Alcohol Abuse & College Students: The Alcohol Literacy Challenge s Role in Campus Prevention

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1 Alcohol Abuse & College Students: The Alcohol Literacy Challenge s Role in Campus Prevention Peter DeBenedittis, Ph.D The Problem Dealing with problematic student alcohol use has been a consistent struggle for colleges and universities across the nation. College student drinking has been repeatedly recognized as the primary public health concern impacting students on college campuses. The scope of the problem becomes apparent when looking at drinking behaviors, use patterns and the rates of alcohol-related negative consequences experienced by this population. A recent national report states that 85% of college students surveyed endorsed having tried alcohol, with 40% reporting occasions of binge drinking (five or more drinks in the past two weeks) and 48% indicated that they had been drunk in the past 30 days (Johnston, O Malley, Bachman, & Schulenberg, 2007). Although alcohol use frequently begins prior to college, students typically experience a significant increase in their alcohol use during their first year (Fromme, Corbin & Kruse, 2008). In addition, college students engage in more high-risk drinking than their non-college attending peers (Johnston et al, 2007; Slutske et al., 2004), making college attendance itself a risk factor for problematic alcohol use. College students drinking patterns tend to vary, with use increasing or decreasing in relation to the academic calendar, holidays, and days of the week. Specifically, student drinking tends to be highest during the beginning and end of the academic year, be 4 times as high on the weekends compared to weekdays, and be lowest during exam periods and highest during holidays or special events (Del Boca, Darkes, Greenbaum, & Goldman, 2004; Greenbaum, Del Boca, Darkes, Wang, & Goldman, 2005). The consequences for college students are grave. Alcohol use contributes to over 1,800 of their deaths, almost 700,000 assaults, and 97,000 cases of sexual assault or date rape among college PETER DEBENEDITTIS, PH.D

2 students each year. Of the alcohol-related college student deaths, 470 were due to unintentional injury (e.g. falls, hypothermia, drowning, etc.) and over 1,300 were motor-vehicle crashes (Hingson, Heeren, Winter, & Wechsler, 2005). Yet despite prevention efforts on campuses throughout the country, the rates of negative consequences are not decreasing. Unfortunately, in almost every category there have actually been increases in alcohol-related harms for college students (Hingson, Zha & Weitzman, 2009). Therefore, the need for evidence-based prevention and intervention efforts has never been greater. Efforts Toward a Solution In order to address high-risk alcohol use amongst college students, colleges and universities have implemented a vast array of different prevention and intervention strategies. Yet, even with increased awareness and widespread prevention efforts to address the problem on college campuses nationwide, little change in college students high-risk drinking has been documented (Wechsler et al., 2002). The lack of reduction in alcohol related harms experienced by college students can be attributed to several obvious problems. For example, past campus alcohol programming has usually suffered from a lack of careful evaluation for effectiveness. In addition, research results on effective strategies have not been disseminated adequately, making the selection of appropriate strategies difficult. In response to the prevalence of risky alcohol use and lack of effective response among colleges and universities, the National Advisory Council of the National Institute on Alcohol Abuse and Alcoholism created a task force to review the relevant research literature on alcohol interventions. The primary objective of the task force was to advise college administrators on effective program implementation and evaluation as well as provide recommendations for future research directions. (National Institute on Alcohol Abuse and Alcoholism, 2002) Through their extensive review, the Task Force evaluated the effectiveness of specific strategies in order to make recommendations for their use within this framework. The resulting recommendations were organized into tiers based on the interventions focus on college students and the degree of empirical PETER DEBENEDITTIS, PH.D

3 support. Tier 1 identified strategies had empirical support specifically with college students, while Tier 2 strategies had empirical support for the general population but had yet to be implemented in college settings. Interventions that required further evaluation to establish effectiveness and those that had evidence of ineffectiveness were included in Tier 3 and Tier 4 respectively. Overall, only three strategies met criteria for Tier 1 designation: interventions using cognitive-behavioral skills training, norms clarifications, and motivational enhancements; interventions that serve as brief motivational enhancements; and interventions aimed at challenging alcohol expectancies. (National Institute on Alcohol Abuse and Alcoholism, 2002) The following are examples of interventions that meet these Tier 1 designations. Alcohol Skills Training Program (ASTP) The Alcohol Skills Training Program (Fromme, Marlatt, Baer, & Kivlahan, 1994) utilizes cognitive-behavioral skills training, motivational enhancement, and harm reduction principles in a 6- to 8- week course administered to a group. Brief Alcohol Screening and Intervention for College Students (BASICS) BASICS is a brief motivational enhancement intervention that represents the most cost-effective ASTP modality (Dimeff, Baer, Kivlahan, & Marlatt, 1999). Similar to the lengthier ASTP course, BASICS focuses on education about basic alcohol information (including alcohol expectancies), cognitive-behavioral skills aimed at moderating drinking, and motivational interviewing and harm reduction principles. Challenging Alcohol Expectancies A method described as expectancy challenge is the third strategy listed among those meeting the Task Force s Tier 1 designation (i.e., empirical support specifically with college students; NIAAA, 2002). In addition to their unique content, the other two Tier 1 programs include a component dealing with the topic of alcohol expectancies. The ASTP includes a placebo drinking experience followed by a general discussion of alcohol expectancies. In BASICS, a discussion of the role of positive alcohol expectancies is PETER DEBENEDITTIS, PH.D

