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1.  Effectiveness of a Web-Based Brief Alcohol Intervention and Added Value of Normative Feedback in Reducing Underage Drinking: A Randomized Controlled Trial 
Background
Current insights indicate that Web-based delivery may enhance the implementation of brief alcohol interventions. Previous research showed that electronically delivered brief alcohol interventions decreased alcohol use in college students and adult problem drinkers. To date, no study has investigated the effectiveness of Web-based brief alcohol interventions in reducing alcohol use in younger populations.
Objective
The present study tested 2 main hypotheses, that is, whether an online multicomponent brief alcohol intervention was effective in reducing alcohol use among 15- to 20-year-old binge drinkers and whether inclusion of normative feedback would increase the effectiveness of this intervention. In additional analyses, we examined possible moderation effects of participant’s sex, which we had not a priori hypothesized.
Method
A total of 575 online panel members (aged 15 to 20 years) who were screened as binge drinkers were randomly assigned to (1) a Web-based brief alcohol intervention without normative feedback, (2) a Web-based brief alcohol intervention with normative feedback, or (3) a control group (no intervention). Alcohol use and moderate drinking were assessed at baseline, 1 month, and 3 months after the intervention. Separate analyses were conducted for participants in the original sample (n = 575) and those who completed both posttests (n = 278). Missing values in the original sample were imputed by using the multiple imputation procedure of PASW Statistics 18.
Results
Main effects of the intervention were found only in the multiple imputed dataset for the original sample suggesting that the intervention without normative feedback reduced weekly drinking in the total group both 1 and 3 months after the intervention (n =575, at the 1-month follow-up, beta = -.24, P = .05; at the 3-month follow-up, beta = -.25, P = .04). Furthermore, the intervention with normative feedback reduced weekly drinking only at 1 month after the intervention (n=575, beta = -.24, P = .008). There was also a marginally significant trend of the intervention without normative feedback on responsible drinking at the 3-month follow-up (n =575, beta = .40, P =.07) implying a small increase in moderate drinking at the 3-month follow-up. Additional analyses on both datasets testing our post hoc hypothesis about a possible differential intervention effect for males and females revealed that this was the case for the impact of the intervention without normative feedback on weekly drinking and moderate drinking at the 1-month follow-up (weekly drinking for n = 278, beta = -.80, P = .01, and for n = 575, beta = -.69, P = .009; moderate drinking for n = 278, odds ratio [OR] = 3.76, confidence interval [CI] 1.05 - 13.49, P = .04, and for n = 575, OR = 3.00, CI = 0.89 - 10.12, P = .08) and at the 3-month follow-up (weekly drinking for n = 278, beta = -.58, P = .05, and for n = 575, beta = -.75, P = .004; moderate drinking for n = 278, OR = 4.34, CI = 1.18 - 15.95, P = .04, and for n = 575, OR = 3.65, CI = 1.44 - 9.25, P = .006). Furthermore, both datasets showed an interaction effect between the intervention with normative feedback and participant’s sex on weekly alcohol use at the 1-month follow-up (for n = 278, beta = -.74, P =.02, and for n = 575, beta = -.64, P =.01) and for moderate drinking at the 3-month follow-up (for n = 278, OR = 3.10, CI = 0.81 - 11.85, P = .07, and for n = 575, OR = 3.00, CI = 1.23 - 7.27, P = .01). Post hoc probing indicated that males who received the intervention showed less weekly drinking and were more likely to drink moderately at 1 month and at 3 months following the intervention. For females, the interventions yielded no effects: the intervention without normative feedback even showed a small unfavorable effect at the 1-month follow-up.
Conclusion
The present study demonstrated that exposure to a Web-based brief alcohol intervention generated a decrease in weekly drinking among 15- to 20-year-old binge drinkers but did not encourage moderate drinking in the total sample. Additional analyses revealed that intervention effects were most prominent in males resulting in less weekly alcohol use and higher levels of moderate drinking among 15- to 20-year-old males over a period of 1 to 3 months.
Trial Registration
ISRCTN50512934; http://www.controlled-trials.com/ISRCTN50512934/ (Archived by WebCite at http://www.webcitation.org/5usICa3Tx)
doi:10.2196/jmir.1465
PMCID: PMC3057308  PMID: 21169172
Web-based brief alcohol intervention; adolescents; normative feedback; moderate drinking; alcohol use
2.  Event- and Context-Specific Normative Misperceptions and High-Risk Drinking: 21st Birthday Celebrations and Football Tailgating* 
Journal of studies on alcohol  2006;67(2):282-289.
Objective
Negative alcohol-related consequences often occur during specific events and in specific contexts (eg., 21st birthday celebrations and tailgating parties). A lack of available event- and context-specific interventions suggests the need to better understand factors associated with heavy drinking in these contexts, with an eye toward developing specific interventions. The purpose of this research was to lay the foundation for developing personalized normative feedback interventions for 21st birthday celebratory drinking and tailgating drinking by evaluating whether students overestimate norms in these specific contexts, as they do more generally.
Method
Perceived descriptive norms and alcohol consumption were assessed at event- and context-specific levels in two studies. Study 1 included 119 students turning 21 years old who reported their 21st birthday drinking behavior and estimated the typical number of drinks consumed by students celebrating (their 21st birthday. Study 2 included 140 undergraduates drawn from a stratified random sample who reported their behavior regarding drinking and tailgating and their perceived norms for typical drinking and tailgating behavior.
Results
Results from Study 1 revealed that students overestimated peer drinking during 21st birthday celebrations, and this overestimation was associated with heavier drinking on one’s own 21st birthday. In Study 2, students underestimated the percentage of tailgaters who drank but overestimated typical consumption. Overestimation was consistently associated with heavier drinking during tailgating.
Conclusions
Successful correction of general normative misperceptions has been shown to reduce drinking in other research. Documentation of normative misperceptions for specific events and context provided by these results represents an important step in developing event- and context-specific interventions utilizing specific normative feedback.
PMCID: PMC2459312  PMID: 16562411
3.  Personalised Normative Feedback for Preventing Alcohol Misuse in University Students: Solomon Three-Group Randomised Controlled Trial 
PLoS ONE  2012;7(9):e44120.
Background
Young people tend to over-estimate peer group drinking levels. Personalised normative feedback (PNF) aims to correct this misperception by providing information about personal drinking levels and patterns compared with norms in similar aged peer groups. PNF is intended to raise motivation for behaviour change and has been highlighted for alcohol misuse prevention by the British Government Behavioural Insight Team. The objective of the trial was to assess the effectiveness of PNF with college students for the prevention of alcohol misuse.
Methodology
Solomon three-group randomised controlled trial. 1751 students, from 22 British Universities, allocated to a PNF group, a normal control group, or a delayed measurement control group to allow assessment of any measurement effects. PNF was provided by email. Participants completed online questionnaires at baseline, 6- and 12-months (only 12-months for the delayed measurement controls). Drinking behaviour measures were (i) alcohol disorders; (ii) frequency; (iii) typical quantity, (iv) weekly consumption; (v) alcohol-related problems; (vi) perceived drinking norms; and (vii) positive alcohol expectancies. Analyses focused on high-risk drinkers, as well as all students, because of research evidence for the prevention paradox in student drinkers.
