- Email: [email protected]
Reported Alcohol and Tobacco Use and Screening Among College Women
RESEARCH 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56
Reported Alcohol and Tobacco Use and Screening Among College Women Kimberly Angelini, Melissa Sutherland, and Heidi Collins Fantasia
Correspondence Kimberly Angelini, WHNP-BC, Boston College, William F. Connell School of Nursing, 140 Commonwealth Ave., Chestnut Hill, MA 02467. [email protected] Keywords alcohol college health college women prevention screening tobacco
Q16
ABSTRACT Objective: To describe the reports of young women in their senior college years related to alcohol and tobacco use and to describe their health screening experiences in college health centers. Design: A secondary analysis of data collected as part of a cross-sectional study of college women. Setting: For the original study, women were recruited from two accredited 4-year universities in the Northeastern United States. The first was a private university, and the second was a public university; both had on-campus health centers. Participants: The participants were 615 female undergraduate students enrolled in their senior year of college. Methods: A Web-based survey was sent to approximately 1,200 women at each university. Women were asked about their alcohol and tobacco use and about screening experiences in college health centers. The mean response rate was 25.8%. Results: Nearly 90% (n ¼ 550) of the women reported drinking alcohol in the last 3 months, and of those, more than two thirds (n ¼ 370) met the Centers for Disease Control and Prevention definition of hazardous drinking. However, only 21.5% (n ¼ 56) reported being screened for alcohol use. Similarly, only 19.7% (n ¼ 52) reported being screened for tobacco use. Conclusion: College health centers are ideally positioned to screen and provide interventions for young women who are at high risk for alcohol misuse and tobacco use. Despite prevalence of use and importance of screening, reported screening is low. Future research is needed to understand barriers to screening and implement recommendations for college health centers.
JOGNN,
-, -–-;
2017. http://dx.doi.org/10.1016/j.jogn.2016.12.004 Accepted December 2016
Kimberly Angelini, WHNP-BC, is a doctoral student in the William F. Connell School of Nursing, Boston College, Chestnut Hill, MA. Melissa A. Sutherland, PhD, FNP-BC, is an associate professor in the William F. Connell School of Nursing, Boston College, Chestnut Hill, MA. Heidi Collins Fantasia, PhD, RN, WHNP-BC, is an assistant professor in the Lowell College of Health Sciences, School of Nursing, University of Massachusetts, Lowell, MA.
A
lcohol and tobacco use continue to be significant public health issues, particularly among college-age students (Centers for Disease Control and Prevention [CDC], 2012; Rigotti, Lee, & Wechsler, 2000). College marks a time of independence, self-discovery, and new opportunities, as well as increased access to alcohol and tobacco products. In combination with developing sexual relationships, use of alcohol has consequences on school performance, sexually transmitted infections, poor decision making, and unplanned pregnancies in college women (CDC, 2016b). Despite interventions and attempts to target alcohol misuse and tobacco use on campuses, rates continue to be high and present a burden to the health of college women.
Alcohol Use The authors report no conflict of interest or relevant financial relationships.
http://jognn.org
An estimated 60% of college students drink alcohol, and 66% engage in heavy or binge drinking, defined as the consumption of four or
more alcoholic beverages for women and five or more for men in a 2-hour time frame (National Institute of Alcohol Abuse and Alcoholism, 2015). The greatest rates of binge drinking are reported among individuals between the ages of 18 and 34 years (CDC, 2012). College students are more likely to engage in heavy drinking than their peers who do not attend college (Grucza, Norberg, & Beirut, 2009). Researchers who conducted the American College Health Association (ACHA) national survey of 93,034 college students indicated that 64% of female students reported consumption of alcohol in the last 30 days. Additionally, 26.4% reported having five or more drinks in a single sitting one to five times in the preceding 2 weeks (ACHA, 2015). Alcohol misuse has been linked to significant negative health consequences including motor vehicle accidents, trauma, physical and sexual assault, unintended pregnancy, sexually transmitted infections, sexual dysfunction, hypertension, stroke, liver disease, and neurologic damage
ª 2017 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
1
57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112
RESEARCH
113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168
Reported Alcohol and Tobacco Use
Hazardous drinking is defined as the consumption of three or more alcoholic beverages per day for women. The use of screening and counseling has been shown to decrease drinking rates.
(National Institute of Alcohol Abuse and Alcoholism, 2012). One objective of Healthy People 2020 is to reduce the percentage of college students who engage in binge drinking (Hingson & White, 2014; U.S. Department of Health and Human Services, 2010).
Tobacco Use Tobacco use is the largest preventable cause of disease and mortality in the United States. Nearly all tobacco use begins in youth and young adulthood, and young adults between 18 and 25 years of age are prime targets for advertisers and marketers. College marks the initiation of smoking habits for many young adults, with almost 40% of college students reporting their first use of a tobacco product in college (Rigotti et al., 2000). According to the Surgeon General’s 2012 report, 24.8% of fulltime college students reported they were current smokers in 2010 (U.S. Department of Health and Human Services, 2012). Researchers who conducted the ACHA national survey found that 8.8% of women reported tobacco use in the last 30 days (ACHA, 2015), and college women have an overall smoking rate of approximately 17.9% (American Lung Association, 2011). Many colleges have committed to be 100% tobacco free, and as of January 2016, 1,475 campuses were smoke free (Tobacco Free College Campus Initiative, 2016). Despite these statistics, many college students do not identify themselves as smokers; rather, they identify themselves as social smokers. Social smokers are those individuals who do not answer in the affirmative to screening questions about tobacco use because they use tobacco only on the weekends or when drinking with a group (Levinson et al., 2007). This distinction may be problematic when screening and determining the need for intervention and counseling.
Alcohol and Tobacco Screening The U.S. Preventive Services Task Force (USPSTF) recommends that all young adults be screened for alcohol use (2015a) and tobacco use (2015b) and that cessation interventions be offered. Risky or hazardous drinking, as defined
2
by the CDC for women, is the consumption of three or more alcoholic beverages in 1 day. According to the CDC, screening and counseling for alcohol use can decrease drinking by 25% (CDC, 2014). The aim of the CDC screening and brief intervention initiative is to encourage and support providers to screen at every setting and offer brief intervention strategies (CDC, 2016a). Despite CDC recommendations, screening rates are low, with only 24.7% of U.S. adults selfreporting being screened for alcohol use (Denny et al., 2016). Similarly, screening rates in college health centers are low and inconsistent across institutions. Lenk, Erickson, Winters, Nelson, & Toomey (2012) reported that most colleges have some sort of screening procedure in place but that these are typically used only after alcohol-related incidents, such as for students who have been caught at an oncampus party or event. These researchers also found that fewer than 55% of campus health centers reported screening for alcohol use at regular health center visits. In a randomized statestratified national sample of U.S. colleges with health centers, only 32% reported routine screening of alcohol use at campus health center visits, and only 11.7% used standardized screening instruments (Foote, Wilkens, & Vavagiakis, 2004). These findings suggest that providers at most campus health centers are not routinely screening or using recommended screening tools, such as the Alcohol Use Disorders Identification Test (AUDIT) or CAGE (Thomas, Babor, Higgins-Biddle, Saunders, & Monteiro, 2001; Ewing, 1984). This is in contrast to the ACHA’s position statement on tobacco use on college campuses (ACHA, 2011) and the health goals of the USPSTF’s Healthy People 2020 initia- Q1 tive, which recommend a reduction in the rates of tobacco use to 12% by 2020 through multiple methods, including screening and intervention. College health centers are often the main health resource for student health care needs (Keeling, 2001). In a study of more than 3,000 college students, researchers found that women, smokers, and fourth-year students were more likely to visit college health centers compared with other students (Sutfin et al., 2012). In a follow-up study, researchers surveyed 71 college health clinical directors from 14 Southeastern U.S. states. Fifty-five percent of the college health clinics reported screening for tobacco use at every visit, and 80% reported offering counseling interventions (Sutfin, Swords, Song, Reboussin, Helme, Klein, & Wolfson, 2015). Reported
JOGNN, -, -–-; 2017. http://dx.doi.org/10.1016/j.jogn.2016.12.004
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
http://jognn.org
169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224
RESEARCH
Angelini, K., Sutherland, M., and Fantasia, H. C.
225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280
Q2
barriers to screening were lack of time, presenting issue for problem rather than prevention, access to pharmacotherapy, and student’s selfidentification as a smoker, because many “social smokers” do not self-identify as tobacco users (Sutfin et al., 2015). Despite limited research on the health risks of social smoking, data on secondhand smoke and light smoking suggest that continued intermittent smoking carries health risks (Schane, Glantz, & Ling, 2009). Because of the prevalence and health consequences of alcohol misuse and tobacco use in the college population, screening and early intervention are a priority. The purpose of our secondary analysis was to document college women’s reports of alcohol and tobacco use during their senior year of college and describe their screening experiences in college health centers.
