For the Degree of Doctor of Philosophy in Psychology
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For the Degree of Doctor of Philosophy in Psychology
Alcohol abuse is a psychiatric diagnosis characterized by the excessive and recurring use of alcohol despite the negative consequences experienced, and it can be categorized as mild, moderate, or severe (American Psychiatric Association [APA], 2013). According to the Tenth revision of the International Classification of Diseases (ICD-10), the six criteria for alcohol dependence diagnosis include: (1) a compulsion to consume alcohol, (2) impaired drinking control capacity, (3) the presence of withdrawal symptoms once alcohol use ceases, (4) evidence of increased alcohol tolerance, (5) preoccupation with alcohol, and (6) continued use despite the harm experienced (World Health Organization [WHO], 1993). In addition to alcohol abuse, binge drinking is also recognized as a problematic form of alcohol consumption and is defined as a drinking pattern that increases blood alcohol concentration to 0.08 g/dL. As a general guideline for the measurement of binge drinking for research purposes, this happens within 2 hours after four drinks for females and after five drinks for males (National Institute on Alcohol Abuse and Alcoholism [NIAAA], n.d.).
Alcohol abuse is a common problem for college students worldwide. A national study of alcohol abuse and dependence in the United States (US) estimated the prevalence of alcohol abuse using a sample of more than 14,000 college students at 119 higher education institutions, and it was found that 31% of the students satisfied the DSM-IV criteria for an alcohol abuse diagnosis (Knight et al., 2002). In the United Kingdom (UK), a survey of 3,075 students from 10 universities showed that 15% of the students reported hazardous drinking while 28% reported binge drinking (Webb, Ashton, Kelly, & Kamali, 1996). A study in Australia found that 88% of the sample (n = 275 college students, age range 18-55 years) reported drinking alcohol, and approximately 40% of those participants were categorized as “at risk for harm” and in the “dependency range” (J. Davey, T. Davey, & Obst, 2002).
Substance use, including alcohol and drugs, is common in the student population, but alcohol is the most commonly abused substance (Wechsler, Lee, Kuo, & Lee, 2000). It is estimated that 80% of college students consume alcohol, and 50% of those who consume alcohol abuse it through binge drinking (NIAAA, 2013). Compared to the estimated rate of illicit substance use of 22% among college students (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013), alcohol abuse is a more significant problem than drugs because it is both legal and perceived as socially acceptable in some social groups. Alcohol abuse in the student population is a serious issue that must not be neglected as it can have serious consequences. According to NIAAA (2013), possible outcomes of alcohol abuse include death (1,825 cases per year), assault (over 690,000 cases per year), sexual abuse (over 97,000 cases per year), alcohol-related health problems (over 150,000 cases per year), and alcohol- or drug-related suicide attempts (estimated 1.2-1.5% of cases per year).
Although the most commonly reported reasons for substance use in college students include experimentation, relaxation, and social or recreational reasons (Johnston & O'Malley, 1986), various psychological and social factors can influence the development of alcohol abuse in the student population. For example, the Latino culture is associated with excessive alcohol consumption, so Latino college students with high ethnic identity are more likely to excessively consume alcohol than peers with low ethnic identity (Zamboanga, Raffaeli, & Horton, 2006). Therefore, ethnicity is one demographic factor that is associated with risk for excessive alcohol consumption.
Psychological health and environmental influences were also associated with increased risk for excessive alcohol use. Mood disorders (i.e., depression and manic disorders), social anxiety disorder, and personality traits (e.g., impulsivity) have been associated with increased risk for alcohol abuse (Chakroun, Johnson, & Swendsen, 2010; Schneier et al., 2010). Various environmental factors, such as peer pressure, socioeconomic status, and cultural heritage, were found to increase the risk for alcohol abuse even in individuals without genetic predispositions to addiction (Li & Burmeister, 2010; Stockdale et al., 2007).
