Journal of Social Work in Public Health (in press)

Abstract

Underage drinking, or binge drinking, (defined as having five or more drinks in a row) has become a major concern in our society. The increase in heavy drinking that occurs across the transition to college has increased professionals' awareness that there is a need for improved interventions to assist in the reduction of alcohol and substance use/abuse. At The University of Tennessee (UT) a computer-based intervention was put into place for the past three years with funding from the Substance Abuse and Mental Health Services Administration (SAMHSA). The intervention was provided to all college students via UT's computer network system and was completed mostly online. Students were given a computerized, standardized assessment of alcohol use and then a brief intervention was given based on the students' information. The intervention targeted students who were at highest risk for developing unsafe alcohol behaviors and/or increasing prior alcohol consumption habits in their first year of college. This intervention has now been provided to over 54,000 graduate and undergraduate students, and since the launch of the program binge drinking has dropped twenty-seven percent on campus. Further, frequent binge drinking dropped forty-four percent, and the number of liquor law violation to 18-to 20-year olds decreased from 542 in 2004 to approximately 158 in 2007. Three yearly independent evaluations confirm these findings. The project has demonstrated that the use of a computer technology to reduce and prevent college drinking has improved students' thoughts and behaviors related to alcohol consumption and binge drinking. This project serves as an example in the use of a harm reduction-based intervention in a venue where substance use is tolerated and normalized. The use of a computer-based intervention was comprehensive, low-cost, and required low-maintenance. Implications to this study were that participants could drop out of the intervention at any time, as well as the difficulty of tracking students who gave inaccurate information.

Introduction

An estimated 18 million adults 18 years and older in the United States currently experience problems as a result of alcohol use and of these, 10.6 million suffer from the disease of alcoholism (Wodarski & Feit, 1995). Furthermore, multiple studies reported to the Centers for Disease Control and Prevention (CDC) in 2008 discovered that approximately 90% of alcohol consumed by youth under 21 in the United States is in the form of binge drinking, as well as the proportion of current drinkers that binge is highest in the 18 to 20 year old groups or (51%) (CDC, 2008). Undergraduate drinking, or binge drinking, (defined as having five or more drinks in a row) has become an urgent concern amongst parents, public health officials, college personnel, and society at-large. The increase in heavy drinking that occurs across the transition to college has prompted alcohol researchers to persistently search for effective interventions to reduce the commonly coined phrase 'binge drinking' (Sher & Rutledge, 2007). Binge drinking has now become the common term used to describe college drinking that has become problematic. So much, however, that the authors of Binge Drinking: Not the Word of Choice have suggested replacing 'binge drinking' with the term 'dangerous drinking' to describe the drinking behavior that results in unintended or undesirable consequences to send a stronger, more identifiable message to adolescents and young adults (Goodhart, Lederman, Stewart, & Laitman, 2003). Nevertheless, young adults, in comparison with any other age group, have the highest prevalence of high-risk drinking in the U.S. (Hingson, Heeren, Zakos, Winter, & Weschler, 2003). This paper's intent is to present an accumulation of insight regarding the causes and consequences of college drinking & binge drinking. In addition, its purpose is to shed light on computerized assessment and feedback that have proven in this study to be effective, if not more effective and less expensive than traditional person-to-person interventions. Further discussion describes a particular computer intervention program being designed and implemented at The University of Tennessee (Wodarski & Long, 2006).