4 provided in the context of basic alcohol education. A stand-alone method of expectancy challenge was also found to meet the criteria for Tier 1 status based on the extensive scientific literature validating the importance of alcohol expectancies in understanding alcohol use, as well as several studies that demonstrated the effectiveness of expectancy challenges in reducing alcohol use. The Alcohol Literacy Challenge (ALC) was developed from the expectancy challenge method validated by Darkes and Goldman (1993, 1995) that was the primary source of the NIAAA Tier 1 designation. The ALC is a brief, group intervention that can be used as a stand alone or complementary strategy to ASTP or BASICS. The ALC maintains the motivational enhancement and harm reduction framework inherent in both ASTP and BASICS, but provides an expansion of the expectancy content with the specific focus of teaching students to challenge their own alcohol expectancies. Information in the ALC is presented within a media literacy framework, and as such, is appropriate for use with the student body as a whole because the content is not targeted solely towards highrisk users. Instead, the program is relevant and engaging for students spanning the spectrum of abstainers to heavy and problematic drinkers. Given the substantial underpinnings of expectancy processes and their impact on drinking behavior, the following chapter details the theoretical foundation for expectancy-based intervention. It also discusses in detail important expectancy-based intervention efforts that have preceded and laid the groundwork for the ALC. Alcohol Expectancy Theory PETER DEBENEDITTIS, PH.D

5 Alcohol expectancies refer to beliefs people hold about the anticipated effects of alcohol. These beliefs are formed at a very early age, and exist from the first time an individual is exposed to information about alcohol. This information about alcohol is stored in the brain and nervous system and becomes activated in memory when a person begins thinking about alcohol. For example, when an individual is presented with an alcoholic drink, expectations based on how consuming the drink will affect the individual emerge based on past experience with alcohol use. This past experience can come in many forms including observing friends or family drink, exposure to the media and advertising for alcohol, and prior drinking experience. Beliefs about the effects of alcohol have been identified as a key component in explaining alcohol dependence. Memories related to alcohol use can influence how an individual thinks about alcohol and its effects, and therefore indirectly influences how much an individual consumes and the pattern of drinking that is developed (Cruz & Dunn, 2003; Fromme & Dunn, 1992; Goldman, 1999a; Rather & Goldman, 1994). Research on expectancies and memory processes has described memory as a symbolic, proximity-based network (Rather & Goldman, 1994). Simply put, memories are stored in a network where they are linked closely or distantly to each other based on how related their meanings are and what the history of learning was for the individual. These networks of memories are activated in a predictable manner whenever the individual encounters stimuli that relates to the previously learned memories. PETER DEBENEDITTIS, PH.D

6 There have been two dimensions identified related to alcohol expectancies. The first dimension is in regards to the positive and negative outcomes of alcohol. The second dimension deals with arousal and sedation, or the observed pharmacological effects of alcohol (Goldman, 1999b; Rather & Goldman, 1992; 1994). Research has demonstrated that high-risk drinkers may be more likely to rapidly associate drinking with the positive and arousing effects rather than the negative and sedative effects. In terms of memory networks, the network of expectancy effects in high-risk drinkers is more tightly packed, leading to the fast activation of the positive-arousing beliefs when they are exposed to alcohol. In contrast, the network of expectancy effects is more dispersed in light drinkers, causing them to form expectancy associations with alcohol more slowly than highrisk drinkers, which in turn may inhibit drinking (Rather & Goldman, 1994). Arousal-based expectancies are generally associated with positive views of alcohol use such as Alcohol will make me feel energetic, or Alcohol will make me feel happy. These expectancies also tend to be associated with early onset for alcohol use and the eventual development of high risk drinking patterns. Sedation-based expectancies focus on the sedating effects of alcohol. An individual with these types of expectancies might believe that Alcohol will make me feel depressed, or Alcohol will make me feel tired. Those who possess primarily sedation-based expectancies tend to drink less (or not at all). Research on alcohol expectancies has found that: A person s expectancies exist before a person has a drinking experience (Dunn & Goldman, 1996; Kraus, Smith, & Ratner, 1994) Expectancies can predict the age of drinking initiation (Christiansen, Smith, Roehling, & Goldman, 1989; Stacy, 1997) Expectancies can differentiate light-drinking and heavy-drinking children and adults (Dunn & Earleywine, 2001; Dunn & Goldman, 1998; 2000; Rather & Goldman, 1994; Rather et al., 1992) PETER DEBENEDITTIS, PH.D