Drinking alcohol in college is often an activity used to socialize with peers, but some students use alcohol as a coping strategy to deal with adjustments to their new educational and social environment. Acculturative stress and social support are often reported as critical issues relevant to first-generation students. Jenkins, Belanger, Connally, Boals, and Durón (2013) found that first-generation students are faced with more socioeconomic cultural transitions when entering college life compared to non-first-generation students, so they show more single-event traumatic stress, more depression symptoms, lower life satisfaction, and have less social support from family and friends than non-first-generation college students. In order to alleviate negative emotions and stress, students often resort to alcohol abuse as a coping strategy, even though it can lead to various negative outcomes (Carey & Correia, 1997).
The consequences of alcohol abuse reflect on students’ personal lives, social interactions, and their academic achievements. It is estimated that around 25% of students who drink report blackouts and driving under the influence of alcohol, whereas 30% get into verbal or physical disputes (Perkins, 2002). Students who satisfy criteria for alcohol abuse or dependence are more likely to fail in their first year of college than students who did not report drinking problems (62.5% vs. 50%; Aertgeerts & Buntinx, 2002) Lack of drinking control also predicts alcohol abuse later in life, and blackouts are predictive of poor academic achievement because they often lead to the escalation of alcohol abuse during college (Read, Wardell, & Bachrach, 2013).
Moderating strategies proved to be successful behavioral interventions for college students diagnosed with alcohol abuse (Scott-Sheldon, Carey, Elliott, Garey, & Carey, 2014). The moderating effects of social support on alcohol abuse in different populations and contexts, and it was consistently found that high social support can moderate the relationship between the stressor and the level of alcohol consumption (Steptoe et al., 1996; Weitzman & Chen, 2005). In educational institutions with higher reported social capital, the students had significantly lower risks for binge drinking, frequent drunkenness, acquisition of binge drinking in college, and diagnosable alcohol abuse compared to institutions where students reported lower levels of social capital (Weitzman & Chen, 2005). Therefore, social support and other environmental factors can be protective factors from alcohol abuse and alcohol-related harm in students.
Although mindfulness training and cognitive-behavioral treatment show the highest success rates in reducing alcohol consumption, routine educational interventions at class-level also show promising results (Conley, Durlak, & Dickson, 2013). Campus-level interventions proved successful only if they conveyed messages that clarified misconceptions about alcohol consumption being harmless and provided counseling to students involved in alcohol abuse rather than punishment (DeJong et al., 2006; Evans-Whipp, Plenty, Catalano, Herrenkohl, & Toumbourou, 2013).
Despite the fact that various interventions aimed at resolving and preventing alcohol abuse among college students proved successful, college students are less likely to receive treatment than peers who are not attending college (Blanco et al., 2008). Some potential barriers to seeking psychological treatment in the student population include time constraints, financial constraints, stigmatizing attitudes about mental disorders, and lack of emotional maturity or openness (Eisenberg, Downs, Golberstein, & Zivin, 2009). The study by Eisenberg, Golberstein, and Gollust (2007) also found that students from low socioeconomic backgrounds and international students were less likely to seek help regarding mental health issues compared to domestic students and students from high socioeconomic backgrounds. Even if students receive treatment, the treatment usually begins only after alcohol abuse has been diagnosed because of their problematic behavior.
Therefore, it is important to determine why college students engage in excessive consumption of alcohol and which risk factors are associated with alcohol abuse so that effective individual-level prevention strategies can be targeted at highest risk populations. Current research indicates that group-level prevention strategies are effective, but no significant reductions in alcohol abuse or negative alcohol-related outcomes have been reported in recent surveys (NIAAA, 2013; SAMHSA, 2013). It is considered that a better understanding of indications for alcohol abuse risk will enable psychologists and counselors to implement timely individual-level interventions that prevent alcohol abuse rather than treat it after its effects become apparent.
