select the day on which the consequence(s) were the most important or meaningful; thereafter these alcohol-related circumstances were called “the event.” When more than one consequence was reported on the event day, participants were asked to select the consequence on the event day that was “the most meaningful or important when you think about your drinking now.” The RA then asked the participant to describe the drinking and social details that led up to and followed the event. 139
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bar, club, or restaurant; sporting event; party; fraternity or sorority function; car; other on-campus location; other off-campus location. They used the same list to indicate where they were when the event happened. Participants were asked about the drinking of others: “How were most of the people around you drinking compared to you?” with the response options of: more than you were; less than you were, about the same as you were, you were alone. Participants were asked “Who were you with when the event happened?” and could indicate any of the answers that applied: no one – you were alone; male friend(s); female friend(s); strangers; significant other; relatives; acquaintances. Participants also reported on the total number of people they were with when the event happened.
Table 1 Most salient negative consequence experienced and the percent of negative consequences endorsed for interview. Negative consequence
Percent reported
Most salient negative consequence
Got physically sick (e.g. vomited, stomach cramps) Couldn't remember some part of the day or night Felt sad or depressed Said something that I wish I hadn't Had problems with school work Disappointed others who are close to me Had a romantic or sexual activity that I now regret Was physically injured Drove after drinking and realized I should not have Got into trouble with my school authorities or police Accidentally physically hurt someone Got into a physical fight Passed out
32.9
20.4
36.3
19.3
22.0 24.1 12.2 17.6
13.9 10.8 8.1 7.8
12.2
6.1
9.2 3.1
3.7 3.1
4.1
2.0
4.1
1.7
2.7 8.1
1.7 1.4
2.3.4. Substance Use Participants were asked whether on the day of the event they had used any drugs other than alcohol including marijuana, cocaine, designer drugs, and other drugs not prescribed to them. Participants also reported if they used any of the above substances in the month before the event. 2.3.5. Reactions to event Participant attributions about the event and aversiveness of the event were adapted from Longabaugh et al. (1995). The three attribution items (e.g., “To what extent do you believe your alcohol consumption was responsible for this event?; α = .71) measured the extent to which the individual believed alcohol and their own behavior were responsible for the event. The three aversiveness items (e.g., “To what extent has this event upset you?”; α = 0.91) measured the extent to which the individual was disturbed about the event. Items are scored ranging from 1 (not at all) to 7 (extremely or totally). Total scores were calculated. In addition, participants were asked “To what do you attribute the event?” and were allowed to indicate one or more of the following: pressure from others, just having fun, too intoxicated to think clearly, carelessness, poor judgment, stupid rules, bad luck, fate, someone's overreaction, and other. Parents, friends and campus administrators' responses to the event were collected by asking: “Does your mother/father/closest friend/campus entity (police, emergency medical services, college infirmary or hospital, resident advisor or peer counselor, campus official) know about your event?” and “How upset was your mother/father/closest friend when he/she heard?” Responses to the second question ranged from 1 (not at all) to 5 (very). For those who did not tell either their mother or father about the event, participants were asked “How concerned are you about this person finding out about the event?” on a scale ranging from 1 (not at all) to 5 (very). Finally, participants responded to the question “How much did you change your drinking as a result of this experience?” Response options were 1) I did not change anything, 2) I did not change how much I drink, but now I am more careful about how I drink and what I do when I drink, 3) Now I drink very little or not at all, and 4) Other.
Note. The total number of negative consequences ranged from zero to eight with a mean of 1.88 (SD = 1.27).