Methods We used data collected as part of a crosssectional study of senior college women for this secondary analysis. The original study recruited senior college women from two accredited 4-year universities located in the Northeast and assessed violence and violence screening among the sample (Sutherland, Fantasia, & Hutchinson, 2016). University 1 was a private university with about 9,000 undergraduates, and University 2 was a public university with approximately 9,800 undergraduates. Both institutions had on-campus health centers. The participants were female college undergraduate students in their final year of college. Institutional review board approval was received from the participating institutions.
Sample and Procedures We evaluated data on health screenings, specifically alcohol and tobacco. Data were collected in the spring semester of 2014 via a selfadministered, Web-based survey. Qualtrics, a Web-based platform, was used to create and distribute the surveys, and responses were anonymous. Students’ responses were not linked to their names, e-mail, or IP addresses. The survey invitation was sent to 1,215 senior college women at University 1 and 1,209 senior college women at University 2. Each university provided the investigators with student e-mail addresses. Response rates were 36.2% and 15.5%, respectively. The final sample consisted of 615 senior
281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336
Nearly 90% of college women reported drinking alcohol in the last 3 months, and more than two thirds met the definition for risky or hazardous drinking. college women (University 1, n ¼ 441; University 2, n ¼ 187).
Measures The survey consisted of 33 questions divided into four sections. Section 1 included questions about demographic characteristics of the sample. Sections 2 and 3 included questions focused on intimate partner and sexual violence experiences. Section 4 included questions about students’ reports of screening (violence, alcohol, tobacco, blood pressure) at college health services. Tobacco and alcohol use. Three items measured tobacco use. Participants were asked whether they used tobacco, what products they used, and how often. Alcohol use was measured using three items: if participants drank, how often, and how many drinks they had in a sitting. Participants were asked specifically about how often they drank beverages containing alcohol and how many drinks containing alcohol they had on a typical day when they drank. The CDC’s definition for risky or hazardous drinking, defined as consumption of three or more alcoholic beverages in 1 day, was used to determine risk/hazardous drinking among participants (CDC, 2014). Screenings at college health centers. Participants were asked about their screening experiences during their last visit to the college health center. Specifically, they were asked whether a health care provider took their blood pressure, performed height and weight measurements, and asked about tobacco or alcohol use—for example, At your last visit to college health services, did any medical person ask about your alcohol use?
Analysis Survey data were downloaded from the Qualtrics system into an SPSS version 20 file. Data were previously analyzed for differences in demographic characteristics (Sutherland et al., 2016) for each site independently and then combined. Descriptive statistics were used to analyze the data. Significance was set at p # .05.
Results The mean age of participants was 21.57 years (standard deviation ¼ 0.95). Almost
JOGNN 2017; Vol. -, Issue -
3
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
RESEARCH
337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392
Reported Alcohol and Tobacco Use
Despite high levels of at-risk drinkers in this study, most were not asked about alcohol use during health care encounters. 97% (n ¼ 595) of the college women were fulltime students, and 72.2% (n ¼ 442) lived on campus. A full description of sample characteristics has been previously published (Sutherland et al., 2016).
Alcohol Use and Reported Screening Of the 615 participants, 89.9% (n ¼ 550) reported drinking alcohol in the preceding 3 months. Of those participants who reported alcohol use, 40.8% (n ¼ 223) reported that they had three or four drinks, and 22.2% (n ¼ 121) reported that they had five or six drinks at one time. More than two thirds (n ¼ 370) of the partipants met the CDC’s definition for risky or hazardous drinking, defined as the consumption of three or more alcoholic beverages in 1 day. Participants from University 1 reported greater rates of alcohol use and risky/hazardous drinking compared with participants from University 2 (see Table 1).
Q3 Q4
4
Discussion In our sample, fewer participants reported tobacco risk behaviors compared with those who reported alcohol risk behaviors. Fewer than 5% of the participants reported using tobacco in the past 3 months, whereas almost 90% reported using alcohol during this same time. In general, national and state rates of tobacco use are declining. In the state where our study was conducted, the last available data from 2013 indicated that 11% of high school students reported current cigarette use (Massachusetts Department of Public Health, 2014). The low rates reported by participants in our study may be a reflection of the continued decline in cigarette use among youth in the United States. Additionally, University 1 does not have a specific policy that bans tobacco on campus. In contrast, University 2 is a tobaccofree campus and with an active tobacco-free campaign. It is unclear whether this had an effect on self-reported tobacco use. Furthermore, participants who smoked tobacco very infrequently may not have considered their tobacco use significant enough to report (e.g., social smokers).
Tobacco Use and Reported Screening
Compared with previous studies, the tobacco screening rates among our sample were low. Sutfin et al. (2012) found that screening rates for tobacco use varied from 48% to 75% in college health centers. Tobacco use is a social health risk behavior, and it is unclear why screening rates at college health services were so low (less than 20%) in our sample. From a clinical perspective, it is possible that risk screening occurs only during new patient intake, annually at visits for a complete physical examination, or at yearly gynecologic examinations. Another possible explanation may relate to the type/focus of the college health visit. Students presenting for episodic or problem-based visits such as injuries, illnesses, immunizations, or mental health care may not receive routine health prevention screenings.
Of the 615 participants, 4.6% (n ¼ 28) reported using tobacco products in the last 3 months. Of those who reported use, 51.9% (n ¼ 14) reported use less than once per month, and 25.9% (n ¼ 7) reported daily use. These values might not take into account the number of participants who smoked socially and did not selfidentify as a smoker. Of the 264 participants who reported a recent visit to college health services, only 19.7% (n ¼ 52) reported that they were screened for tobacco use at this last health visit.
The screening rate for alcohol use among this sample was also low (21.5%). This rate is similar to national reports of alcohol screening (24.5%; Denny et al., 2016) but is significantly lower compared with previous rates of 54% and 32% specific to college health centers (Sutfin et al., 2012; Foote et al., 2004). Of the participants who reported visiting campus health services within the past 3 months, only 21.5% were screened for alcohol use, yet nearly 90% reported that they used alcohol during this time, and more
Approximately 53% (n ¼ 264) of the participants reported that they visited college health services in the past 3 months. At their most recent visit to college health services, only 21.5% (n ¼ 56) reported that they were screened for alcohol use. Furthermore, of the 370 participants who met the definition for risky or hazardous drinking, 186 had visited college health centers since the start of the school year, and during their visits, only 20% (n ¼ 39) were asked about their alcohol use; 70% (n ¼ 130) of these participants were not asked, and 10% (n ¼ 17) did not recall (see Table 2).
JOGNN, -, -–-; 2017. http://dx.doi.org/10.1016/j.jogn.2016.12.004
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
http://jognn.org
393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448
RESEARCH
Angelini, K., Sutherland, M., and Fantasia, H. C.
449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504
505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560
Table 1: Self-Reported Alcohol and Tobacco Use Among Senior Year College Women Total Q11
University 1
University 2
n
%
n
%
n
%
Yes
550
89.9
413
95.2
137
77.0
No
62
10.1
21
4.8
41
23.0
1 or 2
176
32.2
96
23.4
80
58.8
3 or 4
223
40.8
175
42.7
48
35.3
5 or 6
121
22.2
115
28.0
6
4.4
24
4.4
22
5.4
2
1.5
2
0.4
2
0.5
0
0
64
11.6
28
6.8
36
26.3
2 to 4 times a month
172
31.3
107
25.9
65
47.4
2 to 3 times a week
279
50.7
246
59.6
33
24.1
35
6.4
32
7.7
3
2.2
Screening Question Do you drink alcoholic beverages (n ¼ 612)
*
If yes, how many drinks containing alcohol do you have on a typical day when you drink? (n ¼ 550)*
7, 8, or 9 10 or more If yes, how often do you have a drink containing alcohol? (n ¼ 550)* Monthly or less
4 or more times a week Do you use tobacco products? (n ¼ 613) Yes
28
4.6
18
4.1
10
5.6
No
585
95.4
417
95.9
168
94.4
26
4.2
What types of tobacco products used? (n ¼ 28) Cigarettes
17
9
Cigars
1
0.2
—
—
Water pipe
1
0.2
—
—
Chew/smokeless tobacco
1
0.2
—
—
14
51.9
12
2
2 to 3 times a month
3
11.1
—
—
Once a week
2
7.4
—
—
2 to 3 times a week
1
3.7
—
—
Daily
7
25.9
—
—
Q12
How often do you use tobacco products? (n ¼ 28) Less than once a month
*
Significant at p # .001. Column percentages.