Alcohol abuse is a dangerous health risk behavior among college students that leads to other health risk behaviors and can inhibit their academic and social functioning. Even though the most successful types of interventions have been identified, preventive screening strategies aimed at identifying highest-risk students are not used to enable timely treatment delivery. Late treatment reduces the chances of successful recovery because alcohol causes alterations in brain regions associated with self-awareness, behavioral control, and long-term decision-making (Goldstein et al., 2009). Although most students report drinking because they want to experiment, relax, or socialize, various personal and environmental factors have been associated with increased levels of alcohol consumption and alcohol abuse, so a better understanding of those factors in the student population will allow for the development of screening strategies that could successfully reduce the prevalence of alcohol abuse in college students and improve their well-being.
Purpose of the Study
The purpose of this study is to examine the data collected during the National Survey on Drug Use and Health (NSDUH 2013) to understand how students compare to other populations in terms of alcohol consumption and how within-group differences affect alcohol consumption habits. This study will investigate various personal, social, and environmental factors that could be independently associated with alcohol abuse, and the results will allow institutions to implement effective screening strategies. For example, campus-level interventions can be planned in states where the highest prevalence of alcohol abuse among college students is reported. If previous instances of mental health disorders and stressful youth events show a significant correlation with alcohol abuse, routine screening and counseling at an individual level can be used to help students at risk for alcohol abuse.
Although moderating strategies and mindfulness training are considered effective interventions in students who are diagnosed with alcohol abuse, it is considered beneficial to develop screening procedures aimed at high-risk students because individual interventions should start before the diagnosis is established. Timely interventions aimed at addressing risk factors associated with risk for alcohol abuse will increase the chances for preventing the development of alcohol abuse and alcohol-related issues. Consequently, reducing alcohol abuse will reduce the possibility of risks associated with excessive alcohol consumption, including both negative health-related and criminal behavior-related (e.g., physical abuse, sexual abuse, driving under the influence, and property crimes; [NIAAA], 2013) consequences.
A proactive counseling approach on campuses can be used to prevent excessive alcohol consumption and alcohol-related offenses, but it is also expected that this study could potentially contribute to further development of police work related to processing students arrested for alcohol-related offenses. According to Hingson, Heeren, Zakocs, Kopstein, and Wechsler (2002), a survey of 6,930 college students between the ages of 18 and 24 years found that 1.4% of them were arrested for alcohol-related offenses, thus the projected number of alcohol-related arrests in the student population is 112,000 (95% CI = 89,871-134,132). It is likely that some or most of those students were not treated properly because the reported treatment rate was 1.2% for alcohol and drug treatment (projected prevalence 98,584; 95% CI = 71,067-126,101; Hingson et al., 2002). The results of this study will be used to recommend planning screening procedures to reduce the risks for alcohol-related offenses, but the implications for treating known alcohol-related offenders will also be discussed.
Research Questions and Hypotheses
Research Question 1: How does excessive alcohol use compare to other illicit substance use in the student population?
H11: Excessive alcohol use will be more prevalent than illicit substance use, which includes marijuana, crack, cocaine, heroin, hallucinogens, inhalants, pain relievers, tranquilizers, stimulants, and sedatives.
Research Question 2: How is alcohol consumption different based on education status and the level of educational attainment?
H12: Individuals with a higher education level (4+ year college) at any age will more likely report drinking at least once and report drinking more frequently than individuals with a lower level of academic achievement.
H22: College students between the ages of 18 and 22 will more likely report excessive alcohol use and binge drinking compared to other populations.
Research Question 3: How are alcohol consumption levels different among students from different states?
H13: Students from states with higher student concentrations, such as California, Florida, Georgia, Texas, New York, Illinois, and Massachusetts, consume more alcohol than students from other states. Research Question 4: How does alcohol abuse differ based on the ethnicity of the students?
H14: There are no significant differences in alcohol consumption among student ethnic groups. Research Question 5: How do full-time students compare to part-time students in terms of alcohol consumption?
H15: Full-time students are more likely to consume more alcohol compared to part-time students.
Research Question 6: How are socioeconomic factors associated with alcohol consumption?
H16: Household composition and household income are inversely associated with excessive alcohol consumption.
Research Question 7: How does the employment status of college students affect alcohol consumption?
