Family Medicine Vital Signs

Originally published in the Journal of the American Academy of Physician Assistants on December 18, 2017.

The news is unrelenting about the serious problem college campuses have with student drinking. At Penn State, a 19-year-old man died while at a fraternity drinking party. A 20-year-old at Florida State died at a fraternity pledge party, and a 19-year-old woman nearly died on her birthday while attending a fraternity event at Penn State. In November, Ohio State University suspended most of its fraternities due to hazing and alcohol violations.

The prevalence and consequences of college drinking are well-documented. Each year, nearly 2,000 college students die from alcohol-related injuries, including motor vehicle injuries.¹ An estimated 700,000 alcohol-related assaults occur each year on college campuses.^2,3 Alcohol-related sexual assault on college campuses is estimated annually at almost 100,000 students.⁴ According to a study from the National Epidemiologic Study on Alcohol and Related Conditions, nearly 20% of college students meet the criteria for alcohol use disorder.⁵

Yet, despite decades of research, millions of dollars spent on mandatory alcohol reduction training for college freshmen, and fraternity suspensions, the problem remains and appears to be getting worse. The reaction is to ban fraternities, yet binge drinking also occurs in dormitories and at football tailgating parties.³ Students are encouraged to find and join social groups and clubs in college. Belonging to these groups in college is common and a great way to find new friends. Yet these groups can influence students to drink. Members of fraternities, sororities, and sports teams are much more at risk of engaging in risky alcohol behaviors and running into alcohol-related problems such as fights, unwanted sexual advances, date rape, and property damage.⁶ Students who feel the need to join in or be rejected are most likely to respond to group pressure, which puts them at additional risk if they belong to a group that pressures students to drink.

The excuses and blame are endless and unproductive. Didn’t everyone drink in college? Won’t they just “grow out of it?” It’s a fraternity, what did they expect? Blame is either a boys-will-be-boys attitude or a she-shouldn’t-have-attended-that-party victim-shaming excuse. Meanwhile, the social drinking is getting worse. Students have moved from beer to hard liquor and more college students report they are out not just to get drunk but to black out. One estimate involving 119 schools and the Harvard School of Public Health College Alcohol Study estimated 1 in 20 women reported being raped in college, and two-thirds of those rapes occurred while the women were intoxicated.^4,7

In 2007, the National Institute on Alcohol Abuse and Alcoholism issued a report calling for changing the culture of drinking at US colleges via interventions such as screening for alcohol use or counseling referrals.⁸ Colleges were urged to implement social norming interventions such as campuswide alcohol training and comprehensive programs. An example of this is the AlcoholEdu online course that is required for incoming freshmen at many colleges. According to the AlcoholEdu website, more than half a million college students will take the program before attending school for the first time.  An industry of college orientation training, now delivered online, has cost millions of dollars (primarily covered by student fees). Studies are ongoing as to their effectiveness.^9,10

Strategies to prevent alcohol abuse on campus have run the gamut over the last few decades. School administrators have swung between cracking down on alcohol-related violations or throwing up their hands and doing very little. Mandatory alcohol abuse training for freshmen often makes parents and administrators feel they are at least doing something. Many campuses, in fact, do nothing. Policing dorms, bars, tailgate parties, and fraternity parties is an impossible task, and college presidents are reluctant to end money-generating traditions such as football tailgating.

One thing that public health officials agree on is that strategies to reduce college drinking should be multifactorial. College Aim is a National Institutes of Health program designed for college administrators to use and plan research-driven interventions at the individual and community levels. A worksheet tracks the intervention, cost, number of students affected, and the outcome of the intervention. It can be used comprehensively and over time to see if strategies are working, measure costs and make changes if necessary. Some of the research-driven strategies at the individual level include brief motivational interviewing and personalized feedback intervention tools. These individual strategies are on a grid from lowest to highest cost and lowest to highest effectiveness.  Individual interventions can be targeted to students at the highest risk, such as athletes and fraternity members. The website Collegedrinkingprevention has numerous resources for college campuses, links to articles, special features, and college drinking statistics.