Q13
a
than 60% met the criteria for risky or hazardous drinking. Although the mean age of the participants in this sample was 21.57 years, and therefore older than the legal U.S. drinking age, the rate of high-risk drinking remains a cause for concern in this population. Excessive alcohol use is related to unintended injuries, unplanned
pregnancies, and other health issues (National Institute Alcohol Abuse and Alcoholism, 2012). Screening and providing interventions for alcohol misuse are the first steps to prevent many negative health consequences and are essential parts of prevention strategies in the college health setting.
JOGNN 2017; Vol. -, Issue -
5
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
RESEARCH
561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616
Reported Alcohol and Tobacco Use
Table 2: Screening of Senior College Women at College Health Centers (n [ 264) Yes
Q14
No
Do Not Remember
Screening Question
n
%
n
%
n
%
At your last visit to college health did
52
19.9
186
71.3
23
8.8
56
21.5
184
70.8
20
7.7
193
73.4
60
22.8
10
3.8
Measure your height? (n ¼ 259)
84
32.4
163
62.9
12
4.6
Assess your weight? (n ¼ 262)
104
39.7
145
55.3
13
5.0
Take your temperature? (n ¼ 263)
193
73.4
61
23.2
9
3.4
health care professional Ask about your alcohol use? (n ¼ 260) Take your blood pressure? (n ¼ 263)
Limitations
Clinical Implications
There are several limitations to consider in our analysis. The homogeneous geographic location of the sites limits external validity to evaluate screening for alcohol and tobacco use among all college women at various health settings. Future work is needed to examine more diverse populations. Also, as a secondary data analysis, our study was limited to the primary study of senior college women. Although rates of alcohol and tobacco use are known to be greater in men, health care use by men is lower. Future studies examining female and male students should be considered. Finally, because data were collected from the students’ perceptions, issues of recall bias must be considered.
Screening and assessment of health issues among the college population need to match the risk behaviors of this population. Despite high levels of at-risk drinkers in our study (nearly 67% of the participants were considered risky/ hazardous drinkers), the vast majority (70%) were not asked about alcohol use at recent visits to their college health centers. Meanwhile, researchers from the ACHA found that only 3% of students reported having high blood pressure (ACHA, 2015), yet blood pressure is measured at almost every visit. Screening for tobacco and alcohol misuse among a high-risk population is an opportunity to address health prevention and promotion. Assessment of developmentally
Table 3: Alcohol Screening Tools for Primary Care Number of Tool
Validated in
Questions
AUDIT
10
Scoring Questions 1–8 have four multiple choice answers, Questions 9–10 have three answers Total score of >8 is considered
Sample Question Have you or someone else been
3
All questions have four multiple choice answers In women, a score of 3 or more is considered positive
X
injured as a result of your drinking? a) No b) Yes, but not in the last year c) Yes, during the last year
hazardous drinking AUDIT-C
College Students
How often do you have a drink
X
containing alcohol? a) Never
Q15
b) Monthly or less 2–4 times a month c) 2–3 times a week d) 4 or more times a week
CAGE
4
Scored yes ¼ 1, no ¼ 0 >2 is clinically significant
Have you ever had a drink first thing in
X
the morning to steady your nerves or to get rid of a hangover?
Note. AUDIT ¼ Alcohol Use Disorders Identification Test; AUDIT-C ¼ Alcohol Use Disorders Identification Test-Consumption.
6
JOGNN, -, -–-; 2017. http://dx.doi.org/10.1016/j.jogn.2016.12.004
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
http://jognn.org
617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672
RESEARCH
Angelini, K., Sutherland, M., and Fantasia, H. C.
673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728
specific risks and risk behaviors must be considered to ensure optimal health of the population.
Q5
The Agency for Healthcare Research and Quality (2012) recommends the “5 A’s” (Ask, Advise, Assess, Assist, Arrange) for clinical interactions. The recommendation is to ask patients at every visit about their substance use. By asking students about tobacco use at every visit and advising them on cessation methods, clinicians provide opportunities for students to disclose and to receive counseling. Alcohol screening tools recommended by the USPSTF for use in primary care settings include the AUDIT (Thomas et al., 2001), the abbreviated AUDIT-Consumption (Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998), and the single-question screen to identify heavy and binge drinking (USPSTF, 2015a). The AUDIT (World Health Organization, 2016) and the AUDIT-Consumption (Frank, DeBenedetti, Volk, Williams, Kivlahan, & Bradley, 2008) have been validated to have high sensitivity and specificity in college populations and can be provideradministered or self-administered (Kokotailo et al., 2004; see Table 3). Another widely used tool, the CAGE tool (Ewing, 1984), has been used across settings but was not found to detect the spectrum of drinking problems present in the college population (Larimer & Cronce, 2002). Barriers to screening include lack of time, lack of specialty staff and resources, defensiveness of students, unfamiliarity with screening tools, and not enough training in management of and treatment for students with positive results for alcohol misuse (Barry et al., 2004; Van Hook et al., 2007). Identification of these barriers within institutional health centers can help to promote optimal screening and counseling for members of this at-risk population. Additionally, providers in college health centers often have limited time to see students and may be caring for students with complex issues. Adding more screening questions to an already busy schedule can present a challenge for some providers. Routine annual screenings for all students might be a potential solution in the identification of risk behaviors.
729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775 776 777 778 779 780 781 782 783 784
for alcohol and tobacco use, health care pro- Q6 viders must work to ensure that screening and interventions are readily available to every student and at every health center visit. Targeting barriers and familiarizing clinicians with the recommended tools would better address this public health issue. Further research is needed to assess tools and barriers to screening from the perspectives of college health providers.
Acknowledgment Supported by a research enhancement grant from Boston College.
REFERENCES Agency for Healthcare Research and Quality. (2012). Five major steps to intervention (the “5A’s”). Retrieved from http://www.ahrq.gov/ professionals/clinicians-providers/guidelines-recommendations/ tobacco/5steps.html American College Health Association. (2011). Position statement on tobacco on college and university campuses. Retrieved from http://www.acha.org/documents/resources/guidelines/ACHA_ Position_Statement_on_Tobacco_Nov2011.pdf American College Health Association. (2015). American College Health Association–National College Health Assessment II: Reference group executive summary spring 2015. Retrieved from http://www.acha-ncha.org/docs/NCHA-II_WEB_SPRING_2 015_REFERENCE_GROUP_EXECUTIVE_SUMMARY.pdf American Lung Association. (2011). Trends in tobacco use. Retrieved from http://www.lung.org/assets/documents/research/tobaccotrend-report.pdf Barry, K. L., Blow, F. C., Willenbring, M., McCormick, R., Brockmann, L. M., & Visnic, S. (2004). Use of alcohol screening and brief interventions in primary care settings: Implementation and barriers. Substance Abuse, 25(1), 27–36. http://dx.doi.org/10. 1300/J465v25n01_05 Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789–1795. Centers for Disease Control and Prevention. (2012). Vital signs: Binge drinking prevalence, frequency, and intensity among adults— United States, 2010. Morbidity and Mortality Weekly Report, 61(1), 14–19. Centers for Disease Control and Prevention. (2014). Alcohol screening and counseling: An effective but underused health service. CDC Vitalsigns. Retrieved from http://www.cdc.gov/vitalsigns/ alcohol-screening-counseling/ Centers for Disease Control and Prevention. (2015). Current cigarette smoking among adults—United States, 2005–2014. Morbidity and Mortality Weekly Report, 64(44), 1233–1240.
Q7
Centers for Disease Control and Prevention. (2016a). CDC’s screening and brief intervention initiative. Retrieved from http://www.cdc.
Conclusions
gov/ncbddd/fasd/alcohol-screening.html
We add the findings of our study to the current literature focused on health screenings in college health centers and illustrate a missed opportunity in alcohol and tobacco screening among college women. Because this population is at great risk
Centers for Disease Control and Prevention. (2016b). Fact sheets— Excessive alcohol use and risks to women’s health. Retrieved from http://www.cdc.gov/alcohol/fact-sheets/womens-health.htm Denny, C. H., Hungerford, D. W., McKnight-Eily, L. R., Green, P. P., Dang, E. P., Cannon, M. J., et al.Sniezek, J. E. (2016). Selfreported prevalence of alcohol screening among U.S. adults.
JOGNN 2017; Vol. -, Issue -
7
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
RESEARCH
Reported Alcohol and Tobacco Use
785
American Journal of Preventive Medicine, 50(3), 380–383.