Principal Findings
Follow-up rates were low, with only 50% and 40% responding at 6- and 12-months, respectively, though comparable to similar European studies. We found no evidence for any systematic attrition bias. Overall, statistical analyses with the high risk sub-sample, and for all students, showed no significant effects of the intervention, at either time-point, in a completed case analysis and a multiple imputation analysis.
Conclusions
We found no evidence for the effectiveness of PNF for the prevention of alcohol misuse and alcohol-related problems in a UK student population.
Registration
Controlled-Trials.com ISRCTN30784467
doi:10.1371/journal.pone.0044120
PMCID: PMC3440433  PMID: 22984466
4.  Normative Feedback for Parents of College Students: Piloting a Parent Based Intervention to Correct Misperceptions of Students’ Alcohol Use and Other Parents’ Approval of Drinking 
Addictive behaviors  2013;39(1):107-113.
Objective
Multi-component parent-based interventions (PBIs) provide a promising avenue for targeting alcohol use and related consequences in college students. Parents of college-aged children can have a significant influence on their children’s alcohol use decisions. However, parents tend to underestimate their own child’s alcohol use and overestimate other similar parents’ approval of student drinking. These misperceptions could have important implications for parents’ own attitudes and alcohol-related communication with their student. Targeting these misperceptions through normative feedback could help promote greater and more in-depth alcohol-related communication. The present study examines the potential efficacy of web-based alcohol-related normative feedback for parents of college students.
Method
A sample of 144 parents of college students received web-based normative feedback about students’ alcohol use and approval, as well as other same-college parents’ alcohol approval. Parents completed measures of perceived student alcohol use, student alcohol approval, other-parent alcohol approval, and intentions to discuss alcohol use both pre- and post-normative feedback.
Results
Post-feedback, parents reported stronger intentions to talk to their student about alcohol, were less confident in their knowledge of their students’ alcohol use, and believed that their student drank in greater quantity and more frequently than pre-feedback. Parents also perceived other parents to be less approving of alcohol use after viewing normative feedback.
Conclusions
These findings provide preliminary support for the use of web-based normative feedback for parents of college students. Given these promising results, further research developing and testing this approach merits attention.
doi:10.1016/j.addbeh.2013.08.036
PMCID: PMC4035119  PMID: 24099892
Normative feedback; Parent-based intervention; College drinking; Alcohol use
5.  Ethnicity Specific Norms and Alcohol Consumption Among Hispanic/Latino/a and Caucasian Students 
Addictive Behaviors  2012;37(4):573-576.
Previous research has shown that social norms are among the strongest predictors of college student drinking and that normative misperceptions of more similar groups’ drinking behavior may be more influential on individual drinking than those groups perceived to be more different. However, limited research has explored the moderating role of ethnicity in this context. The current study examined the differential impact that Hispanic/Latino/a and Caucasian students’ normative perceptions of both typical and same-ethnicity college students’ drinking behavior had on their own drinking. Participants (N = 5,369 students; 60.4% female; 81.4% Caucasian; mean age 19.9 years) from two colleges completed web-based surveys assessing their alcohol consumption, and their perceptions of the drinking behaviors of both the typical college student and the typical same-ethnicity college student at their campus. Results demonstrated that perceived norms were significantly associated with likelihood of drinking regardless of race or ethnicity specificity, but that Hispanics/Latinos/as typically had weaker relationships between ethnicity-specific norms and drinking than general student norms and drinking. The opposite was true for Caucasians such that the relationship between same-ethnicity norms and drinking was stronger than the relationship between general student norms and drinking. Further, Hispanic/Latino/a students with high perceived norms were less likely to have consumed any alcohol than Caucasians with similar normative beliefs. Further, a campus site interaction suggests that the size of the minority population on campus relative to other students may influence the relationship between norms and drinking. Implications and targets for future investigation are discussed.
doi:10.1016/j.addbeh.2012.01.007
PMCID: PMC3391163  PMID: 22293207
Social Norms; College Student Drinking; Latino; Latina
6.  Estimates and influences of reflective opposite-sex norms on alcohol use among a high-risk sample of college students: Exploring Greek-affiliation and gender effects 
Addictive Behaviors  2011;37(5):596-604.
Reflective opposite sex norms are behavior that an individual believes the opposite sex prefers them to do. The current study extends research on this recently introduced construct by examining estimates and influences of reflective norms on drinking in a large high-risk heterosexual sample of male and female college students from two universities. Both gender and Greek-affiliation served as potential statistical moderators of the reflective norms and drinking relationship. All participants (N = 1790; 57% female) answered questions regarding the amount of alcohol they believe members of the opposite sex would like their opposite sex friends, dates, and sexual partners to drink. Participants also answered questions regarding their actual preferences for drinking levels in each of these three relationship categories. Overall, women overestimated how much men prefer their female friends and potential sexual partners to drink, whereas men overestimated how much women prefer their sexual partners to drink. Greek-affiliated males demonstrated higher reflective norms than non-Greek males across all relationship categories, and for dating partners, only Greek-affiliated males misperceived women’s actual preferences. Among women however, there were no differences between reflective norms estimates or the degree of misperception as a function of Greek status. Most importantly, over and above perceived same-sex social norms, higher perceived reflective norms tended to account for greater variance in alcohol consumption for Greeks (vs. non-Greeks) and males (vs. females), particularly within the friend and sexual partner contexts. The findings highlight that potential benefits might arise if existing normative feedback interventions were augmented with reflective normative feedback designed to target the discrepancy between perceived and actual drinking preferences of the opposite sex.
doi:10.1016/j.addbeh.2011.11.027
PMCID: PMC3395330  PMID: 22305289
reflective norms; college students; alcohol; fraternity and sorority; social norms; normative feedback
7.  Normative Misperceptions and Temporal Precedence of Perceived Norms and Drinking* 
Journal of studies on alcohol  2006;67(2):290-299.
Objective
Previous research has shown that students overestimate the drinking of their peers, and that perceived norms are strongly associated with drinking behavior. Explanations for these findings have been based largely on cross-sectional data, precluding the ability to evaluate the stability of normative misperceptions or to disentangle the direction of influence between perceived norms and drinking. The present research was designed to evaluate (1) the stability of normative misperceptions and (2) temporal precedence of perceived norms and drinking.
Method
Participants were college students (N = 164; 94 women) who completed assessments of perceived norms and reported behavior for drinking frequency and weekly quantity. Most participants (68%) completed the same measures again two months later.
Results
Results indicated large and stable overestimations of peer drinking for frequency and weekly quantity. Results also showed that for weekly quantity, perceived norms predicted later drinking, but drinking also predicted later perceived norms. Results for frequency revealed perceived norms predicted later drinking, but drinking did not predict later perceived norms.
