College students and problematic drinking: A review of the literature
Introduction
This review addresses problematic drinking and the variables associated with problem drinking for college students in the United States. As problematic drinking among college students is an important public health concern with a variety of negative consequences, it is important to understand the variables that may be risk factors for this phenomenon. Further, college students represent a group of individuals who have unique drinking patterns and different risk factors and concerns related to problematic drinking than the population in general. The paper begins by reviewing prevalence of problematic drinking in college students, problems associated with college drinking, and definitions of problematic college drinking. Due to the high variability in drinking among college students, the primary goal of the current paper was to examine psychosocial variables that predict problem drinking and account for variation among college student drinkers. Although there have been a number of other factors associated with problem drinking, such as genetic influences often examined in alcohol-related research, this is not in the scope of the current review and also not necessarily an important influence specifically for college drinking (e.g., see Baer, 2002). Therefore, the current review will cover a subset of factors by focusing on only the primary psychosocial variables linked to college drinking in the literature, beginning with internal influences, leading up to those perceived as external influences. These influences include demographic variables, personality, drinking history, alcohol expectancies, drinking motives, stress and coping, activity involvement, and peer and family influence. Although the current review does not examine interventions for college drinking, understanding such variables and possible models of college drinking can aid in informing prevention and intervention for problem drinking college students. Finally, the review also includes a section examining the research on predicting alcohol problems in the postcollege years.
Heavy and/or problematic alcohol use among college students represents a major public health concern. Although problematic alcohol use occurs across many age groups, young adults aged 18–24 years show the highest rates of alcohol use and have the greatest percentage of problems drinkers Kandel & Logan, 1984, U.S. Department of Health and Human Services, 1997. Although trend data from large-scale studies indicate that there has been a slight improvement in heavy drinking (i.e., drinking large quantities of alcohol in one sitting) among college students O'Malley & Johnston, 2002, Wechsler et al., 1998, the problem still warrants serious concern. According to the Monitoring the Future project, most students have consumed alcohol within the last year (over 80% throughout the 1990s) (Johnston, O'Malley, & Bachman, 2000). As many as 84.2% of college students reported a heavy drinking or “binge drinking” episode (5+ standard drinks for men and 4+ for women in one sitting) within the previous 90 days (Vik, Carrello, Tate, & Field, 2000) and 44% reported binge drinking in the previous 2 weeks Wechsler et al., 1994, Wechsler et al., 2000. Most national studies provide a slightly lower but still alarming estimate, indicating that ∼2 in 5 students are binge drinkers (e.g., O'Malley & Johnston, 2002, Wechsler et al., 1998). Further, 31% of college men consume >21 drinks per week and 19% of college women consume >14 drinks per week, exceeding the established standards for safe levels of drinking (U.S. Department of Health and Human Services, 1990).
The Harvard School of Public Health College Alcohol Study found that the median number of drinks consumed by a random sample of students from 140 4-year colleges across the United States was ∼1.5 drinks per week with a mean of 5 drinks per week (Wechsler, Molnar, Davenport, & Baer, 1999). Although this result seems to imply little problematic drinking in college students, the problem in binge drinkers becomes apparent when examining the median of 14.5 drinks per week for frequent binge drinkers within this sample. Overall, binge drinkers in this sample represented 44% of the college population, but the binge drinkers accounted for 91% of the alcohol consumed by college students. Thus, binge drinkers are consuming large quantities of alcohol that may not be identified when using mean scores in college drinking research. This estimate may even be low when one considers that this particular survey only allowed for up to 9 drinks per sitting in the self-report questionnaires. According to Clements (1999), 13.1% of the 306 undergraduate psychology students sampled met the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) (American Psychiatric Association, 1994) criteria for alcohol abuse and 11.4% for alcohol dependence within the last 12 months.