786
http://dx.doi.org/10.1016/j.amepre.2015.09.016
787
839
tobacco use by student health providers on college campuses.
Journal of American Medical Association, 252(14), 1905–1907.
Journal of American College Health, 60(1), 66–73. http://dx.doi.
Foote, J., Wilkens, C., & Vavagiakis, P. (2004). A national survey of
789
alcohol screening and referral in college health centers. Journal
790
of American College Health, 52(4), 149–157.
792
838
& Wolfson, M. (2012). Screening and brief intervention for
Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire.
788
791
Sutfin, E. L., McNamara, R. S., Blocker, J. N., Ip, E. H., O’Brien, M. C.,
840 841
org/10.1080/07448481.2011.572325 Sutfin, E. L., Swords, D. C., Song, E., Reboussin, B. A., Helme, D.,
842
Klein, E., & Wolfson, M. (2015). Screening and counseling
843
Frank, D., DeBenedetti, A. F., Volk, R. J., Williams, E. C., Kivlahan, D.
for tobacco use in student health clinics: Reports of health
844
R., & Bradley, K. A. (2008). Effectiveness of the AUDIT-C as a
care providers. American Journal of Health Promotion,
screening test for alcohol misuse in three race/ethnic groups.
30(1),
793
Journal of General Internal Medicine, 23(6), 781–787. http://dx.
794
doi.org/10.1007/s11606-008-0595-0
e41–e49.
845
http://dx.doi.org/10.4278/ajhp.130820-
846
QUAN-436 Sutherland, M. A., Fantasia, H. C., & Hutchinson, M. K. (2016).
847
795
Grucza, R. A., Norberg, K. E., & Bierut, L. J. (2009). Binge drinking among
Screening for intimate partner and sexual violence in college
848
796
youths and young adults in the United States: 1979–2006. Journal
women: Missed opportunities. Women’s Health Issues, 26(2),
849
of the American Academy of Child & Adolescent Psychiatry, 48(7),
217–224. http://dx.doi.org/10.1016/j.whi.2015.07.008
797
692–702. http://dx.doi.org/10.1097/CHI.0b013e3181a2b32f
850
Thomas, F., Babor, J., Higgins-Biddle, C., Saunders, J. B., & Monteiro,
798
Hingson, R., & White, A. (2014). New research findings since the 2007
M. G. (2001). The Alcohol Use Disorders Identification Test
851
799
Surgeon General’s call to action to prevent and reduce under-
(AUDIT), guidelines for use in primary care. Geneva,
852
800
age drinking: A review. Journal of Studies on Alcohol & Drugs,
Switzerland: World Health Organization, Department of Mental
853
801
75(1), 158–169. http://dx.doi.org/10.15288/jsad.2014.75.158
Health and Substance Dependence. Retrieved from http://
854
apps.who.int/iris/bitstream/10665/67205/1/WHO_MSD_MSB_
Keeling, R. P. (2001). The college health opportunity. Journal of
802
1080/07448480109596311
Tobacco Free College Campus Initiative. (2016). Tobacco-free & smoke-
856
free campus policies. Retrieved from http://tobaccofreecampus.
857
org/campus-list-progress
858
804
Kokotailo, P. K., Egan, J., Gangnon, R., Brown, D., Mundt, M., &
805
Fleming, M. (2004). Validity of the alcohol use disorders iden-
806
tification test in college students. Alcoholism: Clinical and
U.S. Department of Health and Human Services. (2005). Screening for
Experimental Research, 28(6), 914–920. http://dx.doi.org/10.
alcohol use and alcohol-related problems. Alcohol Alert, 65.
807
855
01.6a.pdf
American College Health, 49(6), 249–252. http://dx.doi.org/10.
803
Q9
Retrieved from http://www.niaaa.nih.gov
1097/01.ALC.0000128239.87611.F5
859 860
808
Larimer, M. E., & Cronce, J. M. (2002). Identification, prevention and
U.S. Department of Health and Human Services. (2010). Healthy
861
809
treatment: A review of individual-focused strategies to reduce
people 2020. Retrieved from https://www.healthypeople.gov/2
862
810
problematic alcohol consumption by college students. Journal
020/leading-health-indicators/2020-LHI-Topics
863
811
of Studies on Alcohol, Supplement, 14, 148–163. http://dx.doi.
U.S. Department of Health and Human Services. (2012). Preventing tobacco use among youth and young adults: A report of
org/10.15288/jsas.2002.s14.148
812
the
Lenk, K. M., Erickson, D. J., Winters, K. C., Nelson, T. F., & Toomey, T. L.
Surgeon
General.
Retrieved
from
http://www.
864 865
813
(2012). Screening services for alcohol misuse and abuse at four-
surgeongeneral.gov/library/reports/preventing-youth-tobacco-
866
814
year colleges in the US. Journal of Substance Abuse Treatment,
use/full-report.pdf
867
815
43(3), 352–358. http://dx.doi.org/10.1016/j.jsat.2012.01. 001
U.S. Preventive Services Task Force. (2014). Final recommendation
868
statement: Intimate partner violence and abuse of elderly and
869
Levinson, A. H., Campo, S., Gascoigne, J., Jolly, O., Zakharyan, A., & Tran,
816 817 818
Z. V. (2007). Smoking, but not smokers: Identity among college
vulnerable adults: Screening. Retrieved from http://www. Q10
students who smoke cigarettes. Nicotine & Tobacco Research,
uspreventiveservicestaskforce.org/Page/Document/Recommen
9(8), 845–852. http://dx.doi.org/10.1080/14622200701484987
dationStatementFinal/intimate-partner-violence-and-abuse-of-
871
elderly-and-vulnerable-adults-screening
872
819
Massachusetts Department of Public Health. (2014). Health and risk
820
behaviors of Massachusetts youth—2013. Retrieved from http://
821 822
870
U.S. Preventive Services Task Force. (2015a). Alcohol misuse:
873
www.doe.mass.edu/cnp/hprograms/yrbs/2013report.pdf
Screening behavioral counseling interventions in primary care.
874
Moyer, V. A. (2013). Screening and behavioral counseling interventions
Retrieved from http://www.uspreventiveservicestaskforce.org/
875
in primary care to reduce alcohol misuse: US Preventive
Page/Document/UpdateSummaryFinal/alcohol-misuse-screening-
823
Services Task Force recommendation statement. Annals of
and-behavioral-counseling-interventions-in-primary-care
876
824
Internal Medicine, 159(3), 210–218. http://dx.doi.org/10.7326/
U.S. Preventive Services Task Force. (2015b). Tobacco smoking
877
cessation in adults, including pregnant women: Behavioral and
878
National Institute of Alcohol Abuse and Alcoholism. (2012). Alcohol’s
pharmacotherapy interventions. Retrieved from http://www.
879
effects on the body. Retrieved from http://www.niaaa.nih.gov/
uspreventiveservicestaskforce.org/Page/Document/Update
alcohol-health/alcohols-effects-body
SummaryFinal/tobacco-use-in-adults-and-pregnant-women-
Q8
825 826 827
0003-4819-159-3-201308060-00652
828
National Institute of Alcohol Abuse and Alcoholism. (2015). College
829
drinking. Retrieved from http://pubs.niaaa.nih.gov/publications/
830
CollegeFactSheet/CollegeFactSheet.pdf
831 832 833
counseling-and-interventions1?ds¼1&s¼tobacco
880 881
Van Hook, S., Harris, S. K., Brooks, T., Carey, P., Kossack, R., Kulig, J.,
882
Knight, J. R., & New England Partnership for Substance Abuse
883
Rigotti, N. A., Lee, J. E., & Wechsler, H. (2000). US college students’
Research (NEPSAR). (2007). The “Six T’s”: Barriers to screening
884
use of tobacco products: Results of a national survey. Journal of
teens for substance abuse in primary care. Journal of
the American Medical Association, 284(6), 699–705. http://dx.
Adolescent Health, 40(5), 456–461. http://dx.doi.org/10.1016/j.
doi.org/10.1001/jama.284.6.699
jadohealth.2006.12.007
885 886
834
Schane, R. E., Glantz, S. A., & Ling, P. M. (2009). Nondaily and social
World Health Organization. (2016). Screening and brief intervention for
887
835
smoking: An increasingly prevalent pattern. Archives of Internal
alcohol problems in primary care. Retrieved from http://www.