Conclusion
These findings underscore the importance of longitudinal designs in evaluating normative influences on drinking. The present findings suggest that normative misperceptions are stable, at least over a relatively short time period. Findings support a mutual influence model of the relationship between perceived norms and drinking quantity but are more strongly associated with conformity explanations for the relationship between perceived norms and drinking frequency. Results are discussed in terms of implications for prevention interventions.
PMCID: PMC2443635  PMID: 16562412
8.  Peer substance use overestimation among French university students: a cross-sectional survey 
BMC Public Health  2010;10:169.
Background
Normative misperceptions have been widely documented for alcohol use among U.S. college students. There is less research on other substances or European cultural contexts. This study explores which factors are associated with alcohol, tobacco and cannabis use misperceptions among French college students, focusing on substance use.
Methods
12 classes of second-year college students (n = 731) in sociology, medicine, nursing or foreign language estimated the proportion of tobacco, cannabis, alcohol use and heavy episodic drinking among their peers and reported their own use.
Results
Peer substance use overestimation frequency was 84% for tobacco, 55% for cannabis, 37% for alcohol and 56% for heavy episodic drinking. Cannabis users (p = 0.006), alcohol (p = 0.003) and heavy episodic drinkers (p = 0.002), are more likely to overestimate the prevalence of use of these consumptions. Tobacco users are less likely to overestimate peer prevalence of smoking (p = 0.044). Women are more likely to overestimate tobacco (p < 0.001) and heavy episodic drinking (p = 0.007) prevalence. Students having already completed another substance use questionnaire were more likely to overestimate alcohol use prevalence (p = 0.012). Students exposed to cannabis prevention campaigns were more likely to overestimate cannabis (p = 0.018) and tobacco use (p = 0.022) prevalence. Other identified factors are class-level use prevalences and academic discipline.
Conclusions
Local interventions that focus on creating realistic perceptions of substance use prevalence could be considered for cannabis and alcohol prevention in French campuses.
doi:10.1186/1471-2458-10-169
PMCID: PMC2858117  PMID: 20350317
9.  RCT of Web-based Personalized Normative Feedback for College Drinking Prevention: Are Typical Student Norms Good Enough? 
Objectives
Personalized normative feedback (PNF) interventions are generally effective at correcting normative misperceptions and reducing risky alcohol consumption among college students. However, research has yet to establish what level of reference group specificity is most efficacious in delivering PNF. This study compared the efficacy of a web-based PNF intervention employing eight increasingly-specific reference groups against a Web-BASICS intervention and a repeated-assessment control in reducing risky drinking and associated consequences.
Method
Participants were 1663 heavy drinking Caucasian and Asian undergraduates at two universities. The referent for web-based PNF was either the typical same-campus student, or a same-campus student at one (either gender, race, or Greek-affiliation), or a combination of two (e.g., gender and race), or all three levels of specificity (i.e., gender, race, and Greek-affiliation). Hypotheses were tested using quasi-Poisson generalized linear models fit by generalized estimating equations.
Results
The PNF intervention participants showed modest reductions in all four outcomes (average total drinks, peak drinking, drinking days, and drinking consequences) compared to control participants. No significant differences in drinking outcomes were found between the PNF group as a whole and the Web-BASICS group. Among the eight PNF conditions, participants receiving typical student PNF demonstrated greater reductions in all four outcomes compared to those receiving PNF for more specific reference groups. Perceived drinking norms and discrepancies between individual behavior and actual norms mediated the efficacy of the intervention.
Conclusions
Findings suggest a web-based PNF intervention using the typical student referent offers a parsimonious approach to reducing problematic alcohol use outcomes among college students.
doi:10.1037/a0034087
PMCID: PMC3983963  PMID: 23937346
alcohol; social norms; personalized normative feedback; college students
10.  Injunctive Peer Misperceptions and the Mediation of Self-Approval on Risk for Driving After Drinking Among College Students 
Journal of health communication  2013;18(4):459-477.
Of the alcohol-related risks faced by college students, it is arguable that none presents a greater public health hazard than driving after drinking (DAD). The present study examined the extent to which students’ injunctive misperceptions toward DAD predicted the likelihood to engage in DAD and how this relation was mediated by self-approval of DAD. Participants were 2,848 college students (59.1% female, 64.6% Caucasian) from two U.S. West Coast universities who completed confidential web-based surveys assessing DAD beliefs and behaviors. Results revealed that respondents tended to overestimate their peers’ approval toward DAD. Moreover, the subgroups likely to engage in DAD—men, 21+ years of age, Greek affiliated students, Caucasians, students with a family history of alcohol abuse—were also more likely to misperceive (i.e., overestimate) their peers’ level of approval toward DAD. Using binary logistic regression analyses, self-approval of DAD emerged as an important statistical mediator in the relation between misperception of typical student approval toward DAD and engagement in DAD. Results point to the considerable role injunctive peer misperceptions may play in the pathways leading to drinking-driving risk. These findings provide preliminary support for DAD-specific social normative interventions, either complementing or supplementing existing alcohol interventions. By targeting high-risk student subgroups and communicating accurate drinking-driving norms, these proposed interventions have the potential to reduce self-approval and incidence of DAD.
doi:10.1080/10810730.2012.727963
PMCID: PMC4254773  PMID: 23379424
11.  Perception of tobacco, cannabis, and alcohol use of others is associated with one’s own use 
Background
Interventions have been developed to reduce overestimations of substance use among others, especially for alcohol and among students. Nevertheless, there is a lack of knowledge on misperceptions of use for substances other than alcohol. We studied the prevalence of misperceptions of use for tobacco, cannabis, and alcohol and whether the perception of tobacco, cannabis, and alcohol use by others is associated with one’s own use.
Methods
Participants (n = 5216) in a cohort study from a census of 20-year-old men (N = 11,819) estimated the prevalence of tobacco and cannabis use among peers of the same age and sex and the percentage of their peers drinking more alcohol than they did. Using the census data, we determined whether participants overestimated, accurately estimated, or underestimated substance use by others. Regression models were used to compare substance use by those who overestimated or underestimated peer substance with those who accurately estimated peer use. Other variables included in the analyses were the presence of close friends with alcohol or other drug problems and family history of substance use.
Results
Tobacco use by others was overestimated by 46.1% and accurately estimated by 37.3% of participants. Cannabis use by others was overestimated by 21.8% and accurately estimated by 31.6% of participants. Alcohol use by others was overestimated by more than half (53.4%) of participants and accurately estimated by 31.0%. In multivariable models, compared with participants who accurately estimated tobacco use by others, those who overestimated it reported smoking more cigarettes per week (incidence rate ratio [IRR] [95% CI], 1.17 [range, 1.05, 1.32]). There was no difference in the number of cigarettes smoked per week between those underestimating and those accurately estimating tobacco use by others (IRR [95% CI], 0.99 [range, 0.84, 1.17]). Compared with participants accurately estimating cannabis use by others, those who overestimated it reported more days of cannabis use per month (IRR [95% CI], 1.43 [range, 1.21, 1.70]), whereas those who underestimated it reported fewer days of cannabis use per month (IRR [95% CI], 0.62 [range, 0.23, 0.75]). Compared with participants accurately estimating alcohol use by others, those who overestimated it reported consuming more drinks per week (IRR [95% CI], 1.57 [range, 1.43, 1.72]), whereas those who underestimated it reported consuming fewer drinks per week (IRR [95% CI], 0.41 [range, 0.34, 0.50]).