Further, it appears that minimum drinking age laws have failed to reduce the availability of alcohol to underage drinkers or reduce drinking rates among 18–20-year-old students. Approximately one in two underage students (i.e., students under the legal drinking age of 21 years old) reported that alcohol was “very easy” to obtain (Wechsler, Lee, Nelson, & Kuo, 2002). Further, odds of binge drinking when under age 21 were slightly higher than being over the legal drinking age (Wechsler, Dowdall, Davenport, & Castillo, 1995).
One difficulty with examining college problem drinking is the lack of a standard operational definition of “problem drinking” (e.g., Clements, 1999), making it difficult to directly compare studies. Before beginning the review of risk factors related to college student drinking, problem drinking must be defined more clearly. Definitions in the literature generally fit into one of the following two categories (Baer, 2002): (1) Drinking rates or levels or (2) Negative alcohol-related consequences experienced. These terms are reviewed here to clarify terms often used in studies of problematic drinking.
Much of the research in college student drinking has employed self-report questionnaires inquiring about drinking quantity or frequency. This research may simply examine overall quantity (i.e., number of standard drinks) or frequency (i.e., days drank alcohol), but these often employ the terms “binge drinking” or “heavy episodic drinking.” Generally, binge drinking is currently defined as the consumption of at least 5 consecutive standard drinks in one sitting for men and 4 consecutive standard drinks in one sitting for women (Wechsler, Dowdall, Davenport, & Rimm, 1995). A standard drink is usually defined as a 12-oz beer, a 4-oz glass of wine, a 12-oz wine cooler, or a 1.25-oz shot of liquor either straight or in a mixed drink (Wechsler et al., 2000). Wechsler et al. (2000) have measured binge drinking as the 4 or 5 standard drinks in one sitting within the previous 2 weeks, although other studies have expanded this to greater periods of time (Vik et al., 2000), asked about the “typical” day or week of drinking, or asked students to monitor their drinking for a specific period of time.
In addition, frequency of binge drinking is often examined. For instance, Wechsler et al. (2000) defined “frequent binge drinkers” as those who had binged ≥3 times in the past 2 weeks (or more than once per week on average), “occasional binge drinkers” as those who had binged 1 or 2 times in the previous 2 weeks, “nonbinge drinkers” as those who had consumed alcohol in the past year but had not binged in the past 2 weeks, and “abstainers” as those who had consumed no alcohol in the past year. O'Hare (1997) defined heavy drinking as consuming 6 or more drinks weekly according to the Alcohol Use Disorders Identification Test (AUDIT) (Saunders, Aasland, Babor, De la Fuente, & Grant, 1993). On reviewing the literature, it seems that frequency of binge drinking is potentially an important component of “problem drinking” in college students.
Many have asserted that quantity and frequency measures of alcohol use are not sufficient to determine the problem status of college student drinkers. For instance, some heavy drinkers may report low levels of alcohol-related problems, while some light or moderate drinkers may experience high levels of alcohol-related problems (White & Labouvie, 1989). As much of the concern with college student drinking deals with the negative alcohol-related consequences, this seems to be the most relevant definition. However, frequent binge drinkers have been found to be more likely to experience alcohol-related problems than other types of students (Wechsler et al., 2000), indicating that frequency of binge drinking may also be an important distinction. Thus, indices of drinking frequency and quantity should serve as an assessment of problematic drinking in addition to alcohol-related negative consequences.
Although diagnostic criteria have been used rarely in the past in college student alcohol research, Clements (1999) asserts that research in the area of problem drinking would be enhanced if more standardized definitions and measures were used, such as the diagnostic criteria for alcohol use disorders established by the DSM-IV. Such diagnoses may also be considered a negative consequence of drinking. However, use of diagnostic criteria should be used with caution in college populations, as alcohol dependence criteria may not be appropriate to the special circumstances of adolescents and college-aged individuals (e.g., MacFarland, 1983). DSM-IV diagnostic criteria involve many of the negative consequences that are used in research investigating alcohol-related problems in college students (e.g., substance-related legal problems, alcohol use in situations in which it is physically hazardous such as while driving, and alcohol-related absences from work or school) (American Psychiatric Association, 1994). In fact, one assessment of alcohol-related problems, the Rutgers Alcohol Problems Inventory (RAPI) (White & Labouvie, 1989), includes nearly all DSM-III-R (American Psychiatric Association, 1987) criteria for an alcohol-related diagnosis.