The minimum drinking age in the United States stands at twenty-one, yet many adolescents and young adults who are underage consume alcohol. The percentage of alcohol consumed by the underage individual before entrance to college typically increases after making the college transition. This transition is accompanied by a major change in drinking behavior that occurs over a relatively brief time span whereas these young adults who were initially drinking less than their peers who did not go to college are now drinking more (Sher & Rutledge, 2007). A research study completed by The Brown University Digest of Addiction Theory and Application found that college freshmen drink at levels well beyond the binge threshold (four or more drinks for females and five or more drinks for males). The findings indicated that frequent binge drinkers binge more often, and are more likely to drink at peak levels 2 and 3 times the binge threshold (2007), thus, increasing their risk to potentially dangerous situations. Alcohol is a factor in nearly half of all accidental deaths, suicides, and homicides, including 42 percent of all deaths from motor vehicle accidents, and this percentage increases with binge drinking (Wodarski & Feit, 1995). Students are likely to experience significantly more problems including, but not limited to, serious health problems, injuries, and unplanned sex (Carey & Correia, 1995; Midanik, Tam, Greenfield, & Caetano, 1996; Wechsler et al., 2002). On many college campuses alcohol consumption is considered a rite of passage, particularly by entering freshman. Freshmen want to be distinguished as college students, not high school students. Due to this pressing desire to be seen as older they are more willing to follow the norms of older college students, thus reinforcing the idea that alcohol is a necessary and acceptable part of college life (Wodarski & Long, 2006). Hawkins, Catalano, & Miller suggest that one of the strongest variables correlated with college drinking is social influence (1992). Due to the perception of some college students' social norms, their amount of alcohol consumption is typical and within their peers' drinking habits. However, some studies have revealed that students often overestimate both the acceptability and the actual drinking behavior of their peers (Parris & Wodarski, 2004; Wechsler, Molnar, Davenport, & Baer, 1999).

In a 2004 study to determine predictors of undergraduate student binge drinking Strano, Cuomo, & Venable uncovered seven variables that were significant predictors of those who had or had not engaged in binge drinking. The seven predictors included: ethnic group (other than African American), freshman status, fraternity or sorority membership, positive alcohol expectancies, prior drug use, no or low perceived risk, and friends' opinion of binge drinking. Further findings demonstrated that race, class, fraternity or sorority membership, use of other drugs in the past 30 days, perception that friends do not disapprove of binge drinking, and perception of high normative drinking were factors in predicting episodes of binge drinking. In addition, students who engaged in binge drinking were more likely to use tobacco or marijuana and to have more sexual partners (Wechsler et al., 1995). Beyond the health and safety concerns, the culture of college drinking must be challenged because of the environmental factors that influence students in the college environment – peer influence/ expectations, past family alcohol consumptions, personality, and biological factors – may dramatically increase students' susceptibility to alcohol use, abuse and/ or addiction (Wodarski & Long, 2006).

The consumption of alcohol is a significant problem amongst college students at multiple university settings and of particular concern to The University of Tennessee (UT). The alarm was heightened in 2001 after UT, home to 19,000 undergraduate students and 5,000 graduate students, was awarded the dubious distinction of the nation's top "party campus" in a Princeton Review. In 2003, the Tennessee Bureau of Investigation reported 11 drug violations, 50 incidence of DUIs (Driving Under the Influence), and 415 liquor violations on The University of Tennessee campus. In addition, data from the UT Core Survey given in the Fall Semester of 2004 to students at UT revealed that over 31% of students are drinking more than 5 drinks at a session (generally seen as indicating at-risk drinking or binge drinking), translating to roughly 8,000 students. Consequences exposed by the UT Core Survey were that 37% of students reported public misconduct (trouble with police, fighting, DWI/DUI, vandalism) and 27% reported serious personal problems (Suicidality, being injured, trying unsuccessfully to stop using, and sexual assault).

The surmounting evidence that UT was losing the battle against substance use on campus spawned a renewed interest in finding new methods and interventions to reduce the use/abuse of alcohol and drugs. Due to the efficacy of computer software that addresses problem drinking and provides brief interventions is so prevalent, as well as the fact that the use of computers is a more cost-effective intervention and is the easiest method of getting the information to the greatest number of participants, it was concluded that a computer-based program to address problem drinking could be used at The University of Tennessee.

Program Description

The Substance Abuse and Mental Health Services Administration (SAMHSA) and Center for Substance Abuse Treatment (CSAT) are funding The University of Tennessee for three years to implement "Using Computers to Screen and Provide Brief Intervention for Underage Alcohol/Substance Abuse on College Campuses." This three-year study of harm reduction-based prevention/early intervention initiative was aimed initially at the undergraduate students, but after further research, incorporated the graduate student population into the study.

The intervention utilized the university's computer network to provide college students with basic knowledge concerning substance use and abuse, feedback on individual drug patterns, two levels of treatment intervention and referrals to university and community treatment agencies in an attempt to reduce the incidence of alcohol consumption among UT students. Additionally, the intervention assisted in increasing students' awareness of their own potential risks by giving immediate feedback and individualized recommendations (Parris & Wodarski, 2004).