Conclusions
Perceptions of substance use by others are associated with one’s own use. In particular, overestimating use by others is frequent among young men and is associated with one’s own greater consumption. This association is independent of the substance use environment, indicating that, even in the case of proximity to a heavy-usage group, perception of use by others may influence one’s own use. If preventive interventions are to be based on normative feedback, and their aim is to reduce overestimations of use by others, then the prevalence of overestimation indicates that they may be of benefit to roughly half the population; or, in the case of cannabis, to as few as 20%. Such interventions should take into account differing strengths of association across substances.
doi:10.1186/1940-0640-8-15
PMCID: PMC3853223  PMID: 24499600
Overestimation; Substance use; Perception; Alcohol; Tobacco; Cannabis
12.  A Population-Based Study on Alcohol and High-Risk Sexual Behaviors in Botswana 
PLoS Medicine  2006;3(10):e392.
Background
In Botswana, an estimated 24% of adults ages 15–49 years are infected with HIV. While alcohol use is strongly associated with HIV infection in Africa, few population-based studies have characterized the association of alcohol use with specific high-risk sexual behaviors.
Methods and Findings
We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana using a stratified two-stage probability sample design. Multivariate logistic regression was used to assess correlates of heavy alcohol consumption (>14 drinks/week for women, and >21 drinks/week for men) as a dependent variable. We also assessed gender-specific associations between alcohol use as a primary independent variable (categorized as none, moderate, problem and heavy drinking) and several risky sex outcomes including: (a) having unprotected sex with a nonmonogamous partner; (b) having multiple sexual partners; and (c) paying for or selling sex in exchange for money or other resources. Criteria for heavy drinking were met by 31% of men and 17% of women. Adjusted correlates of heavy alcohol use included male gender, intergenerational relationships (age gap ≥10 y), higher education, and living with a sexual partner. Among men, heavy alcohol use was associated with higher odds of all risky sex outcomes examined, including unprotected sex (AOR = 3.48; 95% confidence interval [CI], 1.65 to 7.32), multiple partners (AOR = 3.08; 95% CI, 1.95 to 4.87), and paying for sex (AOR = 3.65; 95% CI, 2.58 to 12.37). Similarly, among women, heavy alcohol consumption was associated with higher odds of unprotected sex (AOR = 3.28; 95% CI, 1.71 to 6.28), multiple partners (AOR = 3.05; 95% CI, 1.83 to 5.07), and selling sex (AOR = 8.50; 95% CI, 3.41 to 21.18). A dose-response relationship was seen between alcohol use and risky sexual behaviors, with moderate drinkers at lower risk than both problem and heavy drinkers.
Conclusions
Alcohol use is associated with multiple risks for HIV transmission among both men and women. The findings of this study underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.
Alcohol use is associated with multiple risks for HIV transmission in men and women. The findings underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.
Editors' Summary
Background.
Human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS), is most commonly spread through unprotected sex with an infected partner. HIV enters the body through the lining of the sex organs, rectum, or mouth, and destroys immune system cells, leaving the infected person susceptible to other viruses and bacteria. Although HIV education and prevention campaigns emphasize the importance of safe sex in reducing HIV transmission, people continue to become infected by having unprotected sex (that is, not using a condom) with either a nonmonogamous partner or multiple sexual partners, or in situations where they are paying for or selling sex. Research in different populations suggested that heavy alcohol use is associated with risky sexual behaviors. This is because alcohol relaxes the brain and body, reduces inhibitions, and diminishes risk perception. Drinking alcohol may further increase the risk of becoming infected with HIV through its suppressive effects on the immune system.
Why Was This Study Done?
Alcohol abuse is widespread in sub-Saharan Africa where most HIV infections occur and has been associated with risky sexual behaviors. It may therefore be one of the most common, potentially modifiable HIV risk factors in this region. However, research to date has concentrated on the association between alcohol consumption and risky sex in people attending HIV-treatment clinics or recruited at beer halls, and these populations may not be representative of the general population of sub-Saharan Africa. In this study, the researchers have investigated the potential role of alcohol in perpetuating the HIV epidemic by undertaking a population-based study on alcohol use and high-risk sexual behaviors in Botswana. Nearly a quarter of adults are infected with HIV here, and alcohol abuse is also common, particularly in the townships.
What Did the Researchers Do and Find?
The researchers recruited a random cross-section of people from the five districts of Botswana with the highest number of HIV-infected individuals and interviewed all 1,268 participants using a questionnaire. This included general questions about the participants (for example, their age and marital status) and questions about alcohol use, sexual behavior, and knowledge of HIV. Overall, 31% of the men in the study and 17% of the women were heavy drinkers—more than 21 drinks/week for men, 14 for women; a drink is half a pint of beer or a glass of wine. Heavy alcohol use was associated with being male, being in an intergenerational relationship (at least 10 years age difference between partners; intergenerational sex facilitates the continued spread of HIV in sub-Saharan Africa), having had more education, and living with a sexual partner. Among men, those who drank heavily were three to four times more likely to have unprotected sex or multiple partners or to pay for sex than nondrinkers. Among women, there was a similar association between heavy drinking and having unprotected sex or multiple partners, and heavy drinkers were eight times as likely to sell sex as nondrinkers. For both men and women, the more they drank, the more likely they were to have risky sex. The study did not address behavior among same-sex partnerships.
What Do These Findings Mean?
This study indicates that heavy alcohol consumption is strongly and consistently associated with sexual risk behaviors in both men and women in Botswana. Because of the study design, it does not prove that heavy alcohol use is the cause of such behaviors but provides strong circumstantial evidence that this is the case. It is possible that these results may not apply to neighboring African countries—Botswana is unique in being relatively wealthy and in its government being strongly committed to tackling HIV. Nevertheless, taken together with the results of other studies, this research strongly argues for the need to deal with alcohol abuse within HIV prevention programs in sub-Saharan Africa. Strategies to do this could include education campaigns that target both alcohol use and HIV in schools and in social venues, including beer halls. But, stress the researchers, any strategy that is used must consider the cultural and social significance of alcohol use (in Botswana, alcohol use is a symbol of masculinity and high socioeconomic status) and must simultaneously tackle not only the overlap between alcohol use and risky sexual behavior but also the overlap between alcohol and other risk behaviors such as intergenerational sex.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030392.