H17: Unemployed students are more likely to engage in excessive alcohol consumption than employed college students.
Research Question 8: How does personal history affect alcohol use in college students?
H18: Stressful events experienced in youth and a history of criminal behavior are positively associated with alcohol consumption.
Research Question 9: How does mental health affect alcohol consumption in college students?
H19: Students with a history of mental illness will more likely engage in excessive alcohol consumption than students without a history of mental illness.
Research Question 10: How does peer pressure affect alcohol consumption in college students?
H110: Students exposed to peer pressure are more likely to develop excessive alcohol consumption and engage in binge drinking than students who are not exposed to peer pressure.
H210: Students familiar with alcohol-related issues through education will more likely resist excessive alcohol consumption and binge drinking in spite of peer pressure compared to students who did not receive similar educational classes.
Two frameworks will be used to respond to the research questions of this study and analyze the results because the motivations for excessive alcohol consumption can vary. According to the theory of normative social behavior (NSB), the students’ normative beliefs determine their alcohol consumption, and the most common influences on their normative beliefs include injunctive norms, group identity, and outcome expectations (Rimal & Mollen, 2013). All of these factors are influenced by the beliefs or behaviors of majority of the students in general or within a specific group are alcohol users, and an individual develops positive expectancies (e.g., belief that alcohol will be beneficial for their social status). The study by Rimal and Mollen (2013) expanded the theory of normative social behavior by introducing issue familiarity as the moderating variable, which means that students familiar with the issues associated with alcohol use were less likely to develop excessive alcohol consumption, despite the potential peer pressure or desire to conform to group norms.
In addition to socialization and experimentation, alcohol abuse is also one of the indirect coping strategies students often use to alleviate negative emotions and stress, but drinking is an ineffective strategy because it does not resolve the issues students are trying to cope with and leads to reduced self-care, high-risk health behaviors, possible criminal behaviors, and low academic achievement (Carey & Correia, 1997). According to the stress buffering model, psychological and material support is critical for overcoming stressful situations (LaRocco, House, & French, 1980; Cohen & Wills, 1985). Therefore, it is expected that socioeconomic status, employment status, and supporting environmental factors (i.e. household composition and lack of negative peer pressure) will be inversely correlated with alcohol abuse.
Scope of the Study
Although the NSDUH 2013 study includes a national sample consisting of various populations, this study will focus on the student population, including both full-time and part-time students. Full-time students who participated in the study are between the ages of 18 and 22 whereas part-time students are a group that can consist of adults because they can enroll in part-time education. The students who participated in the study are located throughout the US.
Other populations that participated in the study will be included in some analyses for comparison purposes. For example, a comparison of alcohol consumption in students and alcohol consumption in employed middle-aged adults will be one of the analyses conducted to determine how students compare to other populations.
Significance of the Study
This study will use a dataset that includes information about alcohol and drug abuse in a nationally representative sample, so it is expected that the results obtained will be credible despite the retrospective nature of the study. The results and interpretations presented in this study will be mainly of interest to higher education counselors who are interested in reducing alcohol abuse among college students. The practical implementations of the results in terms of policy development and preventive screening for alcohol abuse will be discussed, and directions for future research aimed at implementing and evaluating interventions aimed at addressing risk factors associated with alcohol abuse in the college student population will be recommended.
Alcohol abuse is a significant issue in the student population, but preventive strategies are usually developed at group-level whereas individual-level interventions occur only after alcohol abuse is diagnosed. However, it has been established that various risk factors can lead to increased risk for alcohol abuse, so the purpose of this study is to identify those factors using a nationally representative sample of college students. A thorough understanding of risk factors associated with alcohol abuse in the student population will aid in the development of preventive measures that will aim to reduce negative alcohol-related consequences.
Chapter 2 will present the review of literature relevant to alcohol use in the student population. The variables contained in the dataset that will be used to perform the analyses will also be listed and discussed in this chapter. Chapter 3 will present the procedures and statistical tests used to analyze the data and the rationale for the selection of appropriate tests.
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