A computer-based screening and intervention program based on the BASICS (Brief Alcohol Screening and Intervention for College Students) intervention developed by Dimeff, Baer, Kivlahan, & Marlatt (1999) was provided to all students (n= approximately 24,000). The adaptation of the program provided a computer-based screening and brief intervention, reinforced with peer outreach workers. These workers provided outreach services in high-risk situations, including residence halls, Spring Break venues, football/basketball games and other sporting events, and Greek Events, in order to provide additional outreach to potential high risk students.

Due to the majority of students having access to computers, either by means of their own personal computers or by the computers found on UT's campus, the intervention was provided on the campus computer network. Several components were applied on the prevention and intervention website. Students were given a computerized, standardized assessment of alcohol use. Following the assessment, a brief intervention was provided in response to the information gathered from the student during the standardized assessment of alcohol use. Then students were provided with referral sites, along with resources available from The University of Tennessee.

The intervention targeted students who are at highest risk for developing unsafe alcohol behaviors and/or increasing prior alcohol consumption habits in their first year of college. All incoming freshmen had the opportunity to participate in the study. Once a student opened his or her college email account, he or she was given the opportunity via Internet link to participate in the study. The Internet site provided more in-depth information concerning the College Substance Abuse Prevention Program (CSAPP) and provided contact information for students if they had further questions or if they were in need of technical assistance. Students who decided to participate must have signed a confidentiality statement, which insures strict confidentiality, as well as informs upfront that participation is completely voluntary and the student reserves the right to withdraw at any time. The student was then given a random identification number to maintain the individual’s anonymity, after which the participant continued on to complete the five components of the computer-based intervention.

Component 1: General Information

A computerized self-report assessment obtains measures of a student's (a) typical drinking pattern and episodic drinking occasions, (b) expectations concerning alcohol use, (c) perceptions about the norms of college student drinking, (d) support for alcohol use in the student's peer group, (e) health risk behaviors, and (f) negative consequences stemming from alcohol use. Students' answers to these questions helped determine their level of alcohol consumption.

Component 2: The Nonuser

A distinguishing factor of the "using computers to prevent irresponsible college drinking" intervention is the explicit recognition that some students entering college have not begun alcohol use.

• Screen I- presented non-drinking students with an acknowledgment of their decision not to drink. It will present statistics on the negative consequences the student is missing by not drinking
• Screen II- presented the distribution of weekly drinking activity the college population. The percentage of nondrinkers will be highlighted.
• Screen III- emphasized the factors that commonly influence alcohol use initiation: conformance to the behaviors of friends (norms), expectations of the benefit of alcohol use, modeling by older students, and lack of "fun" activities.
• Screen IV- presented the student with information on how to recognize alcohol-related behaviors in other students and provide a listing of campus-based services that can be contacted to get help with the disturbances that can accompany alcohol use by students on campus (loud noise, aggressive behaviors, and alcohol overdose).
• Screen V- acknowledged the student's choice in not drinking as a legitimate, sound decision and part of the student's own choice for building a healthy lifestyle. It will then list campus organizations that are alcohol free.

Component 3: The Occasional User

Most students (54%) report having fewer than eight drinks per week (Johnson et al., 1994). This level of consumption places them in the low to moderate range for alcohol use. In preparing feedback to students in this category, a harm reduction approach was followed. Students were encouraged to examine their use of alcohol and weigh the perceived benefits of use against the actual biological effects of alcohol and the risk of negative consequences such as hangovers, missed classes, and deterioration of school performance.

• Screen I- presented the student's weekly drinking habits recorded previously (General Information) with the weekly number of drinks in the college population.
• Screen II- discussed alcohol, along with explanations of gender differences in metabolism of alcohol that affect blood alcohol levels (BAC).
• Screen III- reported the degree of peer support for alcohol use and discussed the influence that peer groups have on reinforcing potentially harmful behaviors.
• Screen IV- discussed the effects alcohol has on mood and other mental states. Also, this screen will explain the basic effects of alcohol in general.
• Screen V- explored the negative consequences attributed to alcohol use. Feedback will be given on the level of negative consequence the student attributes to her or his alcohol use. This information will be obtained from the general information screen previously completed by the student.
• Screen VI- encouraged the student to create a change plan with reduced consumption goals. During this screen, the student will complete an online version of the Alcohol Use Disorder Identification Test (AUDIT).
• Screen VII- directed the student to campus activities that promote alcohol-and drug free lifestyles.