US National Institute of Allergy and Infectious Diseases factsheet on HIV infection and AIDS
US Department of Health and Human Services information on AIDS
US Centers for Disease Control and Prevention information on HIV/AIDS
US National Institute on Alcohol Abuse and Alcoholism patient information on alcohol and HIV/AIDS]
Aidsmap, information on HIV and AIDS provided by the charity NAM,which includes some information on HIV infections and alcohol
AVERT information on HIV and AIDS in Botswana
doi:10.1371/journal.pmed.0030392
PMCID: PMC1592342  PMID: 17032060
13.  Associations of descriptive and reflective injunctive norms with risky college drinking 
The current study describes the relative predictive power of descriptive norms (i.e., how much the target student believes referents “drink until they get drunk”) and reflective injunctive norms (i.e., target student’s perception of referents’ approval of the target student drinking until drunk) across various reference groups. The aim of this study was to gain further insight into which types of norms and reference groups are most highly concurrently correlated with risky drinking. It was hypothesized that both reflective injunctive and descriptive norms would be significantly positively correlated with risky drinking outcomes, and that more proximal reference group norms would be more highly predictive than more distal reference group norms. Participants (N = 837) were college students on the US west coast who completed questionnaires in the context of a longitudinal parent study. Cross-sectional, zero-inflated negative binomial regressions were used to test the relative strengths of correlations between descriptive and reflective injunctive norms (i.e., for typical college students, closest friend, person whose opinion they value most and closest family member) and risky drinking (i.e., peak alcohol quantity, frequency of heavy drinking episodes, and alcohol-related problems). Findings showed that descriptive and reflective injunctive norms were most consistently, strongly and positively correlated with risky drinking when they involved referents who were closer to the target college drinkers (i.e., closest friend and person whose opinion you value the most). Norms for typical college students were less consistent correlates of risky drinking. These findings may contribute to the knowledge base for enhancing normative re-education and personalized normative feedback interventions to include more personally salient and powerful normative information.
doi:10.1037/a0032828
PMCID: PMC3988317  PMID: 24364691
College drinking; descriptive norms; reflective injunctive norms; risky drinking; alcohol use
14.  Implications of Formal Alcohol Screening in Burn Patients 
The purpose of this study was to screen burn patients for alcohol use disorders to identify those at increased risk for repeat injury and adverse effects of alcohol use. We examined associations of at-risk drinking and dependence symptoms as measured by a formal screening tool and blood alcohol concentration (BAC) to guide further screening, treatment, and research. We hypothesized that the majority of drinkers would not have symptoms of alcohol dependence, that BAC would be inadequate to screen for alcohol disorders, and that at-risk drinkers would be more likely to be unemployed and uninsured than healthy drinkers. Formal screening of English speakers, age 16 to 75, admitted to the burn service for over 24 hours was conducted for a 6-month period, using the Alcohol Use Disorders Identification Test. Of the 123 patients eligible for the study, 110 (89.4%) were approached for formal screening, four refused (3.6%), and 13 were missed (10.6%). BAC was obtained in 68 of 110 (61.8%); no patient who reported abstinence had a positive BAC. Of the 106 screened, 34.9% were nondrinkers, 11.3% drank daily or almost daily, and 28.3% binge drank at least monthly (>4 drinks per occasion for men, >3 for women). Of the patients who drank, only eight patients reported one or more sign of dependence in the last year (11.6%). For the group as a whole, 20.9% met Alcohol Use Disorders Identification Test criteria for at-risk drinking, with an average BAC of 39.8 mg/dl, (range 0–242 mg/dl). Using BAC of ≥80 mg/dl, only 5.6% of patients would have been identified as at-risk drinkers. Twenty-three percent of patients had no health insurance, 36% of whom were at-risk drinkers compared with 17.3% of insured patients (P < .05). For the group as a whole, 41.8% of patients were unemployed. At-risk drinking did not differ between employed and unemployed patients (24.6% vs 17.8%, P > .05). Among burn patients, formal alcohol screening identified that one in five patients is at risk for further problems from their drinking and that most at-risk drinkers are binge drinkers and do not show signs of dependency. Formal screening identified more at-risk drinkers than BAC. Implications of the screening findings are 1) because most burn patients who drink are binge but not dependent drinkers, alcohol withdrawal should be infrequent, and 2) animal models of alcohol use and burn injury should study acute intoxication and binge exposure. In addition, 3) we would expect burn patients to respond to brief interventions for alcohol use disorders similar to trauma and primary care patients.
doi:10.1097/BCR.0b013e3181921f31
PMCID: PMC2920748  PMID: 19060726
15.  Alcohol disorders in Canada as indicated by the CAGE questionnaire 
OBJECTIVE: To describe alcohol disorders in the general Canadian population, using as a standard indicator the CAGE questionnaire (Have you felt you needed to cut down on your drinking? Have you felt annoyed by criticism of your drinking? Have you felt guilty about drinking? Have you felt you needed a drink first thing in the morning [eye-opener]?). DESIGN: Secondary analysis of data from Canada's Alcohol and Other Drugs Survey (CADS), a national telephone survey conducted in 1994 of a representative sample of 12,155 people aged 15 years or more. PARTICIPANTS: The CAGE questionnaire was administered to 5894 drinkers who had consumed alcohol in the 12 months before the CADS survey. MAIN OUTCOME MEASURES: Respondents with positive (2 or more affirmative responses) and negative results on the CAGE questionnaire were compared as to demographic characteristics, alcohol consumption and harmful consequences of their drinking. Independent predictors of a positive result were identified by means of logistic regression analysis. RESULTS: A total of 5.8% of CAGE-tested current drinkers had a positive result on the past-year CAGE in 1994. The proportion of respondents reporting alcohol-related problems in one or more areas of their life was 7 times greater among drinkers with a positive result on the CAGE questionnaire than among those with a negative result (66.8% v. 9.5%) (p < 0.0001). When all demographic characteristics were controlled for simultaneously, male sex, residence in the Atlantic provinces, Quebec or the Prairies, single/never married or divorced/separated marital status, and low education level were found to be independent risk factors for a positive result on the CAGE questionnaire. About 85% of the respondents with a positive result had not sought help for their drinking. Applying the estimated sensitivity and specificity of the CAGE questionnaire in detecting alcohol dependence, as per criteria of the Diagnostic and Statistical Manual, in a general US population, the authors estimated that 4.1% of Canadians had an alcohol dependence in 1994. CONCLUSION: The large proportion of current drinkers with a positive result on the CAGE questionnaire who did not seek help for their drinking underscores the need for identification and brief interventions by physicians. Further research is needed to elucidate the underlying reasons for regional differences in CAGE status.
PMCID: PMC1228563  PMID: 9400407
16.  Normative Misperceptions of Drinking Among College Students: A Look at the Specific Contexts of Prepartying and Drinking Games* 
Objective
In the collegiate context, misperceptions of student drinking norms are among the most salient predictors of heavy drinking, Despite overall overestimations of peer alcohol use, misperceptions of context-specific behaviors have been infrequently studied. The present study examines students' perceptions of the high-risk behaviors of prepartying and drinking games and investigates the relationship between perceived and actual behaviors.
Method
A sample of 524 college students completed an online assessment of actual and perceived alcohol use related to prepartying and drinking games. Quantity and frequency of overall drinking, prepartying, and drinking games were assessed for perceptions of all students at the university, as well as for male and female students separately. Questions also assessed participants' overall drinking, prepartying, and drinking game behaviors.