888
836
Medicine, 169(19), 1742–1744.
who.int/substance_abuse/activities/sbi/en
889 890
837
8
JOGNN, -, -–-; 2017. http://dx.doi.org/10.1016/j.jogn.2016.12.004
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
http://jognn.org
Reported Alcohol and Tobacco Use and Screening Among College Women Kimberly Angelini, Melissa Sutherland, and Heidi Collins Fantasia
Correspondence Kimberly Angelini, WHNP-BC, Boston College, William F. Connell School of Nursing, 140 Commonwealth Ave., Chestnut Hill, MA 02467. [email protected] Keywords alcohol college health college women prevention screening tobacco
Q16
ABSTRACT Objective: To describe the reports of young women in their senior college years related to alcohol and tobacco use and to describe their health screening experiences in college health centers. Design: A secondary analysis of data collected as part of a cross-sectional study of college women. Setting: For the original study, women were recruited from two accredited 4-year universities in the Northeastern United States. The first was a private university, and the second was a public university; both had on-campus health centers. Participants: The participants were 615 female undergraduate students enrolled in their senior year of college. Methods: A Web-based survey was sent to approximately 1,200 women at each university. Women were asked about their alcohol and tobacco use and about screening experiences in college health centers. The mean response rate was 25.8%. Results: Nearly 90% (n ¼ 550) of the women reported drinking alcohol in the last 3 months, and of those, more than two thirds (n ¼ 370) met the Centers for Disease Control and Prevention definition of hazardous drinking. However, only 21.5% (n ¼ 56) reported being screened for alcohol use. Similarly, only 19.7% (n ¼ 52) reported being screened for tobacco use. Conclusion: College health centers are ideally positioned to screen and provide interventions for young women who are at high risk for alcohol misuse and tobacco use. Despite prevalence of use and importance of screening, reported screening is low. Future research is needed to understand barriers to screening and implement recommendations for college health centers.
JOGNN,
-, -–-;
2017. http://dx.doi.org/10.1016/j.jogn.2016.12.004 Accepted December 2016
Kimberly Angelini, WHNP-BC, is a doctoral student in the William F. Connell School of Nursing, Boston College, Chestnut Hill, MA. Melissa A. Sutherland, PhD, FNP-BC, is an associate professor in the William F. Connell School of Nursing, Boston College, Chestnut Hill, MA. Heidi Collins Fantasia, PhD, RN, WHNP-BC, is an assistant professor in the Lowell College of Health Sciences, School of Nursing, University of Massachusetts, Lowell, MA.
A
lcohol and tobacco use continue to be significant public health issues, particularly among college-age students (Centers for Disease Control and Prevention [CDC], 2012; Rigotti, Lee, & Wechsler, 2000). College marks a time of independence, self-discovery, and new opportunities, as well as increased access to alcohol and tobacco products. In combination with developing sexual relationships, use of alcohol has consequences on school performance, sexually transmitted infections, poor decision making, and unplanned pregnancies in college women (CDC, 2016b). Despite interventions and attempts to target alcohol misuse and tobacco use on campuses, rates continue to be high and present a burden to the health of college women.
Alcohol Use The authors report no conflict of interest or relevant financial relationships.
http://jognn.org
An estimated 60% of college students drink alcohol, and 66% engage in heavy or binge drinking, defined as the consumption of four or
more alcoholic beverages for women and five or more for men in a 2-hour time frame (National Institute of Alcohol Abuse and Alcoholism, 2015). The greatest rates of binge drinking are reported among individuals between the ages of 18 and 34 years (CDC, 2012). College students are more likely to engage in heavy drinking than their peers who do not attend college (Grucza, Norberg, & Beirut, 2009). Researchers who conducted the American College Health Association (ACHA) national survey of 93,034 college students indicated that 64% of female students reported consumption of alcohol in the last 30 days. Additionally, 26.4% reported having five or more drinks in a single sitting one to five times in the preceding 2 weeks (ACHA, 2015). Alcohol misuse has been linked to significant negative health consequences including motor vehicle accidents, trauma, physical and sexual assault, unintended pregnancy, sexually transmitted infections, sexual dysfunction, hypertension, stroke, liver disease, and neurologic damage
ª 2017 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
1
57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112
RESEARCH
113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168
Reported Alcohol and Tobacco Use
Hazardous drinking is defined as the consumption of three or more alcoholic beverages per day for women. The use of screening and counseling has been shown to decrease drinking rates.
(National Institute of Alcohol Abuse and Alcoholism, 2012). One objective of Healthy People 2020 is to reduce the percentage of college students who engage in binge drinking (Hingson & White, 2014; U.S. Department of Health and Human Services, 2010).
Tobacco Use Tobacco use is the largest preventable cause of disease and mortality in the United States. Nearly all tobacco use begins in youth and young adulthood, and young adults between 18 and 25 years of age are prime targets for advertisers and marketers. College marks the initiation of smoking habits for many young adults, with almost 40% of college students reporting their first use of a tobacco product in college (Rigotti et al., 2000). According to the Surgeon General’s 2012 report, 24.8% of fulltime college students reported they were current smokers in 2010 (U.S. Department of Health and Human Services, 2012). Researchers who conducted the ACHA national survey found that 8.8% of women reported tobacco use in the last 30 days (ACHA, 2015), and college women have an overall smoking rate of approximately 17.9% (American Lung Association, 2011). Many colleges have committed to be 100% tobacco free, and as of January 2016, 1,475 campuses were smoke free (Tobacco Free College Campus Initiative, 2016). Despite these statistics, many college students do not identify themselves as smokers; rather, they identify themselves as social smokers. Social smokers are those individuals who do not answer in the affirmative to screening questions about tobacco use because they use tobacco only on the weekends or when drinking with a group (Levinson et al., 2007). This distinction may be problematic when screening and determining the need for intervention and counseling.
Alcohol and Tobacco Screening The U.S. Preventive Services Task Force (USPSTF) recommends that all young adults be screened for alcohol use (2015a) and tobacco use (2015b) and that cessation interventions be offered. Risky or hazardous drinking, as defined
2
by the CDC for women, is the consumption of three or more alcoholic beverages in 1 day. According to the CDC, screening and counseling for alcohol use can decrease drinking by 25% (CDC, 2014). The aim of the CDC screening and brief intervention initiative is to encourage and support providers to screen at every setting and offer brief intervention strategies (CDC, 2016a). Despite CDC recommendations, screening rates are low, with only 24.7% of U.S. adults selfreporting being screened for alcohol use (Denny et al., 2016). Similarly, screening rates in college health centers are low and inconsistent across institutions. Lenk, Erickson, Winters, Nelson, & Toomey (2012) reported that most colleges have some sort of screening procedure in place but that these are typically used only after alcohol-related incidents, such as for students who have been caught at an oncampus party or event. These researchers also found that fewer than 55% of campus health centers reported screening for alcohol use at regular health center visits. In a randomized statestratified national sample of U.S. colleges with health centers, only 32% reported routine screening of alcohol use at campus health center visits, and only 11.7% used standardized screening instruments (Foote, Wilkens, & Vavagiakis, 2004). These findings suggest that providers at most campus health centers are not routinely screening or using recommended screening tools, such as the Alcohol Use Disorders Identification Test (AUDIT) or CAGE (Thomas, Babor, Higgins-Biddle, Saunders, & Monteiro, 2001; Ewing, 1984). This is in contrast to the ACHA’s position statement on tobacco use on college campuses (ACHA, 2011) and the health goals of the USPSTF’s Healthy People 2020 initia- Q1 tive, which recommend a reduction in the rates of tobacco use to 12% by 2020 through multiple methods, including screening and intervention. College health centers are often the main health resource for student health care needs (Keeling, 2001). In a study of more than 3,000 college students, researchers found that women, smokers, and fourth-year students were more likely to visit college health centers compared with other students (Sutfin et al., 2012). In a follow-up study, researchers surveyed 71 college health clinical directors from 14 Southeastern U.S. states. Fifty-five percent of the college health clinics reported screening for tobacco use at every visit, and 80% reported offering counseling interventions (Sutfin, Swords, Song, Reboussin, Helme, Klein, & Wolfson, 2015). Reported
JOGNN, -, -–-; 2017. http://dx.doi.org/10.1016/j.jogn.2016.12.004
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
http://jognn.org
169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224
RESEARCH
Angelini, K., Sutherland, M., and Fantasia, H. C.
225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280
Q2
barriers to screening were lack of time, presenting issue for problem rather than prevention, access to pharmacotherapy, and student’s selfidentification as a smoker, because many “social smokers” do not self-identify as tobacco users (Sutfin et al., 2015). Despite limited research on the health risks of social smoking, data on secondhand smoke and light smoking suggest that continued intermittent smoking carries health risks (Schane, Glantz, & Ling, 2009). Because of the prevalence and health consequences of alcohol misuse and tobacco use in the college population, screening and early intervention are a priority. The purpose of our secondary analysis was to document college women’s reports of alcohol and tobacco use during their senior year of college and describe their screening experiences in college health centers.