What are students doing to prevent the harms associated with college drinking? Campus leaders and fraternity and sorority members are at the center of the alcohol issue and potentially most well-positioned to make changes. Dormitory resident advisors are the start of a referral hub into campus staff that can help especially vulnerable students. Fraternity and sorority leaders can increase student involvement in fundraising activities, outdoor activities, and

social activities that strengthen relationships and discourage risky behavior related to alcohol.

Parents are being asked to talk to their children about drinking before they drop them off at college. Some topics to cover include:
• Binge drinking, defined as 5 or more drinks over the course of 2 hours for men or 4 or more drinks in 2 hours for women.
• Hard alcohol such as shots of liquor can be deadly because they can quickly lead to alcohol poisoning.
• Some states have drop-off laws that let people drop some at the ED without fear of law enforcement.
• Students should monitor each other for signs of being dangerously over intoxicated and should call 911.
• Encourage students to take a taxi or ride-share service instead of driving when intoxicated or riding with someone who is intoxicated.
• Because most undergraduates are between ages 18 and 21 years, nearly all of college drinking is underage drinking and illegal. Students could face charges of underage drinking, public intoxication, or being drunk and disorderly.
• High-stakes consequences such as the loss of an academic or athletic scholarship can actually discourage students from doing the right thing.
• Review resources such as on-campus wellness centers and student health services, healthcare insurance, and access to healthcare on and off campus.

A renewed call to action by public health and campus health organizations should be of paramount importance. Working together, communities, parents, campus leaders, and college administration can help students have a fun and socially meaningful college experience without the pitfalls and problems associated with college drinking culture.

Jennifer Coombs, PhD, PA-C, has been a Physician Assistant (PA) for over 25 years. She is an Associate Professor in the Department of Family and Preventive Medicine Division of Physician Assistant Studies.

REFERENCES

1. Hingson RW, Zha W, Weitzman ER. Magnitude of and trends in alcohol-related mortality and morbidity among US college students ages 18-24, 1998-2005. J Stud Alcohol Drugs Suppl. 2009(16):12-20.

2. Hingson RW, Zakocs RC, Heeren T, Winter MR, Rosenbloom D, DeJong W. Effects on alcohol related fatal crashes of a community based initiative to increase substance abuse treatment and reduce alcohol availability. Inj Prev. 2005;11(2):84-90.

3. Hingson RW, Zha W, White AM. Drinking beyond the binge threshold: predictors, consequences, and changes in the US. Am J Prev Med. 2017;52(6):717-727.

4. Abbey A, Wegner R, Pierce J, Jacques-Tiura AJ. Patterns of sexual aggression in a community sample of young men: risk factors associated with persistence, desistance, and initiation over a one year interval. Psychol Violence. 2012;2(1):1-15.

5. Blanco C, Okuda M, Wright C, et al. Mental health of college students and their non-college-attending peers. Results from the National Epidemiologic Study on Alcohol and Related Conditions. Arch Gen Psychiat. 2008;65(12):1429-1437.

6. Turrisi R, Mallett KA, Mastroleo NR, Larimer ME. Heavy drinking in college students: who is at risk and what is being done about it? J Gen Psychol. 2006;133(4):401-420.

7. Mohler-Kuo M, Dowdall GW, Koss MP, Wechsler H. Correlates of rape while intoxicated in a national sample of college women.J Stud Alcohol. 2004;65(1):37-45.

8. Hingson R, White A. New research findings since the 2007 Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking: a review. J Stud Alcohol Drugs. 2014;75(1):158-169.

9. Paschall MJ, Antin T, Ringwalt CL, Saltz RF. Effects of AlcoholEdu for college on alcohol-related problems among freshmen: a randomized multicampus trial. J Stud Alcohol Drugs. 2011;72(4):642-650.

10. Barry AE, Hobbs LA, Haas EJ, Gibson G. Qualitatively assessing the experiences of college students completing AlcoholEdu: do participants report altering behavior after intervention? J Health Commun. 2016;21(3):267-275.