Following this event identification interview, the RA administered the Timeline Followback (see 2.3.2 below), after which participants selfadministered the rest of the measures. 2.3. Measures Gender, year in school, and race/ethnicity were collected in the baseline survey of the parent study. The Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, De la Fuente, & Grant, 1993) was collected at the same time and was used to compare participants in the current study to students who were not selected. 2.3.1. Biweekly Surveys On each biweekly survey, participants provided the number of drinks consumed on each day for the past week. Participants who reported drinking in the past week were asked to indicate whether they had experienced any of 13 negative alcohol-related consequences in the past week derived from common measures of alcohol-related consequences (Table 1). Cronbach's alphas for these items ranged from 0.79–0.83 each week. 2.3.2. Timeline followback (Sobell & Sobell, 1995) This structured, calendar-aided assessment of alcohol use on each of the thirty days prior to the event was administered by the RA. Participants reported the number of drinks consumed on each day and the length of time spent drinking. Number of drinking days and number of heavy drinking days (4 or more drinks for women, 5 or more for men) in the month were calculated. For each drinking day, an estimate of BAC was calculated (eBAC; Matthews & Miller, 1979), from which average and peak eBAC were derived. Event day number of drinks and eBAC were also calculated.
2.4. Data Analysis Chi-square analyses were used to compare participants who were and were not selected, and among those who were selected, between those who did and did not complete the interviews. Correlations and independent samples t-tests were conducted to examine the three aims. Furthermore, chi-square analyses were also conducted to examine gender differences. All analyses were conducted in SPSS.
2.3.3. Event Characteristics Participants were asked specific questions about the circumstances surrounding their drinking event, including intoxication: “Did you feel drunk at the time of the event?” and intoxication intentions: “That day, before you started drinking, or at some point during your drinking, did you decide to get intoxicated?” The measure of drinking location was: “Where were you when you were drinking?” and participants could answer one or more of the following: own residence; friend residence;
3. Results The method we used intentionally sampled earlier occurrences of alcohol-related events, by allowing each participant to be eligible for selection on any week he/she reported a negative alcohol consequence. Further, because consequences tend to be higher earlier in the school year (Hoeppner et al., 2012), more participants were eligible in the 140
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drinking day, and 15.9% of the sample reported using a drug besides alcohol on the day of the event, with the most common drug being marijuana (84.6%). As shown in Table 1, the most frequently endorsed negative consequences on the event day were blacking out (36.1%), getting sick (32.8%), and saying something regretted (24.0%). The average total number of consequences experienced in the event was 1.88 (Mdn = 1.0, SD = 1.26), ranging from one to eight. Total number of consequences was positively associated with the number of drinks (r (295) = 0.20, p < 0.001) and eBAC (r(295) = 0.31, p = 0.001) on that day. The difference in the number of negative consequences experienced among those who used both alcohol and marijuana (M = 1.95, SD = 1.20) and those who only consumed alcohol (M = 1.87, SD = 1.28) on event day was not significant, t(293) = −0.40, p = 0.69.
Table 2 Locations where alcohol was consumed and where the event happened.
Friend residence Your residence Party Fraternity/sorority function Other place off-campus Bar/club/restaurant Other place on-campus Car Sporting event
Locations where alcohol was consumed
Location where most salient event happened
61.9 32.7 27.9 14.3
32.8 32.4 7.8 6.8
12.9 9.2 6.5 1.4 0.3
6.5 5.1 6.1 2.4 0
Note. Participants could report multiple locations where alcohol was consumed, thus it sums to over 100. For 73.9% of the sample, the most salient event occurred at a location where alcohol was consumed.