Results
Participants significantly overestimated the prepartying and drinking game behaviors of all students, male students, and female students at their university. For men, perceptions of same-sex prepartying quantity and drinking game frequency and quantity were associated with actual behavior. For women, perceptions of both same-sex and other-sex prepartying quantity were associated with actual behavior.
Conclusions
These findings provide preliminary support for the association between context-specific perceived norms and actual prepartying and drinking game behaviors. Addressing these same-sex and opposite-sex norms during interventions may help students reduce their own engagement in these risky behaviors
PMCID: PMC4235610  PMID: 18432383
17.  Identification of Trajectories of Social Network Composition Change and the Relationship to Alcohol Consumption and Norms 
Drug and alcohol dependence  2013;132(0):309-315.
Background
College drinking is embedded in a social context, drawing attention to the effects of social network composition on consumption. The presence of heavy drinking friends in social networks predicts later alcohol misuse, but little is known about how the composition of one’s social network composition changes over time. This study identified changes in social network composition in a sample of at-risk students and examined the relationship among network trajectories, alcohol consumption, and descriptive norms.
Methods
Participants were 503 students (64% male) mandated to participate in an alcohol prevention intervention for residence hall alcohol policy violations. At baseline, students provided self-report data about alcohol consumption, perceived peer drinking norms, and peer alcohol involvement. Parallel assessments were completed at 6- and 12-months post-baseline.
Results
Growth-mixture models identified four groups of individuals with similar levels of heavy drinkers in their social networks. The majority of students had stable or decreasing numbers of heavy drinkers in their networks across the study, whereas two groups reported relatively stable densities of heavy drinkers from baseline to 6-months and increasing densities from 6- to 12-months. At baseline, the four groups were generally equivalent on consumption and normative perceptions. At 6- and 12-months, however, the groups differed significantly on consumption and norms.
Conclusions
These results suggest that changes in the number of heavy drinkers in college students’ social networks may have significant implications for at-risk drinking.
doi:10.1016/j.drugalcdep.2013.02.020
PMCID: PMC3748204  PMID: 23523132
college drinking; social networks; alcohol prevention; descriptive norms; trajectories
18.  Evaluating Personal Alcohol Feedback as a Selective Prevention for College Students with Depressed Mood 
Addictive behaviors  2007;32(12):2776-2787.
Objective
This research evaluated a brief mailed intervention for alcohol use as an adjunct to a brief depression treatment for college students with depression symptoms. The intervention aimed to correct normative misperceptions and reduce students’ drinking and related consequences.
Method
One hundred seventy seven college students (70% Female) with elevated scores on the Beck Depression Inventory were randomly assigned to intervention or control group. Participants in the intervention were mailed feedback and information detailing their reported alcohol use, moderation strategies, and accurate normative information regarding student drinking.
Results
Results indicated no main effects of the intervention on drinking or related problems but students receiving feedback showed significant reductions in their perception of drinking norms compared to the control group. Furthermore, students whose normative perceptions reduced showed significant reductions in total drinks per week and total alcohol related problems compared to those whose norms did not reduce.
Conclusions
Results support the importance of correcting normative perceptions and provide direction for selective prevention of alcohol use and related problems among college students with depressed mood.
doi:10.1016/j.addbeh.2007.04.014
PMCID: PMC3650834  PMID: 17499445
Alcohol; Norms; Selective Prevention; College Students
19.  Alcohol and blood pressure: the INTERSALT study. 
BMJ : British Medical Journal  1994;308(6939):1263-1267.
OBJECTIVES--To assess the relation between alcohol intake and blood pressure in men and women and in men at younger and older ages; to examine the influence of amount and pattern of alcohol consumption, as well as of acute effects, taking into account body mass index, smoking, and urinary sodium and potassium excretion. DESIGN--Subjects reported alcohol consumption for each of seven days before standardised blood pressure measurement, and whether they had consumed any alcohol in the 24 hours before measurement. SETTING--50 centres worldwide. SUBJECTS--4844 men and 4837 women aged 20-59. MAIN OUTCOME MEASURES--Effect of alcohol on blood pressure estimated by taking a weighted average of regression coefficients from centres. Acute effect assessed by examining mean differences in blood pressure of non-drinkers and of heavy drinkers who had and had not consumed alcohol in the 24 hours before measurement. Effect of pattern of consumption assessed by examining mean differences in blood pressure of non-drinkers compared with drinkers (i) whose intake was concentrated in fewer days or who were drinking more frequently, and (ii) whose alcohol intake varied little over the seven days or varied more substantially, as indicated by the standard deviation of daily consumption. RESULTS--Of the 48 centres in which some people reported consuming at least 300 ml/week of alcohol, 35 had positive regression coefficients linking heavy alcohol consumption to blood pressure. Overall, alcohol consumption was associated with blood pressure, significantly at the highest intake. After account was taken of key confounders, men who drank 300-499 ml alcohol/week had systolic/diastolic blood pressure on average 2.7/1.6 mmHg higher than non-drinkers, and men who drank > or = 500 ml alcohol/week had pressures of 4.6/3.0 mmHg higher. For women, heavy drinkers (> or = 300 ml/week) had blood pressures higher by 3.9/3.1 mmHg than non-drinkers. Heavy drinking and blood pressure were strongly associated in both sexes, and in men at both younger (20-39 years) and older (40-59 years) ages. In men who were heavy drinkers, episodic drinkers (those with great variation in daily alcohol consumption) had greater differences in blood pressure compared with non-drinkers than did regular drinkers of relatively constant amounts. CONCLUSION--The significant relation of heavy drinking (3-4 or more drinks/day) to blood pressure, observed in both men and women, and in younger and older men, was independent of and added to the effect on blood pressure of body mass index and urinary excretion of sodium and potassium. The findings indicate the usefulness of targeting those at high risk as well as the general population to reduce the adverse effects of alcohol on blood pressure.
PMCID: PMC2540174  PMID: 7802765
20.  Decomposing associations between acculturation and drinking in Mexican Americans 
Background
Acculturation to life in the United States is a known predictor of Hispanic drinking behavior. We compare the ability of 2 theoretical models of this effect – sociocultural theory and general stress theory – to account for associations between acculturation and drinking in a sample of Mexican Americans. Limitations of previous evaluations of these theoretical models are addressed by using a broader range of hypothesized cognitive mediators and a more direct measure of acculturative stress. In addition, we explore nonlinearities as possible underpinnings of attenuated acculturation effects among males.
Methods
Respondents (N = 2,595, current drinker N = 1,351) were interviewed as part of 2 recent multistage probability samples in a study of drinking behavior among Mexican Americans in the United States. The ability of norms, drinking motives, alcohol expectancies, and acculturation stress to account for relations between acculturation and drinking outcomes (volume and heavy drinking days) were assessed with a hierarchical linear regression strategy. Nonlinear trends were assessed by modeling quadratic effects of acculturation and acculturation stress on cognitive mediators and drinking outcomes.