Methods We used data collected as part of a crosssectional study of senior college women for this secondary analysis. The original study recruited senior college women from two accredited 4-year universities located in the Northeast and assessed violence and violence screening among the sample (Sutherland, Fantasia, & Hutchinson, 2016). University 1 was a private university with about 9,000 undergraduates, and University 2 was a public university with approximately 9,800 undergraduates. Both institutions had on-campus health centers. The participants were female college undergraduate students in their final year of college. Institutional review board approval was received from the participating institutions.
Sample and Procedures We evaluated data on health screenings, specifically alcohol and tobacco. Data were collected in the spring semester of 2014 via a selfadministered, Web-based survey. Qualtrics, a Web-based platform, was used to create and distribute the surveys, and responses were anonymous. Students’ responses were not linked to their names, e-mail, or IP addresses. The survey invitation was sent to 1,215 senior college women at University 1 and 1,209 senior college women at University 2. Each university provided the investigators with student e-mail addresses. Response rates were 36.2% and 15.5%, respectively. The final sample consisted of 615 senior
281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336
Nearly 90% of college women reported drinking alcohol in the last 3 months, and more than two thirds met the definition for risky or hazardous drinking. college women (University 1, n ¼ 441; University 2, n ¼ 187).
Measures The survey consisted of 33 questions divided into four sections. Section 1 included questions about demographic characteristics of the sample. Sections 2 and 3 included questions focused on intimate partner and sexual violence experiences. Section 4 included questions about students’ reports of screening (violence, alcohol, tobacco, blood pressure) at college health services. Tobacco and alcohol use. Three items measured tobacco use. Participants were asked whether they used tobacco, what products they used, and how often. Alcohol use was measured using three items: if participants drank, how often, and how many drinks they had in a sitting. Participants were asked specifically about how often they drank beverages containing alcohol and how many drinks containing alcohol they had on a typical day when they drank. The CDC’s definition for risky or hazardous drinking, defined as consumption of three or more alcoholic beverages in 1 day, was used to determine risk/hazardous drinking among participants (CDC, 2014). Screenings at college health centers. Participants were asked about their screening experiences during their last visit to the college health center. Specifically, they were asked whether a health care provider took their blood pressure, performed height and weight measurements, and asked about tobacco or alcohol use—for example, At your last visit to college health services, did any medical person ask about your alcohol use?
Analysis Survey data were downloaded from the Qualtrics system into an SPSS version 20 file. Data were previously analyzed for differences in demographic characteristics (Sutherland et al., 2016) for each site independently and then combined. Descriptive statistics were used to analyze the data. Significance was set at p # .05.
Results The mean age of participants was 21.57 years (standard deviation ¼ 0.95). Almost
JOGNN 2017; Vol. -, Issue -
3
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
RESEARCH
337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392
Reported Alcohol and Tobacco Use
Despite high levels of at-risk drinkers in this study, most were not asked about alcohol use during health care encounters. 97% (n ¼ 595) of the college women were fulltime students, and 72.2% (n ¼ 442) lived on campus. A full description of sample characteristics has been previously published (Sutherland et al., 2016).
Alcohol Use and Reported Screening Of the 615 participants, 89.9% (n ¼ 550) reported drinking alcohol in the preceding 3 months. Of those participants who reported alcohol use, 40.8% (n ¼ 223) reported that they had three or four drinks, and 22.2% (n ¼ 121) reported that they had five or six drinks at one time. More than two thirds (n ¼ 370) of the partipants met the CDC’s definition for risky or hazardous drinking, defined as the consumption of three or more alcoholic beverages in 1 day. Participants from University 1 reported greater rates of alcohol use and risky/hazardous drinking compared with participants from University 2 (see Table 1).
Q3 Q4
4
Discussion In our sample, fewer participants reported tobacco risk behaviors compared with those who reported alcohol risk behaviors. Fewer than 5% of the participants reported using tobacco in the past 3 months, whereas almost 90% reported using alcohol during this same time. In general, national and state rates of tobacco use are declining. In the state where our study was conducted, the last available data from 2013 indicated that 11% of high school students reported current cigarette use (Massachusetts Department of Public Health, 2014). The low rates reported by participants in our study may be a reflection of the continued decline in cigarette use among youth in the United States. Additionally, University 1 does not have a specific policy that bans tobacco on campus. In contrast, University 2 is a tobaccofree campus and with an active tobacco-free campaign. It is unclear whether this had an effect on self-reported tobacco use. Furthermore, participants who smoked tobacco very infrequently may not have considered their tobacco use significant enough to report (e.g., social smokers).
Tobacco Use and Reported Screening
Compared with previous studies, the tobacco screening rates among our sample were low. Sutfin et al. (2012) found that screening rates for tobacco use varied from 48% to 75% in college health centers. Tobacco use is a social health risk behavior, and it is unclear why screening rates at college health services were so low (less than 20%) in our sample. From a clinical perspective, it is possible that risk screening occurs only during new patient intake, annually at visits for a complete physical examination, or at yearly gynecologic examinations. Another possible explanation may relate to the type/focus of the college health visit. Students presenting for episodic or problem-based visits such as injuries, illnesses, immunizations, or mental health care may not receive routine health prevention screenings.
Of the 615 participants, 4.6% (n ¼ 28) reported using tobacco products in the last 3 months. Of those who reported use, 51.9% (n ¼ 14) reported use less than once per month, and 25.9% (n ¼ 7) reported daily use. These values might not take into account the number of participants who smoked socially and did not selfidentify as a smoker. Of the 264 participants who reported a recent visit to college health services, only 19.7% (n ¼ 52) reported that they were screened for tobacco use at this last health visit.
The screening rate for alcohol use among this sample was also low (21.5%). This rate is similar to national reports of alcohol screening (24.5%; Denny et al., 2016) but is significantly lower compared with previous rates of 54% and 32% specific to college health centers (Sutfin et al., 2012; Foote et al., 2004). Of the participants who reported visiting campus health services within the past 3 months, only 21.5% were screened for alcohol use, yet nearly 90% reported that they used alcohol during this time, and more
Approximately 53% (n ¼ 264) of the participants reported that they visited college health services in the past 3 months. At their most recent visit to college health services, only 21.5% (n ¼ 56) reported that they were screened for alcohol use. Furthermore, of the 370 participants who met the definition for risky or hazardous drinking, 186 had visited college health centers since the start of the school year, and during their visits, only 20% (n ¼ 39) were asked about their alcohol use; 70% (n ¼ 130) of these participants were not asked, and 10% (n ¼ 17) did not recall (see Table 2).
JOGNN, -, -–-; 2017. http://dx.doi.org/10.1016/j.jogn.2016.12.004
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
http://jognn.org
393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448
RESEARCH
Angelini, K., Sutherland, M., and Fantasia, H. C.
449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504
505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560
Table 1: Self-Reported Alcohol and Tobacco Use Among Senior Year College Women Total Q11
University 1
University 2
n
%
n
%
n
%
Yes
550
89.9
413
95.2
137
77.0
No
62
10.1
21
4.8
41
23.0
1 or 2
176
32.2
96
23.4
80
58.8
3 or 4
223
40.8
175
42.7
48
35.3
5 or 6
121
22.2
115
28.0
6
4.4
24
4.4
22
5.4
2
1.5
2
0.4
2
0.5
0
0
64
11.6
28
6.8
36
26.3
2 to 4 times a month
172
31.3
107
25.9
65
47.4
2 to 3 times a week
279
50.7
246
59.6
33
24.1
35
6.4
32
7.7
3
2.2
Screening Question Do you drink alcoholic beverages (n ¼ 612)
*
If yes, how many drinks containing alcohol do you have on a typical day when you drink? (n ¼ 550)*
7, 8, or 9 10 or more If yes, how often do you have a drink containing alcohol? (n ¼ 550)* Monthly or less
4 or more times a week Do you use tobacco products? (n ¼ 613) Yes
28
4.6
18
4.1
10
5.6
No
585
95.4
417
95.9
168
94.4
26
4.2
What types of tobacco products used? (n ¼ 28) Cigarettes
17
9
Cigars
1
0.2
—
—
Water pipe
1
0.2
—
—
Chew/smokeless tobacco
1
0.2
—
—
14
51.9
12
2
2 to 3 times a month
3
11.1
—
—
Once a week
2
7.4
—
—
2 to 3 times a week
1
3.7
—
—
Daily
7
25.9
—
—
Q12
How often do you use tobacco products? (n ¼ 28) Less than once a month
*
Significant at p # .001. Column percentages.