Component 4: The Heavy Drinker

This component of the intervention has eight screens directed toward reducing or eradicating heavy drinking behavior of students who admit to drinking heavily.

• Screen I- compared the student's weekly drinking habits recorded previously (General Information) with the weekly number of drinks in the college population.
• Screen II- discussed alcohol, along with explanations of gender differences in metabolism of alcohol that affect blood alcohol levels (BAC).
• Screen III- reported the degree of peer support for alcohol use and discusses the influence that peer groups have on reinforcing potentially harmful behaviors.
• Screen IV- discussed the effects alcohol has on mood and other mental states. Also, this screen will explain the basic effects of alcohol in general.
• Screen V- explored the negative consequences attributed to alcohol use. Feedback will be given on the level of negative consequences the student attributes to his or her alcohol use. This information will be obtained from the general information screen previously completed by the student.
• Screen VI- encouraged the student to create a change plan with reduced consumption goals. During this screen, the student will complete an online version of the Alcohol Use Disorder Identification Test (AUDIT). Those scoring above 8 will be strongly encouraged to seek professional help.
• Screen VII- allowed students to identify settings in which they are likely to engage in drinking behavior, evaluate the risk of heavy drinking for that setting, and develop consumption targets as guides for controlling their alcohol consumption.
• Screen VIII- directed the student to campus activities that promote alcohol-and drug free lifestyles.

Component 5: Alcohol Dependence

Students whose information suggests they might be severely alcohol dependent or who have medical conditions for which the use of alcohol is contraindicated (e.g., pregnancy, ulcers, diabetes) were strongly encouraged to abstain from alcohol use and to accept a referral to an abstinence-based treatment program. A listing of campus-based referral sources and contact numbers will be provided.

Tracking System

The tracking system used the student's email address, which is given during registration of the program. Once the email address is in the system this is how the participant will receive feedback. Registration also includes a password, age, gender, weight (for BMI purposes), race, and class level.

Current research suggests that less invasive interventions are more acceptable than traditional group or individual counseling with college-age students. Because of this, there are several benefits of a computer-based intervention. First, the individual may be more likely to disclose personal and sensitive information if the information can be given via e-mail. Second, the individual who chooses to participate in the study is likely to already have an interest in the topic of alcohol consumption. Third, computer-based interventions offer low-cost, preliminary treatment options to serve a greater number of clients at one time (Squires & Hester, 2002).

Limitations

The website also contained a detailed disclaimer explaining that this program is not intended to provide therapy and is not a substitute for a licensed therapist. The program is implemented with incoming freshmen in mind, although other undergraduate and graduate students do benefit from the intervention as well. The program did allow students to quit at any time, due to the intervention being completely voluntary which makes these students difficult to track. Another dilemma is that it was often difficult to track students who did not give accurate information. Finally, a third obstacle was that the program utilizes self-reports and therefore the confidentiality guaranteed to students did not allow for third party monitoring.

Results

Nearly two and a half years later after first starting this project back on January 1, 2006 the intervention has been provided to approximately 54,000 students. A subset completed the brief intervention (n=5,775) and 76.7% were transitioned to a computer-based self-assessment (n=4,430). Based on the results of the self-assessment (AUDIT score greater than 8), in-person services were offered (n=1,122), and accepted by over one-third of participants (41.8%, n=469). Formal treatment services were accepted by over half (n=238, 81.7% of goal) and completed by 160 (85.1% of goal) including a subset of individuals with extremely high AUDIT scores (n=36).

Individuals AUDIT scores improved at statistically significant rates. Since the launch of the program binge drinking has dropped 27% on campus (48% to 35% reduction in number of student reporting drinking five or more drinks at a time), and frequent binge drinking has dropped 44% (25% to 14% reduction in the number of students reporting drinking five or more drinks at a time three or more times in the past two weeks). The trend analysis demonstrates through time the intervention is statistically significant. Yearly independent evaluations confirm the findings. These evaluations consisted of 5,000 randomly chosen students who were administered independent inventories by The University of Tennessee's Student Services.