Results
Consistent with previous findings, acculturation effects on drinking outcomes were stronger for females than males. Among females, only drinking motives explained acculturation associations with volume or heavy drinking days. Among males, acculturation was linked to increases in norms, and norms were positive predictors of drinking outcomes. However, adjusted effects of acculturation were non-existent or trending in a negative direction, which counter-acted this indirect normative influence. Acculturation stress did not explain positive associations between acculturation and drinking.
Conclusions
Stress and alcohol outcome expectancies play little role in the positive linear association between acculturation and drinking outcomes, but drinking motives appears to at least partially account for this effect. Consistent with recent reports, these results challenge stress models of linear acculturation effects on drinking outcomes and provide (partial) support for sociocultural models. Inconsistent mediation patterns – rather than nonlinearities – represented a more plausible statistical description of why acculturation-drinking associations are weakened among males.
doi:10.1111/j.1530-0277.2011.01712.x
PMCID: PMC3349785  PMID: 22316139
Mexican Americans; Acculturation
21.  Alcohol Consumption at Midlife and Successful Ageing in Women: A Prospective Cohort Analysis in the Nurses' Health Study 
PLoS Medicine  2011;8(9):e1001090.
Using the Nurses' Health Study, Qi Sun and colleagues examine whether moderate alcohol intake is associated with overall health and well-being among women who survive to older age.
Background
Observational studies have documented inverse associations between moderate alcohol consumption and risk of premature death. It is largely unknown whether moderate alcohol intake is also associated with overall health and well-being among populations who have survived to older age. In this study, we prospectively examined alcohol use assessed at midlife in relation to successful ageing in a cohort of US women.
Methods and Findings
Alcohol consumption at midlife was assessed using a validated food frequency questionnaire. Subsequently, successful ageing was defined in 13,894 Nurses' Health Study participants who survived to age 70 or older, and whose health status was continuously updated. “Successful ageing” was considered as being free of 11 major chronic diseases and having no major cognitive impairment, physical impairment, or mental health limitations. Analyses were restricted to the 98.1% of participants who were not heavier drinkers (>45 g/d) at midlife. Of all eligible study participants, 1,491 (10.7%) achieved successful ageing. After multivariable adjustment of potential confounders, light-to-moderate alcohol consumption at midlife was associated with modestly increased odds of successful ageing. The odds ratios (95% confidence interval) were 1.0 (referent) for nondrinkers, 1.11 (0.96–1.29) for ≤5.0 g/d, 1.19 (1.01–1.40) for 5.1–15.0 g/d, 1.28 (1.03–1.58) for 15.1–30.0 g/d, and 1.24 (0.87–1.76) for 30.1–45.0 g/d. Meanwhile, independent of total alcohol intake, participants who drank alcohol at regular patterns throughout the week, rather than on a single occasion, had somewhat better odds of successful ageing; for example, the odds ratios (95% confidence interval) were 1.29 (1.01–1.64) and 1.47 (1.14–1.90) for those drinking 3–4 days and 5–7 days per week in comparison with nondrinkers, respectively, whereas the odds ratio was 1.10 (0.94–1.30) for those drinking only 1–2 days per week.
Conclusions
These data suggest that regular, moderate consumption of alcohol at midlife may be related to a modest increase in overall health status among women who survive to older ages.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
People have always drunk alcoholic beverages but throughout history there have been arguments about the risks and benefits of beer, wine, and spirits. It is clear that excessive alcohol use—heavy drinking (an average of more than two drinks per day for men or more than one drink per day for women; in the US, a “drink” is defined as 15 g of alcohol or, roughly speaking, a can of beer or a small glass of wine) or binge drinking (five or more drinks on a single occasion for men; 4 or more drinks at one time for women)—is harmful. It causes liver damage and increases the risk of developing some types of cancer. It contributes to depression and violence and interferes with relationships. And it is often implicated in fatal traffic accidents. However, in contrast to these and other harms associated with excessive alcohol use, moderate alcohol consumption seems to reduce the risk of specific diseases such as heart disease, stroke, and cognitive decline (deterioration in learning, reasoning, and perception).
Why Was This Study Done?
Although people who drink moderate amounts of alcohol have a reduced risk of premature death compared to abstainers or heavy drinkers, it is not known whether moderate alcohol consumption is associated with overall health among ageing populations. In many countries, elderly people are an increasingly large part of the population, so it is important to know how moderate alcohol consumption affects their well-being. In this study, the researchers examine the effect of alcohol consumption at midlife on successful ageing among the participants of the Nurses' Health Study. The researchers study the effect of midlife alcohol consumption because the chronic conditions that affect elderly people develop slowly and it is likely that factors in earlier life determine health in later life. Successful ageing is defined as being free of major chronic diseases such as cancer and heart disease, and having no major cognitive impairment, physical impairment, or mental health problems. The Nurses' Health Study enrolled 121,700 female registered nurses in 1976 to investigate the long-term effects of oral contraceptive use but has provided insights into many aspects of health and disease.
What Did the Researchers Do and Find?
The researchers assessed the alcohol consumption of the study participants at midlife (average age 58 years) from food frequency questionnaires completed in 1980 and 1984. Successful ageing for 13,984 participants who survived past 70 years was assessed by analyzing biennial health status questionnaires and cognitive function test results. One tenth of the women achieved successful ageing. After allowing for other factors that might affect their health such as smoking, women who drank light or moderate amounts of alcohol had a modestly increased chance of successful ageing compared to nondrinkers. For example, compared to nondrinkers, women who drank 5–15 g of alcohol per day (between one-third and one drink per day) had about a 20% higher chance of successful ageing. Independent of total alcohol intake, women who drank alcohol regularly had a better chance of successful ageing than occasional drinkers. Thus, compared to nondrinkers, women who drank five to seven days a week had nearly a 50% greater chance of successful ageing whereas women who drank only one or two days a week had a similar likelihood of successful ageing.
What Do These Findings Mean?
These findings suggest that regular, moderate consumption of alcohol at midlife may be related to a modest increase in overall health among women who survive to older ages. Because this is an observational study, it is possible that the women who drank moderately share other unknown characteristics that are actually responsible for their increased chance of successful ageing. Moreover, because all the study participants were women and most had European ancestry, these findings cannot be applied to men or to other ethnic groups. Nevertheless, these findings provide support for the 2010 US Department of Agriculture dietary guidelines, which state that consumption of up to one alcoholic drink per day for women and up to two alcoholic drinks per day for men may provide health benefits. Importantly, they also suggest that drinking alcohol regularly in moderation rather than occasional heavy drinking may be associated with a greater likelihood of successful ageing.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001090.
The US National Institute on Alcohol Abuse and Alcoholism has detailed information about alcohol and its effects on health, including a fact sheet on women and alcohol and a booklet entitled Alcohol, a woman's health issue
The US Centers for Disease Control and Prevention has a website on alcohol and public health
The UK National Health Service Choices website provides detailed information about drinking and alcohol, including how to calculate consumption
The Nutrition Source, a website maintained by the Department of Nutrition at Harvard School of Public Health, has an article entitled Alcohol: balancing risks and benefits
MedlinePlus provides links to many other resources on alcohol and on seniors' health
Details of the Nurses' Health Study are available
The 2010 US Department of Agriculture dietary guidelines are available
doi:10.1371/journal.pmed.1001090
PMCID: PMC3167795  PMID: 21909248
22.  An exploratory cluster randomised trial of a university halls of residence based social norms intervention in Wales, UK 
BMC Public Health  2012;12:186.