3.2.2. Characteristics of drinking and the drinking setting on the event day On the event day, 70.8% of the sample had decided in advance to get intoxicated, and 88.4% of the sample reported feeling drunk at the time of the event. There was a significant difference in the number of negative consequences experienced between those who felt drunk at the time of event (M = 1.95, SD = 1.31) and those who did not (M = 1.35, SD = 0.65; t(1,75) = −4.37, p < 0.001). However, there was not a significant difference in the number of negative consequences experienced between those who decided to get intoxicated (M = 1.93, SD = 1.29) and those who did not (M = 1.75, SD = 1.17; t(1289) = −1.08, p = 0.28). As shown in Tables 2, 61.7% of participants reported consuming alcohol at a friend's residence, 32.5% at their own residence, and 27.8% at a party. Consumption was less likely to occur at a bar, club, or restaurant, sporting event, Greek function, car, and other on-campus/offcampus locations. A little over half (52.7%) of the participants consumed alcohol at only one location, with 32.3% consuming alcohol at two locations, 11.2% at three locations, and 3.8% at four or more locations. The number of negative consequences experienced was not associated with the total number of drinking locations (r(294) = −0.02, p = 0.74). Similarly, there was no difference in negative consequences between those who consumed alcohol at more than one location and those who consumed alcohol at only one location (t(292) = −0.33, p = 0.75). The majority of participants (63.7%) stated that most of the people around them were drinking at similar rates as they were, 23.5% reported that others were drinking more, 12.5% indicated that others were drinking less, and 0.3% of participants were drinking alone. As indicated in Table 2, the majority of participants reported experiencing the event at either their own (32.4%) or a friend's residence (32.8%), and 87.1% of participants were not alone when the event happened. Of those who were with others at the time of the event, participants reported being with: at least one same-sex friend (75.8%), at least one opposite-sex friend (67.2%), acquaintances (29.7%), strangers (22.7%), their significant other (17.6%), and relatives (2.3%). The majority of the sample (54.4%) indicated that they were with more than one of these categories when the event occurred. When participants estimated the number of people they were with when the event happened, they reported being with: one person (23.0%), two to five people (33.2%), six to ten people (20.3%), 11 to 99 people (18.0%), 100 people or more (3.1%). For 73.9% of the sample, the most salient event occurred at the same location type where alcohol was consumed. We also examined gender differences in the characteristics of drinking and the drinking setting on the event day. Regarding the drinking setting, men had a greater tendency to consume alcohol at a friends' residence (χ2(1) = 7.56, p < 0.01). When the event happened, men had a greater tendency to be with at least one male friend (χ2(1) = 13.75, p < 0.001) and to be with strangers (χ2(1) = 7.47, p < 0.01). Furthermore, when the event happened, men were more likely to be with more different types of groups (e.g., same-sex friend,
beginning of each year. By the end of two years of eligibility, 77.2% of the original sample who had at least one consequence was selected.1 Of the 326 participants selected for the assessment interview, 296 (90.8%) completed it.2One person was removed from the analysis due to providing inconsistent data. The sample was 78.0% freshman and 60.3% female. Of the sample, 59.0% were from College 1, 27.8% from College 2, and 13.2% from College 3. Most (74.9%) reported their race as White, 8.1% were Asian, 5.1% were Black, 6.4% reported more than one race, and 5.4% reported no race. Latino/Hispanic ethnicity was reported by 5.1% of the sample. An average of 16.6 days (Mdn = 16; SD = 5.4) elapsed between the day the event was experienced and the interview day. 3.1. Substance use before the event day In the month before the event, the average number of drinking days was 5.26 days (SD = 4.32) and the average number of heavy drinking days was 3.07 days (SD = 3.50). Participants reported an average eBAC of 0.09 (SD = 0.06) and a peak eBAC of 0.15 (SD = 0.09). Half (49.0%) of the sample reported using marijuana at least once in the month before the event, and 10.9% of the sample reported using a drug besides marijuana at least once in the month before the event. There was no difference in the number of negative consequences experienced on the event day between those who used only alcohol in the month before the event (M = 1.77, SD = 1.15) and those who use both alcohol and marijuana in the month before the event (M = 1.98, SD = 1.35; t(292) = − 1.41, p = 0.16). 3.2. Event-related Information 3.2.1. Substance use and consequences on event day On average, participants reported consuming 7.43 (SD = 4.57) standard drinks on the event day, resulting in an average eBAC of 0.15 (SD = 0.09). For 79.7% of the sample, the event day was a heavy 1 As reported by Magill, Kahler, Monti, and Barnett (2012), the participants who were and were not selected for interviews did not differ by gender, frequency of pre-college drinking or pre-college number of heavy drinking days, but they were more likely to identify as white or multi-race, (χ2 (5, 684) =30.69, p < 0.001) and showed higher AUDIT scores (5.2 [SD = 4.5] vs. 3.2 [SD = 3.6]; t(686) = 5.18, p < 0.001). Also as reported by Magill et al. (2012) there were no significant differences on substance use between participants assigned to the interview (N = 326) and those assigned to control (N = 196). 2 There was no difference in gender (χ2(1) = 0.15, p = 0.70), race (χ2(4) = 0.33, p = 0.99), maximum drinking quantity (t(316) = 0.26, p = 0.80), number of drinks per week (t(316) = − 0.43, p = 0.67), and number of heavy drinking days in the past month (t(311) = −0.87, p = 0.39) between those who attended the interview and those who were selected, but did not attend. These groups were compared on alcohol use from the parent dataset which included annual surveys. Sophomores were less likely to attend the interview compared to freshmen (χ2(1) = 4.86, p = 0.03).