More recently, other measures similar to the RAPI have been developed to assess alcohol-related problems in college students such as the College Alcohol Problems Scale (CAPS) (O'Hare, 1997) and the Young Adult Alcohol Problems Screening Test (YAAPST) (Hurlbut & Sher, 1992). Although there have not been many studies providing cutoff scores for problem drinking in college students, a cutoff of six problems on the YAAPST demonstrated the optimal combination of specificity and sensitivity (Hurlbut & Sher, 1992). Thombs and Beck (1994) provided definitions of four categories of drinkers based on a combination of alcohol-related problems and quantity/frequency measures. The most severe group (“high-consequence drinkers”) was defined by cutoff score of >15 on the RAPI. The other three groups (“light drinkers,” “moderate drinkers,” and “heavy drinkers”) were defined by a score of ≤15 on the RAPI and different levels of drinking frequency and quantity (see Thombs & Beck, 1994, for detailed description). Similarly, Baer, Kivlahan, Blume, McKnight, and Marlatt (2001) defined high-risk drinking as a combination of drinking quantity and frequency (5–6 drinks at least once in the past month) and negative consequences (at least three negative consequences 3–5 times in the previous 3 years based on the RAPI).
The current paper defines problematic alcohol use as heavy alcohol use (i.e., binge drinking) and/or high levels of alcohol-related negative consequences in examining the related psychosocial factors in college students. Optimally, problem drinking should take into consideration both alcohol use quantity and frequency as well as alcohol-related negative consequences.
The pattern of young adult drinking is unique because it seems to be relatively variable and have a transitory course with only a subset of students exhibiting heavy drinking patterns consistently across time into adulthood (Weingardt et al., 1998). After an initial increase in alcohol consumption, many students show a gradual reduction in alcohol consumption to a more moderate level throughout later years in college and following college. This phenomenon, often called “maturing out” or “developmentally limited alcoholism” (Zucker, 1987), suggests that as young adults gain more life responsibilities (e.g., employment and family obligations), their drinking rates decline (Marlatt, Larimer, Baer, & Quigley, 1993). College student drinkers are also unique in that they differ from individuals of the same age that do not attend college. This is evidenced by the greater drinking rates in 18–22-year-old college students versus the drinking habits of 18–22-year-olds that do not attend college O'Malley & Johnston, 2002, Schulenberg et al., 1994. Although those who do not attend college have greater drinking levels during high school years than future college attendees on average, those who attend college still have greater levels of alcohol consumption during the 18–22 age range (O'Malley & Johnston, 2002). Although many college students appear to transition into healthier drinking patterns after college, some do not (e.g., Marlatt et al., 1993, Weingardt et al., 1998). Moreover, heavy drinking puts these students at risk for experiencing significant negative alcohol-related consequences during their college years. Greater frequency of binge drinking has been associated with greater alcohol-related problems Wechsler et al., 1998, Wechsler et al., 1999, Wechsler et al., 2000. Furthermore, findings indicated that alcohol-related problems progress along a continuum (Vik et al., 2000), beginning with greater rates of the more common, relatively less problematic behaviors (i.e., “careless behaviors” such as missing class or getting injured) to more extreme, less frequent behaviors (i.e., “problems with authorities” such as arrests resulting from drinking). Thus, even heavy drinkers who have not experienced problems or experienced minor problems are not immune to experiencing more frequent and/or severe alcohol-related difficulties in the future.