Background
Excessive alcohol consumption amongst university students has received increasing attention. A social norms approach to reducing drinking behaviours has met with some success in the USA. Such an approach is based on the assumption that student's perceptions of the norms of their peers are highly influential, but that these perceptions are often incorrect. Social norms interventions therefore aim to correct these inaccurate perceptions, and in turn, to change behaviours. However, UK studies are scarce and it is increasingly recognised that social norm interventions need to be supported by socio ecological approaches that address the wider determinants of behaviour.
Objectives
To describe the research design for an exploratory trial examining the acceptability, hypothesised process of change and implementation of a social norm marketing campaign designed to correct misperceptions of normative alcohol use and reduce levels of misuse, implemented alongside a university wide alcohol harm reduction toolkit. It also assesses the feasibility of a potential large scale effectiveness trial by providing key trial design parameters including randomisation, recruitment and retention, contamination, data collection methods, outcome measures and intracluster correlations.
Methods/design
The study adopts an exploratory cluster randomised controlled trial design with halls of residence as the unit of allocation, and a nested mixed methods process evaluation. Four Welsh (UK) universities participated in the study, with residence hall managers consenting to implementation of the trial in 50 university owned campus based halls of residence. Consenting halls were randomised to either a phased multi channel social norm marketing campaign addressing normative discrepancies (n = 25 intervention) or normal practice (n = 25 control). The primary outcome is alcohol consumption (units per week) measured using the Daily Drinking Questionnaire. Secondary outcomes assess frequency of alcohol consumption, higher risk drinking, alcohol related problems and change in perceptions of alcohol-related descriptive and injunctive norms. Data will be collected for all 50 halls at 4 months follow up through a cross-sectional on line and postal survey of approximately 4000 first year students. The process evaluation will explore the acceptability and implementation of the social norms intervention and toolkit and hypothesised process of change including awareness, receptivity and normative changes.
Discussion
Exploratory trials such as this are essential to inform future definitive trials by providing crucial methodological parameters and guidance on designing and implementing optimum interventions.
Trial registration number
ISRCTN: ISRCTN48556384
doi:10.1186/1471-2458-12-186
PMCID: PMC3315745  PMID: 22414293
23.  Live Interactive Group-Specific Normative Feedback Reduces Misperceptions and Drinking in College Students: A Randomized Cluster Trial 
This research evaluated the efficacy of a live and interactive group-specific normative feedback intervention designed to correct misperceptions of alcohol-related group norms and subsequently reduce drinking behavior. Campus organizations (N = 20) containing 1,162 college students were randomly assigned to intervention or assessment-only control conditions. Participants in the intervention condition attended an intervention during their organization’s regular standing meeting. Data were gathered in vivo using computerized handheld keypads into which participants entered personal responses to a series of alcohol-related questions assessing perceptions of normative group behavior as well as actual individual behavior. These data were then immediately presented in graphical form to illustrate discrepancies between perceived and actual behavioral group norms. Results indicated that compared with the control group, the intervention group reduced drinking behavior and misperceptions of group norms at 1-month and 2-month follow-ups. Changes in perceived norms mediated the reductions in drinking. Results demonstrate the effectiveness of a novel, technologically advanced, group-based, brief alcohol intervention that can be implemented with entire groups at relatively low cost.
doi:10.1037/0893-164X.22.1.141
PMCID: PMC4221269  PMID: 18298241
normative feedback; misperceptions; intervention; alcohol behavior; handheld keypads
24.  Missed and Inconsistent Classification of Current Drinkers: Results from the 2005 US National Alcohol Survey 
Addiction (Abingdon, England)  2012;108(2):10.1111/j.1360-0443.2012.04079.x.
Aims
This study compares current 12-month drinkers who do not report drinking in the last 30 days with current drinkers who drank in the last 30 days and assesses possible misclassification errors from use of a 30-day consumption measure.
Design
Data are from the 2005 US National Alcohol Survey (N=6919), a national household probability survey.
Setting
Telephone interviews were used to measure alcohol use and alcohol-related problems.
Participants
This study compared 1,300 current drinkers who did not drink in the last 30 days with 2,956 current drinkers who drank in the last 30 days.
Measurements
Volume was measured by Quantity/Frequency Scales (12-month and 30-day) and a Graduated Frequency Scale (12-month). Both groups were compared by demographic, alcohol volume, days of 5 or more drinks, social consequences and dependence measures.
Findings
Results indicate a significantly lower prevalence rate of current drinking for 30-day measures - 47.3% (45.8%, 48.8%) versus 67.3% (66.0%, 68.7%) with 12-month measure. Further, 385 non 30-day drinkers reported 12-month drinking frequencies of once a month or more often, suggesting a possibly inconsistent reporting of their alcohol use. When this group of “inconsistent” respondents is compared with the 915 non 30-day current drinkers who reported less than monthly drinking, they reported significantly higher yearly volume, days of 5 or more drinks, mean social consequences, and proportion reporting alcohol dependence.
Conclusions
In population surveys assessing alcohol use, asking about the previous 12 months rather than the past 30 days provides higher estimates of current use including more days of heavy episodic use.
doi:10.1111/j.1360-0443.2012.04079.x
PMCID: PMC3810534  PMID: 22974256
measurement; inconsistent reporting; alcohol consumption; 30-day measures; 12-month measures; current drinkers
25.  What Makes Group MET Work? A Randomized Controlled Trial of College Student Drinkers in Mandated Alcohol Diversion 
Nationally, college drinkers exhibit the highest rates of alcohol consumption and represent the largest percentage of problem drinkers. Group motivational enhancement therapy (GMET) has been found to catalyze problem drinking reductions among college student samples. While research supporting the use of single-session GMET in college samples (general and mandated) is emergent, no studies have evaluated a comprehensive model of the potential active ingredients of this group intervention. College students (N = 206; 88% Caucasian; 63% male; M age = 18.6) mandated to a university alcohol diversion program were randomly assigned to one of three conditions: the standard-of-care two-session ‘Focus on Alcohol Concerns’ education group (FAC), a single group motivational enhancement therapy (GMET), or a single Alcohol Information-only control group (AI) to evaluate the role of five putative mediators: readiness to change, self-efficacy, perceived risk, norm estimates, and positive drinking expectancies. At three and six month follow-ups, GMET students demonstrated greater reductions in problem drinking outcomes (drinks per drinking day, hazardous drinking symptoms, and alcohol-related problems). Of the five mediators proposed, only self-efficacy emerged as a significant mediator.
doi:10.1037/a0016633
PMCID: PMC2802458  PMID: 20025366
Group Motivational Enhancement Therapy; Mandated; College Students; Drinking; Self-Efficacy

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