7 Expectancies can mediate the influence of antecedent variables (such as family history), or precursors to drinking, on alcohol use (Darkes & Goldman, 1998; Sher, Walitzer, Wood, & Brent, 1991; Stacy, Newcomb, & Bentler, 1991) Regarding heavy-drinking college students, if an individual s expectancies are modified to be consistent with sedation-based expectations, it can result in decreased alcohol consumption over time (Darkes & Goldman, 1993, 1998; Dunn, Lau, & Cruz, 2000; Goldman, 1999b)] Expectancy research most relevant to intervention strategies has focused on changing expectancies in an effort to change alcohol use. These efforts are strategies that the NIAAA Task Force identified for Tier 1 designation due to the empirical support demonstrated with college students. Referred to as an Expectancy Challenge (Darkes & Goldman, 1993, 1998; Dunn, Lau, & Cruz, 2000; Lau-Barraco & Dunn, 2008) this approach involves the use of a simulated-bar environment recreated in a laboratory and consists of multiple sessions. During the sessions, heavy-drinking college students are exposed to information about expectancies and are encouraged to engage in discussions of how true are expectancies of alcohol s chemical effects. During the key session, arousal-based expectancies with regard to alcohol use are challenged. The challenge typically involves an experiential activity in which each participating student is told to expect to receive either an alcoholic or non-alcoholic drink when joining the activity. Students are also given the rule not to speak about what they believe they are drinking. The key is that while students are told to expect a certain type of beverage, they may or may not actually receive the expected drink. In reality, half of the students expecting alcohol unknowingly receive a non-alcoholic drink. Following a period of socialization designed to replicate what might occur in a party or bar-setting, the students are asked to identify who among all individuals (including themselves) actually received an alcoholic drink and who did not. Because of the rules of the challenge, the students are forced to make their predictions solely on behavior they observed during the socialization period. Students PETER DEBENEDITTIS, PH.D

8 expect that those who were the most outgoing and social were among the individuals who received alcohol, and are surprised to find that these are the students who expected alcohol but actually received a non-alcoholic drink. Failure to identify who had been influenced by alcohol at better than chance levels and the realization that the behaviors most often associated with alcohol use (becoming energetic, outgoing, social) are actually a result of expectancies and not alcohol itself disconnects the associations between alcohol use and the expected experiences. The aim is that through this disconnect, students expectancy processes will shift and lead to decreased alcohol use (Lau-Barraco & Dunn, 2008; Goldman, 1999b; Darkes & Goldman, 1993). Darkes & Goldman (1993; 1998) conducted studies using a threesession Expectancy Challenge intervention to validate the effectiveness of this approach and to further establish the casual relationship between alcohol expectancies and consumption. Using moderate to heavy drinking male college students, they were able to demonstrate significant decreases in their positive expectancies and corresponding decreases in drinking at a 2-week follow-up for participants in the intervention group as compared to controls. Using the same Expectancy Challenge protocol, Dunn et al. (2000) were able to replicate the effectiveness of this intervention and model changes in memory processes related to changes in alcohol use. Although women were included in this sample, changes in likely activation patterns and corresponding decreases in drinking were only demonstrated in men. In an attempt to address the limitation of a multi-session format and increase generalizability, Lau-Barraco & Dunn (2008) adapted the Darkes & Goldman (1993, 1998) protocol to a single session intervention with additional content targeted to women. This modified protocol resulted in significant decreases in expectancies and drinking across genders as compared to control subjects. However powerful the bar laboratory-based Expectancy Challenge can be, there are limitations to the original form of the protocol that represents a huge barrier to its utilization in colleges across the country. First, the necessity of a state-of-the-art bar-laboratory makes the administration of the protocol difficult for many institutions. PETER DEBENEDITTIS, PH.D