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endorsed negative consequences were blacking out, vomiting, and saying something that was later regretted. These event-level findings are consistent with those using global retrospective surveys (Mallett et al., 2011; Mallett et al., 2011), suggesting that when summary measures covering a longer time-frame are used, the prevalence of consequences are quite similar to those found with much shorter retrospective surveys. Of note, we found that participants' estimated level of intoxication on the event day was not different from their peak eBAC in the month prior to the event, suggesting that our procedure of randomly selecting a day with consequences identified a drinking day that was not more extreme than the participant's most recent (prior) peak drinking day. The fact that the estimated intoxication on the event day was more extreme than the past-month typical intoxication suggests that consequences were more likely to occur (and therefore be selected for this study) on extreme drinking days than on typical drinking days. Co-use of alcohol and other substances in the month before the event or on the day of the event were not related to a higher number of alcohol consequences. This is contrary to previous findings using global retrospective survey methods and a recent event-level study that have demonstrated escalated risks associated with co-occurring use (Hammer & Pape, 1997; Mallett et al., 2017; Shillington & Clapp, 2001; Simons & Carey, 2006). In the current study the use of alcohol and other substances was measured at the day level, thus, we cannot be certain if participants used the substances simultaneously (i.e., at the same time). This may explain the discrepant finding from the other event-level study (Mallett et al., 2017). Furthermore, the current study examined these associations among individuals who reported at least one alcohol-related consequence; thus, our finding may not be generalizable to all drinkers. This study's findings reflect the importance of peers before, during, and after a drinking episode that resulted in at least one alcohol-related consequence. The vast majority of drinking events and the negative consequences of drinking occurred in the presence of same-age peers. Furthermore, the majority of the sample reported that their closest friend knew about the event, whereas campus administrators and parents were unlikely to know about the event. However, reactions of students and peers to the events were mild. Students expressed little concern about the consequences they experienced, and best friends were only mildly upset (as perceived by the participant). There was consistency between the participant's own aversiveness ratings and the perceived upset of friends and mothers, but the effect of the experience on future drinking was generally low; nearly half of participants reported that the event had no effect on their subsequent drinking behaviors, and another 41% of participants reported they would drink more carefully but not alter the amount they would drink. Interestingly, 70.8% of the sample had decided in advance to become intoxicated, and 88.4% of the sample reported feeling drunk at the time of the event. However, the decision whether or not to become intoxicated did not influence the number of consequences experienced, but those who felt drunk at the time of event experienced more consequences. Although ample research has highlighted predictors of drinking intention (e.g., health messaging, alcohol expectancies, and drinking refusal self-efficacy; e.g., (Glanton & Wulfert, 2013; Glock & Krolak-Schwerdt, 2013; Kim, Lee, & Macias, 2014) and prospectively linked drinking intentions with actual drinking behaviors in college students (Pedersen, LaBrie, & Hummer, 2009), there is a paucity of research examining the relationship between drinking intentions and alcohol consequences. One possible explanation for this finding is that students intending to become intoxicated may take precautions and/or use protective behaviors to avoid consequences. We found a few significant gender differences in the characteristics of drinking and the drinking setting on the event day and the reactions to the event. Men tended to consume alcohol at a friends' residence and when the event happened, they were also more likely to be with other men and strangers. In sum, the lack of results suggest that in a sample of individuals with at least one alcohol-related consequence, the drinking