Alcohol contributes to many deaths in the United States (McGinnis & Foege, 1993), and alcohol-related accidents represent the leading cause of death in young adults aged 17–24 years (National Institute on Alcohol Abuse and Alcoholism, 1984). It is estimated that there were at least 1400 unintentional, alcohol-related fatal injuries among college students aged 18–24 years in 1998 (Hingston, Heeren, Zakocs, Kopstein, & Wechsler, 2001). Further, as many as 500,000 of 4-year college students are unintentionally hurt or injured while under the influence of alcohol annually (Hingston et al., 2001). Since the mid-1990s, there has been greater media attention given to alcohol-related deaths among college students, including deaths by acute alcohol poisoning, falls, drownings, automobile collisions, fires, and hypothermia resulting from exposure (Wechsler et al., 2000). However, there is a multitude of other, less severe negative consequences more commonly experienced by binge drinkers that may be neglected by the media. For instance, Wechsler et al. (1994) found that frequent binge drinkers were 25 times more likely than nonbinge drinkers to have experienced five or more alcohol-related consequences such as a hangover, doing something they regretted, missing class, falling behind in school work, forgetting where they were or what they did, arguing with friends, engaging in unplanned and/or unprotected sexual activity, getting hurt or injured, damaging property, getting in trouble with law enforcement, or requiring medical treatment for an alcohol overdose. Heavy drinking also lowers immunity and decreases physical health. Evidence suggests that heavy alcohol consumption in college students contributes to lowered resistance to common illnesses (e.g., upper respiratory infections) that is not associated with light-to-moderate drinking (Engs & Aldo-Benson, 1995). Heavy drinking also increases probability of sexual victimization. Alcohol use increased the risk of being victim to sexual assault as well as the severity of the sexual assault in a sample of college women Testa & Parks, 1996, Ullman et al., 1999.
Unfortunately, binge drinkers are not the only students who are affected by their behavior. Heavy drinking endangers not only the individual consuming the alcohol but also other college students and the community in general. Abstinent and/or nonbinge drinking students are being dramatically affected by binge drinking friends, roommates, and peers. According to Wechsler (1996), on campuses where more than half of the students participate in binge drinking, 87% of students that live on campus have experienced some “secondhand effects” of binge drinking. This trend is also true, but at a lesser extent, at schools where less than one third of students participate in binge drinking (Wechsler, 1996). Some of the most common secondhand effects of binge drinking include being insulted or humiliated, experiencing unwanted sexual advances, having interrupted sleep, and baby-sitting friends or roommates. It is clear that the secondhand effects of binge drinking are widespread and impact most college students (Wechsler, 1996).
Further, the consequences of binge drinkers for others may be quite devastating. For instance, there is increase in physical assault, sexual assault, or damaging property committed by students when intoxicated (Wechsler et al., 1994). Over 600,000 college students are hit or assaulted by drinking college students each year (Hingston et al., 2001). Driving while under the influence of alcohol poses another threat to others. Approximately 32% of college drinkers report driving under the influence of alcohol (Wechsler et al., 1994), putting themselves and others at risk for injury and possibly death. According to Hingston et al. (2001), in addition to the 2 million college students in the United States that drove under the influence of alcohol in 1999, over 3 million rode as a passenger with a drinking driver. These high-risk behaviors associated with binge drinking put many individuals in danger of fatal injury and death.
Section snippets
Demographic factors
Demographic factors, particularly gender, have been frequently cited as variables associated with problematic drinking in college students, perhaps due to the number of large epidemiological studies on college drinking that have such demographic factors as gender and ethnicity easily accessible.
Predicting future drinking problems in college students
Although many college students discontinue problematic drinking after college, even those engaging in very high-risk drinking behaviors, there are still individuals who continue or progress in their problem drinking (Vik et al., 2000). Further, although problem drinkers are more likely than nonproblem drinkers to show significant drinking problems 7 years (O'Neill & Sher, 2000) or even 20 years later Fillmore, 1974, Fillmore, 1975, only a small portion of problem drinkers develop these
Conclusions
Although many individuals “mature out” of problematic college drinking, students put themselves and others at risk for negative consequences due to their high-risk drinking behavior. Thus, problematic college drinking represents a major public health concern. Additionally, there are some individuals who continue problematic drinking after college. Due to the high variability in drinking among college students, the primary goal of the current paper was to examine the primary psychosocial
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