(HR- High Risk Drinking / FHR- Frequent High Risk)

Discussion

The total costs of adolescents and young adults binge drinking are incalculable. Binge drinking is best viewed as a complex activity that needs to be challenged at multiple levels-through making simultaneous changes in the campus culture, norms among friends, personal attitudes and other behavior, and perceptions of risk. No one influence on binge drinking can be addressed without considering the other major influences, thus a successful intervention necessitates attention to the diverse factors (Strano, Cuomo, & Venable, 2004). The computerized intervention utilized on the campus of The University of Tennessee has taken these multiple factors into account by providing students with the most up-to-date information pertaining to alcohol use and abuse. Students were informed of their own as well as the greater student bodies typical drinking patterns, perceptions about the norms of college student drinking, health risk behaviors and negative consequences stemming from alcohol use. Students were informed that despite the fact that there are differences in how alcohol affects BAC among men and women, the marginal impact of heavy episodic drinking on grades is essentially the same for both genders. Men and women face similar decreases in GPA of about a third of a point on a four-point scale (Wolaver, 2007). In addition, students were made aware of factors that influence alcohol use, explore the different effects of alcohol on mood and other mental states, and were encouraged (if needed) to create a plan of change to reduce consumption. This project served as an example in the use of a harm reduction-based intervention in a venue where substance use is tolerated and normalized, and may have provided implications for other similar arenas.

The project demonstrated that the use of a computerized intervention--completed primarily online by most students--using the campus computer network had significant improvements in students' thoughts and behaviors related to alcohol consumption and binge drinking. Furthermore, the intervention showed the capability to screen an entire campus and make big changes. The project illustrated that students are more likely to access treatment more readily via computer network, thus allowing more individuals to be reached. According to the survey results from the past three years from the SEE committee, UT's drinking rates have declined significantly. In fact, from 2004 to 2007, high-risk drinking has declined by 27 percent compared to the national high-risk drinking levels. Additionally, in accordance with decreased drinking levels, the number of liquor law violations to 18-to 20-year-olds has decreased from 542 in 2004 to approximately 158 in 2007 according to the UT Police Department.

However, to continue to address the multiple levels to this epidemic there is a need for stronger involvement from the campus community. One component, which could assist to a great extent UT's binge drinking intervention, would be assistance from the local bars and restaurants. Currently, at some locations, happy hour includes two for one specials on alcoholic beverages or on select nights at other locations customers can purchase quarter beers. Furthermore, many of the local restaurants and bars have received citations and suspensions due to serving alcoholic beverages to minors. Eliminating extravagant alcohol specials and increased training for bar tenders on the dangers associated with binge drinking as well as the risks to serving a minor could begin to alter the perception of drinking and thereafter the campus culture. With increased advertising and peer outreach there is likelihood that myths regarding alcohol could be dispelled leaving only room for facts.

Conclusion

The consequences of excessive drinking by college students are more significant, more destructive, and more costly than ever, and these consequences affect students whether they drink or not (NIAAA, 2007). Interventions timed to occur in the early months of college may disrupt the momentum of previously established drinking behavior, therefore breaking bad habits before they have the ability to further deteriorate. However, for those individuals who are in the thick of the use/abuse, the stigma that is linked to alcohol related problems presents barriers to traditional methods of prevention and treatment. Yet, computer-based interventions permit at least one solution to this barrier. This program is a systematic way in which college students can be targeted for alcohol problems through the use of a computer intervention. By using this method students maintain a sense of anonymity while receiving non-judgmental help for their drinking problems. Thus, allowing students to seek help, when and if they are ready, from the privacy of their own homes, (Wodarski & Long, 2006).

Due to brief interventions being among the least costly and most efficient treatment interventions, the program discussed here was designed to adapt brief intervention technology, developed in the alcohol treatment field, to a computer-based delivery system. This comprehensive, low-cost, low-maintenance intervention can be promoted campus wide and on college campuses as a voluntary information site about alcohol. Another opportunity for this program is to implement it as a portion of the orientation experience for students, thereby ensuring that all incoming freshman students visit the site, if not complete the program in an effort to continue to reduce the effects of binge drinking at universities, (Wodarski & Long, 2006).

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