opposite-sex friend, acquaintances) than women (M = 2.22, SD = 1.17 and M = 1.86, SD = 1.06, respectively; t(227) = 2.71, p < 0.01). No other significant differences were found. 3.2.3. Comparison of past-month and event day drinking eBAC on the event day was significantly greater than the past-month average eBAC (t(259) = 11.84, p < 0.001), but was not significantly different than the past-month peak eBAC (t(259) = 0.64, p = 0.52). 3.2.4. Reactions to event Participants mainly attributed the event to: just having fun (58.7%), poor judgment (46.1%), carelessness (35.5%), and too intoxicated to think clearly (33.8%). On the extent to which participants thought their own alcohol or behavior was responsible for the event, the average was M = 4.73 (SD = 1.50) on a scale from 1 to 7, roughly equivalent to a response of “mostly”. Feeling personal responsibility for the event was positively associated with event day drinking (r(294) = 0.28, p < 0.001) and event eBAC (r(294) = 0.29, p < 0.001). Participants' average aversiveness rating of the event was 2.75 (SD = 1.43), equivalent to a response of “somewhat,” and aversiveness was positively related to number of negative consequences experienced (r(294) = 0.41, p < 0.001). Most participants (85.0%) indicated that their closest friend knew about their event, 14.7% reported that their mother knew about their event, and 7.6% reported that their father knew about the event. When asked how upset these people were on a scale ranging from 1 (not at all) to 5 (very), closest friend's upset mean score was 1.71 (SD = 1.06), mother's upset mean score was 2.28 (SD = 1.08), and father's upset mean score was 1.81 (SD = 1.08). For those who did not tell either their mother or father about the event, participants were asked how concerned they were about this person finding out about the event. On a scale ranging from 1 to 5, the mean concern of mother and father finding out about the event were 2.42 (SD = 1.42) and 2.50 (SD = 1.50), respectively, equivalent to responses of “somewhat”. Responsibility for the event was positively related to participant concern of both mother and father finding out about the event (r(246) = 0.19, p < 0.01, and r(256) = 0.18, p < 0.01), but not with friend upset (r(246) = − 0.12, p = 0.07), mother upset (r(43) = 0.15 p = 0.32), or father upset (r(21) = 0.21, p = 0.37). Aversiveness was positively related to concern about mother (r(246) = 0.20, p < 0.01) and father (r(256) = 0.24, p < 0.001) finding out, friend upset (r (246) = 0.39, p < 0.001), and mother upset (r(43) = 0.43, p < 0.01), but not father upset (r(21) = 0.04, p = 0.88). Lastly, 13.3% of the sample reported that a campus entity knew about the event. Of those who reported that a campus entity knew about the event, only 7.7% reported having to attend counseling or health education because of it. When asked to indicate how much this experience changed their drinking, 45.9% stated that it had no effect on their drinking, 41.2% stated that “it did not change how much they drank, but they are now careful about how much they drink and what they do when they drink”, 3.7% indicated that they “drink very little or not at all”, and 9.2% of the sample indicated “other”. Last, only one gender difference was found regarding reactions to the event. Although there was no difference in mom knowing about the event between men and women (χ2(1) = 2.88, p = 0.09), mothers of women tended to be more upset about the event than mothers of men (t(41) = −2.07, p = 0.04). 4. Discussion The main aim of this study was to describe randomly-selected alcohol-related negative consequences experienced by first- and secondyear college students at three universities, including the circumstances that preceded and followed these events, and associations between the event characteristics, the consequences, and post-event reactions of the participants and important others. We found that the most commonly 142
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college students. Taken together, the findings of the study suggest that the vast majority of alcohol consumption and alcohol-related consequences occur in the presence of other individuals. Future work could investigate methods to leverage peer relationships in an effort to reduce alcohol-related consequences in the context of existing harm reduction strategies such as interventions and social norms campaigns.