9 Second, the initial format of the Expectancy Challenge was intended to be held over multiple sessions and heavy drinking students can be reluctant to start an intervention program that requires an extended commitment. Lastly, the early form of the protocol was also designed for heavy-drinking males, and there were variable effects in modifying the expectancies and drinking patterns of heavy-drinking females (Lau-Barraco & Dunn, 2008; Musher-Eizenman & Kulick, 2003; Wiers & Kummeling, 2004). For the wide-spread use of an expectancyfocused prevention program, there was a need for a protocol that could be quickly administered in typical settings and could be effective with both male and female students, i.e., a classroom-based Expectancy Challenge. Challenging Expectancies in Classroom Settings The Alcohol Literacy Challenge (ALC) is a classroom-based prevention intervention designed to help students modify their expectancy activation patterns during a single-session. The goal is for the students to become more likely to activate sedative expectancies when exposed to alcohol-related stimuli as opposed to arousal-based expectancies, and to do this without the necessity of the experiential component key in the bar laboratory-based protocol. To this end, the ALC was designed. Its classroom-based curriculum is comprised of introductory lessons on expectancies and the true effects of alcohol as a depressant. It also includes a component that addresses how the media (e.g. advertisements, commercials) can impact one s perceptions about alcohol. The students are asked to identify inaccurate representations of alcohol in different advertisements and engage in activities that deconstruct ads that promote positive or arousal-based expectancies about alcohol. The effectiveness of the classroom-based prevention program has been demonstrated in various college setting including small classrooms, large classrooms, and fraternities and sororities. Sivasithamparam (2008) implemented a protocol with small classes (< 50 students) of first-year college students and compared alcohol use between those exposed to the program with a control-group (group that did not participate in the presentation.) The results of the study revealed that the Alcohol Literacy Challenge led to significant decreases in the amount of alcohol consumed among both male and PETER DEBENEDITTIS, PH.D

10 female first-year students compared to the control group. Specifically, the participants in the ALC group compared to those in the control group had a greater decrease in both the average number of drinks consumed per week and number of binge episodes over the previous month. Schreiner (2010) implemented the protocol with large classes (100+ students) of primarily freshman and sophomore students and also found the participants receiving the ALC had decreased their average drinks consumed per sitting over a one month period, while students in the control group increased. And most recently, Fried (2010) implemented the protocol with fraternities and sororities and found that ALC participants significantly decreased their average number of drinks consumed per sitting and their drinking frequency over one-month when compared to members in the control group. The ALC in its present form has become an effective intervention protocol involving the use of trained expert peers or near-peers to present all the information and engage participants. The students get exposed to concepts such as expectancies, the biphasic effects of alcohol, brand recognition research, the placebo effect, and other important content in an interactive manner that encourages attention and processing of the information. Using a Media Literacy The information about alcohol and alcohol expectancies in the ALC is delivered in the framework of a media literacy program. The use of advertising allows practice identifying expectancies. As such, learning to deconstruct alcohol advertisements is integral to the curriculum. This is highly salient for adolescents and young adults as a majority of the beverage ads that they are exposed to endorse alcoholic drinks (Austin & Hust, 2005; Center on Alcohol Marketing and Youth, 2002). Media literacy is used to refer to the ability to think critically about messages conveyed in the media and advertisements as well as an understanding of how and why media messages are created (Brown, 1998; Hobbs, 1998). Print and digital portrayals of alcohol use reinforce social and behavioral aspects of drinking. Research PETER DEBENEDITTIS, PH.D

11 suggests that exposure to alcohol media is linked to favorable alcohol expectancies (Grube & Wallack, 1994). With the intention of selling alcohol, media advertisements consistently portray effects of alcohol that are seen as desirable regardless of whether these outcomes are related to the actual pharmacological effects of alcohol. In fact most alcohol ads have themes equivalent to those of non-alcoholic beverage ads with the addition of sexually suggestive themes (Austin, 2006). In the evaluation of a media literacy training program for children, Austin and Johnson (1997) demonstrated its effectiveness for decreasing expectations of positive consequences from alcohol use. Students were less likely to rate alcohol ads positively, were less attracted to alcohol promotional material, and showed greater disdain for alcohol commercials. Researchers looking at 9th and 12th graders found that the potential risk of frequent exposure to persuasive alcohol portrayals via late-night talk shows, sports, music videos, and prime-time television for underage drinking is moderated by parental reinforcement and counter-reinforcement of messages (Austin, Pinkleton & Fujioka, 2000). This research suggests that giving parents and students the media literacy skills to talk back to television reduces underage drinking. Recent research has provided further empirical support for the benefit of media literacy education by demonstrating that such education programs predicted alcohol use for teens at a two-year follow-up (Epstein & Botvin, 2007). Thus media literacy is an engaging and interactive framework through which students can begin to challenge their own expectancies as well as the ones being portrayed in the media. References Austin, E. (2006). Why advertisers and researchers should focus on media literacy to respond to the effects of alcohol advertising on youth. International Journal of Advertising: The Quarterly Review of Marketing Communications, 25(4), Retrieved from EBSCOhost. Austin, E., & Hust, S. T. (2005). Targeting Adolescents? The Content and Frequency of Alcoholic and Nonalcoholic Beverage Ads in Magazine and PETER DEBENEDITTIS, PH.D

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18 Young, R. M., Oei, T. P., & Knight, R. G. (1990). The tension reduction hypothesis revisited: An alcohol expectancy perspective. British Journal of Addiction, 85(1), doi: /j tb00621.x PETER DEBENEDITTIS, PH.D