Q13
a
than 60% met the criteria for risky or hazardous drinking. Although the mean age of the participants in this sample was 21.57 years, and therefore older than the legal U.S. drinking age, the rate of high-risk drinking remains a cause for concern in this population. Excessive alcohol use is related to unintended injuries, unplanned
pregnancies, and other health issues (National Institute Alcohol Abuse and Alcoholism, 2012). Screening and providing interventions for alcohol misuse are the first steps to prevent many negative health consequences and are essential parts of prevention strategies in the college health setting.
JOGNN 2017; Vol. -, Issue -
5
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
RESEARCH
561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616
Reported Alcohol and Tobacco Use
Table 2: Screening of Senior College Women at College Health Centers (n [ 264) Yes
Q14
No
Do Not Remember
Screening Question
n
%
n
%
n
%
At your last visit to college health did
52
19.9
186
71.3
23
8.8
56
21.5
184
70.8
20
7.7
193
73.4
60
22.8
10
3.8
Measure your height? (n ¼ 259)
84
32.4
163
62.9
12
4.6
Assess your weight? (n ¼ 262)
104
39.7
145
55.3
13
5.0
Take your temperature? (n ¼ 263)
193
73.4
61
23.2
9
3.4
health care professional Ask about your alcohol use? (n ¼ 260) Take your blood pressure? (n ¼ 263)
Limitations
Clinical Implications
There are several limitations to consider in our analysis. The homogeneous geographic location of the sites limits external validity to evaluate screening for alcohol and tobacco use among all college women at various health settings. Future work is needed to examine more diverse populations. Also, as a secondary data analysis, our study was limited to the primary study of senior college women. Although rates of alcohol and tobacco use are known to be greater in men, health care use by men is lower. Future studies examining female and male students should be considered. Finally, because data were collected from the students’ perceptions, issues of recall bias must be considered.
Screening and assessment of health issues among the college population need to match the risk behaviors of this population. Despite high levels of at-risk drinkers in our study (nearly 67% of the participants were considered risky/ hazardous drinkers), the vast majority (70%) were not asked about alcohol use at recent visits to their college health centers. Meanwhile, researchers from the ACHA found that only 3% of students reported having high blood pressure (ACHA, 2015), yet blood pressure is measured at almost every visit. Screening for tobacco and alcohol misuse among a high-risk population is an opportunity to address health prevention and promotion. Assessment of developmentally
Table 3: Alcohol Screening Tools for Primary Care Number of Tool
Validated in
Questions
AUDIT
10
Scoring Questions 1–8 have four multiple choice answers, Questions 9–10 have three answers Total score of >8 is considered
Sample Question Have you or someone else been
3
All questions have four multiple choice answers In women, a score of 3 or more is considered positive
X
injured as a result of your drinking? a) No b) Yes, but not in the last year c) Yes, during the last year
hazardous drinking AUDIT-C
College Students
How often do you have a drink
X
containing alcohol? a) Never
Q15
b) Monthly or less 2–4 times a month c) 2–3 times a week d) 4 or more times a week
CAGE
4
Scored yes ¼ 1, no ¼ 0 >2 is clinically significant
Have you ever had a drink first thing in
X
the morning to steady your nerves or to get rid of a hangover?
Note. AUDIT ¼ Alcohol Use Disorders Identification Test; AUDIT-C ¼ Alcohol Use Disorders Identification Test-Consumption.
6
JOGNN, -, -–-; 2017. http://dx.doi.org/10.1016/j.jogn.2016.12.004
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
http://jognn.org
617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672
RESEARCH
Angelini, K., Sutherland, M., and Fantasia, H. C.
673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728
specific risks and risk behaviors must be considered to ensure optimal health of the population.
Q5
The Agency for Healthcare Research and Quality (2012) recommends the “5 A’s” (Ask, Advise, Assess, Assist, Arrange) for clinical interactions. The recommendation is to ask patients at every visit about their substance use. By asking students about tobacco use at every visit and advising them on cessation methods, clinicians provide opportunities for students to disclose and to receive counseling. Alcohol screening tools recommended by the USPSTF for use in primary care settings include the AUDIT (Thomas et al., 2001), the abbreviated AUDIT-Consumption (Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998), and the single-question screen to identify heavy and binge drinking (USPSTF, 2015a). The AUDIT (World Health Organization, 2016) and the AUDIT-Consumption (Frank, DeBenedetti, Volk, Williams, Kivlahan, & Bradley, 2008) have been validated to have high sensitivity and specificity in college populations and can be provideradministered or self-administered (Kokotailo et al., 2004; see Table 3). Another widely used tool, the CAGE tool (Ewing, 1984), has been used across settings but was not found to detect the spectrum of drinking problems present in the college population (Larimer & Cronce, 2002). Barriers to screening include lack of time, lack of specialty staff and resources, defensiveness of students, unfamiliarity with screening tools, and not enough training in management of and treatment for students with positive results for alcohol misuse (Barry et al., 2004; Van Hook et al., 2007). Identification of these barriers within institutional health centers can help to promote optimal screening and counseling for members of this at-risk population. Additionally, providers in college health centers often have limited time to see students and may be caring for students with complex issues. Adding more screening questions to an already busy schedule can present a challenge for some providers. Routine annual screenings for all students might be a potential solution in the identification of risk behaviors.
729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775 776 777 778 779 780 781 782 783 784
for alcohol and tobacco use, health care pro- Q6 viders must work to ensure that screening and interventions are readily available to every student and at every health center visit. Targeting barriers and familiarizing clinicians with the recommended tools would better address this public health issue. Further research is needed to assess tools and barriers to screening from the perspectives of college health providers.
Acknowledgment Supported by a research enhancement grant from Boston College.
REFERENCES Agency for Healthcare Research and Quality. (2012). Five major steps to intervention (the “5A’s”). Retrieved from http://www.ahrq.gov/ professionals/clinicians-providers/guidelines-recommendations/ tobacco/5steps.html American College Health Association. (2011). Position statement on tobacco on college and university campuses. Retrieved from http://www.acha.org/documents/resources/guidelines/ACHA_ Position_Statement_on_Tobacco_Nov2011.pdf American College Health Association. (2015). American College Health Association–National College Health Assessment II: Reference group executive summary spring 2015. Retrieved from http://www.acha-ncha.org/docs/NCHA-II_WEB_SPRING_2 015_REFERENCE_GROUP_EXECUTIVE_SUMMARY.pdf American Lung Association. (2011). Trends in tobacco use. Retrieved from http://www.lung.org/assets/documents/research/tobaccotrend-report.pdf Barry, K. L., Blow, F. C., Willenbring, M., McCormick, R., Brockmann, L. M., & Visnic, S. (2004). Use of alcohol screening and brief interventions in primary care settings: Implementation and barriers. Substance Abuse, 25(1), 27–36. http://dx.doi.org/10. 1300/J465v25n01_05 Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789–1795. Centers for Disease Control and Prevention. (2012). Vital signs: Binge drinking prevalence, frequency, and intensity among adults— United States, 2010. Morbidity and Mortality Weekly Report, 61(1), 14–19. Centers for Disease Control and Prevention. (2014). Alcohol screening and counseling: An effective but underused health service. CDC Vitalsigns. Retrieved from http://www.cdc.gov/vitalsigns/ alcohol-screening-counseling/ Centers for Disease Control and Prevention. (2015). Current cigarette smoking among adults—United States, 2005–2014. Morbidity and Mortality Weekly Report, 64(44), 1233–1240.
Q7
Centers for Disease Control and Prevention. (2016a). CDC’s screening and brief intervention initiative. Retrieved from http://www.cdc.
Conclusions
gov/ncbddd/fasd/alcohol-screening.html
We add the findings of our study to the current literature focused on health screenings in college health centers and illustrate a missed opportunity in alcohol and tobacco screening among college women. Because this population is at great risk
Centers for Disease Control and Prevention. (2016b). Fact sheets— Excessive alcohol use and risks to women’s health. Retrieved from http://www.cdc.gov/alcohol/fact-sheets/womens-health.htm Denny, C. H., Hungerford, D. W., McKnight-Eily, L. R., Green, P. P., Dang, E. P., Cannon, M. J., et al.Sniezek, J. E. (2016). Selfreported prevalence of alcohol screening among U.S. adults.
JOGNN 2017; Vol. -, Issue -
7
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
RESEARCH
Reported Alcohol and Tobacco Use
785
American Journal of Preventive Medicine, 50(3), 380–383.
786
http://dx.doi.org/10.1016/j.amepre.2015.09.016
787
839
tobacco use by student health providers on college campuses.