setting and the location of the event is largely the same among men and women. These results highlight two primary and intersecting directions for intervention development. First, the presence of peers during drinking and consequences put them squarely in the position to help others avoid these consequences. These findings point to the potential of bystander training for alcohol harm reduction. Same-age peers represent potential bystanders who can help their peers avoid or prevent consequences, deal with consequences that do occur, and engage in discussions about the consequences (Banyard, Moynihan, & Grossman, 2009; Banyard, Plante, & Moynihan, 2004). Thus, providing students with knowledge about how to intervene at various stages in a drinking event could be an effective strategy to reduce negative alcohol-related consequences in this population. Furthermore, because students' reactions were mild, overall, and that the majority of the sample decided to become intoxicated, providing education about the harms of drinking would also be useful. These findings also have important implications for intervention approaches that intervene shortly after adverse events (i.e., “teachable moments”; (Longabaugh et al., 1995) to stimulate one's engagement in behavior change and possible additional counseling (Carey, Scott-Sheldon, Garey, Elliott, & Carey, 2016).
Role of funding source This research was supported in part by grant numbers R01AA13970 and T32AA007459-32 from the National Institute on Alcohol Abuse and Alcoholism, and T32DA016184 from the National Institute on Drug Abuse. NIAAA and NIDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Contributors MKM analyzed the results of the study, and was the primary contributor to the composition of the manuscript. SRK and NB were the secondary contributors to the composition of the manuscript. NB contributed to the primary design and provided oversight of all aspects of the study.
4.1. Strengths and limitations
Conflict of interest
One strength of the current study is that the initial biweekly assessment of alcohol-related consequences occurred close to the actual event, and the subsequent interview occurred within about two weeks. Prior investigations of drinking events do not typically assess participants soon after the event; for example evaluations of mandated students can occur months after the student violation (Morgan, White, & Mun, 2008). However, it is possible that even in those two weeks' time, participants' interpretations of events changed from their initial recall of the event. EMA methodology may be useful to better understand students' evaluation of negative consequences and their reactions to them, and potentially intervene with students as soon as possible after an adverse event has occurred (Wray, Merrill, & Monti, 2014). Another limitation of the study is that we only sampled those who had a negative consequence, which does not allow us to conduct a complete investigation of the characteristics of drinking events that do and do not lead to consequences. Another limitation is that eBAC estimates are prone to error (Clapp et al., 2009). However, the findings from the eBAC complement the other drinking findings. By the end of the participants' sophomore year, we had selected approximately 80% of those who had reported consequences, and our completion rate for the interviews was excellent. One artifact of our methodology was that participants who had repeated consequences were more likely to be sampled because they were eligible more often, and therefore although the events were sampled randomly, each participant did not have the same likelihood of being selected. Still, there were few differences between those who were selected and those who were not. It is also possible that participants who had consequences and were selected early in college had different experiences than those who were selected later; we did not investigate time of the consequence as a factor. Furthermore, even though we intentionally oversampled more serious consequences, we found in this sample that the consequences we thought were more serious (fights, injuries) were not perceived as such by participants (Barnett et al., 2014) which should reduce concern about the oversampling affecting our findings. Our sample included only first- and second-year college students from three New England colleges and the sample was primarily White, so our findings may not generalize to other settings and populations.
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