Journal of American Medical Association, 252(14), 1905–1907.
Journal of American College Health, 60(1), 66–73. http://dx.doi.
Foote, J., Wilkens, C., & Vavagiakis, P. (2004). A national survey of
789
alcohol screening and referral in college health centers. Journal
790
of American College Health, 52(4), 149–157.
792
838
& Wolfson, M. (2012). Screening and brief intervention for
Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire.
788
791
Sutfin, E. L., McNamara, R. S., Blocker, J. N., Ip, E. H., O’Brien, M. C.,
840 841
org/10.1080/07448481.2011.572325 Sutfin, E. L., Swords, D. C., Song, E., Reboussin, B. A., Helme, D.,
842
Klein, E., & Wolfson, M. (2015). Screening and counseling
843
Frank, D., DeBenedetti, A. F., Volk, R. J., Williams, E. C., Kivlahan, D.
for tobacco use in student health clinics: Reports of health
844
R., & Bradley, K. A. (2008). Effectiveness of the AUDIT-C as a
care providers. American Journal of Health Promotion,
screening test for alcohol misuse in three race/ethnic groups.
30(1),
793
Journal of General Internal Medicine, 23(6), 781–787. http://dx.
794
doi.org/10.1007/s11606-008-0595-0
e41–e49.
845
http://dx.doi.org/10.4278/ajhp.130820-
846
QUAN-436 Sutherland, M. A., Fantasia, H. C., & Hutchinson, M. K. (2016).
847
795
Grucza, R. A., Norberg, K. E., & Bierut, L. J. (2009). Binge drinking among
Screening for intimate partner and sexual violence in college
848
796
youths and young adults in the United States: 1979–2006. Journal
women: Missed opportunities. Women’s Health Issues, 26(2),
849
of the American Academy of Child & Adolescent Psychiatry, 48(7),
217–224. http://dx.doi.org/10.1016/j.whi.2015.07.008
797
692–702. http://dx.doi.org/10.1097/CHI.0b013e3181a2b32f
850
Thomas, F., Babor, J., Higgins-Biddle, C., Saunders, J. B., & Monteiro,
798
Hingson, R., & White, A. (2014). New research findings since the 2007
M. G. (2001). The Alcohol Use Disorders Identification Test
851
799
Surgeon General’s call to action to prevent and reduce under-
(AUDIT), guidelines for use in primary care. Geneva,
852
800
age drinking: A review. Journal of Studies on Alcohol & Drugs,
Switzerland: World Health Organization, Department of Mental
853
801
75(1), 158–169. http://dx.doi.org/10.15288/jsad.2014.75.158
Health and Substance Dependence. Retrieved from http://
854
apps.who.int/iris/bitstream/10665/67205/1/WHO_MSD_MSB_
Keeling, R. P. (2001). The college health opportunity. Journal of
802
1080/07448480109596311
Tobacco Free College Campus Initiative. (2016). Tobacco-free & smoke-
856
free campus policies. Retrieved from http://tobaccofreecampus.
857
org/campus-list-progress
858
804
Kokotailo, P. K., Egan, J., Gangnon, R., Brown, D., Mundt, M., &
805
Fleming, M. (2004). Validity of the alcohol use disorders iden-
806
tification test in college students. Alcoholism: Clinical and
U.S. Department of Health and Human Services. (2005). Screening for
Experimental Research, 28(6), 914–920. http://dx.doi.org/10.
alcohol use and alcohol-related problems. Alcohol Alert, 65.
807
855
01.6a.pdf
American College Health, 49(6), 249–252. http://dx.doi.org/10.
803
Q9
Retrieved from http://www.niaaa.nih.gov
1097/01.ALC.0000128239.87611.F5
859 860
808
Larimer, M. E., & Cronce, J. M. (2002). Identification, prevention and
U.S. Department of Health and Human Services. (2010). Healthy
861
809
treatment: A review of individual-focused strategies to reduce
people 2020. Retrieved from https://www.healthypeople.gov/2
862
810
problematic alcohol consumption by college students. Journal
020/leading-health-indicators/2020-LHI-Topics
863
811
of Studies on Alcohol, Supplement, 14, 148–163. http://dx.doi.
U.S. Department of Health and Human Services. (2012). Preventing tobacco use among youth and young adults: A report of
org/10.15288/jsas.2002.s14.148
812
the
Lenk, K. M., Erickson, D. J., Winters, K. C., Nelson, T. F., & Toomey, T. L.
Surgeon
General.
Retrieved
from
http://www.
864 865
813
(2012). Screening services for alcohol misuse and abuse at four-
surgeongeneral.gov/library/reports/preventing-youth-tobacco-
866
814
year colleges in the US. Journal of Substance Abuse Treatment,
use/full-report.pdf
867
815
43(3), 352–358. http://dx.doi.org/10.1016/j.jsat.2012.01. 001
U.S. Preventive Services Task Force. (2014). Final recommendation
868
statement: Intimate partner violence and abuse of elderly and
869
Levinson, A. H., Campo, S., Gascoigne, J., Jolly, O., Zakharyan, A., & Tran,
816 817 818
Z. V. (2007). Smoking, but not smokers: Identity among college
vulnerable adults: Screening. Retrieved from http://www. Q10
students who smoke cigarettes. Nicotine & Tobacco Research,
uspreventiveservicestaskforce.org/Page/Document/Recommen
9(8), 845–852. http://dx.doi.org/10.1080/14622200701484987
dationStatementFinal/intimate-partner-violence-and-abuse-of-
871
elderly-and-vulnerable-adults-screening
872
819
Massachusetts Department of Public Health. (2014). Health and risk
820
behaviors of Massachusetts youth—2013. Retrieved from http://
821 822
870
U.S. Preventive Services Task Force. (2015a). Alcohol misuse:
873
www.doe.mass.edu/cnp/hprograms/yrbs/2013report.pdf
Screening behavioral counseling interventions in primary care.
874
Moyer, V. A. (2013). Screening and behavioral counseling interventions
Retrieved from http://www.uspreventiveservicestaskforce.org/
875
in primary care to reduce alcohol misuse: US Preventive
Page/Document/UpdateSummaryFinal/alcohol-misuse-screening-
823
Services Task Force recommendation statement. Annals of
and-behavioral-counseling-interventions-in-primary-care
876
824
Internal Medicine, 159(3), 210–218. http://dx.doi.org/10.7326/
U.S. Preventive Services Task Force. (2015b). Tobacco smoking
877
cessation in adults, including pregnant women: Behavioral and
878
National Institute of Alcohol Abuse and Alcoholism. (2012). Alcohol’s
pharmacotherapy interventions. Retrieved from http://www.
879
effects on the body. Retrieved from http://www.niaaa.nih.gov/
uspreventiveservicestaskforce.org/Page/Document/Update
alcohol-health/alcohols-effects-body
SummaryFinal/tobacco-use-in-adults-and-pregnant-women-
Q8
825 826 827
0003-4819-159-3-201308060-00652
828
National Institute of Alcohol Abuse and Alcoholism. (2015). College
829
drinking. Retrieved from http://pubs.niaaa.nih.gov/publications/
830
CollegeFactSheet/CollegeFactSheet.pdf
831 832 833
counseling-and-interventions1?ds¼1&s¼tobacco
880 881
Van Hook, S., Harris, S. K., Brooks, T., Carey, P., Kossack, R., Kulig, J.,
882
Knight, J. R., & New England Partnership for Substance Abuse
883
Rigotti, N. A., Lee, J. E., & Wechsler, H. (2000). US college students’
Research (NEPSAR). (2007). The “Six T’s”: Barriers to screening
884
use of tobacco products: Results of a national survey. Journal of
teens for substance abuse in primary care. Journal of
the American Medical Association, 284(6), 699–705. http://dx.
Adolescent Health, 40(5), 456–461. http://dx.doi.org/10.1016/j.
doi.org/10.1001/jama.284.6.699
jadohealth.2006.12.007
885 886
834
Schane, R. E., Glantz, S. A., & Ling, P. M. (2009). Nondaily and social
World Health Organization. (2016). Screening and brief intervention for
887
835
smoking: An increasingly prevalent pattern. Archives of Internal
alcohol problems in primary care. Retrieved from http://www.
888
836
Medicine, 169(19), 1742–1744.
who.int/substance_abuse/activities/sbi/en
889 890
837
8
JOGNN, -, -–-; 2017. http://dx.doi.org/10.1016/j.jogn.2016.12.004
FLA 5.4.0 DTD JOGN183_proof 3 March 2017 5:35 am ce
http://jognn.org