Reported by two out of every five college students nationally, heavy episodic or binge drinking may be the most frequently reported and researched mental health problem among college youth. Effective prevention and treatment should reflect the heterogeneity of binge drinking, as it can cause substantial and serious harms.
Misuse and abuse of alcohol are among the most prevalent mental health problems among young adults today (Grant, 1997), and there is good evidence that these problems have increased along with depression and anxiety disorders (Fombonne, 1998; Kessler and Walters, 1998). Young adults are among the heaviest drinkers in the United States (Naimi et al., 2003), and college students drink more heavily than their non-college attending peers (Johnston et al., 1997). In fact, colleges have proven uniquely risky for several mental health and behavioral problems, including alcohol, tobacco and illicit drug use (Hingson et al., 2002; Johnston et al., 1997; O'Malley and Johnston, 2002).
Heavy episodic or binge drinking may be the most frequently reported and researched mental health problem among college youth. About 44% of U.S. college students binge drink--consuming five or more drinks in a row for males and four or more drinks for females on one or more occasions during a two-week period. Half of these students do so frequently (i.e., three or more times within two weeks) (Centers for Disease Control and Prevention, 1997; Douglas et al., 1997;Wechsler et al., 1994).
This article includes a summary of research on social and developmental aspects of binge drinking in college, and an overarching framework for considering vulnerability and life course issues relevant to prevention and treatment.
Social and Developmental Correlates of Binge Drinking
Young people come to campus with social demographic, family and drinking histories that influence their drinking in college. For example, one out of every 10 college students reports growing up with a problem drinking parent and, once in college, these young people either abstain from alcohol at greater than expected rates or disproportionately engage in binge drinking and abuse alcohol (Weitzman and Wechsler, 2000).
In college, a range of factors related to students' peers, affiliations, normative surrounds and living contexts influence the students' alcohol consumption and harms (Figure 1) (Wechsler et al., 1995). Both personal and institutional attachments affect high-risk drinking (Hawkins et al., 1992). High rates of binge drinking exist among athletes and sports fans (Nelson and Wechsler, 2003, 2001), fraternity and sorority members, and highly social students, while female, racial/ethnic minority, religious, married, older or non-traditional students all tend to consume less alcohol (Wechsler et al., 1995).
Peer norms, activities, and patterns of social connection and activity correlate positively with binge drinking (Bachman et al., 1984; Perkins and Wechsler, 1996), as do residence with multiple roommates or in a group house (Wechsler et al., 1995). Volunteering, working for pay and engagement with outside community organizations are associated with decreased risks (Wechsler et al., 1995; Weitzman and Kawachi, 2000). Levels of social bonding and trust within the campus community protect against heavy episodic drinking. For example, exposure to high campus community norms of volunteering, an indicator of social trust, individual investment in the group or social capital (Coleman, 1988; Putnam, 1993), appears to lessen individual risks for heavy episodic drinking even after controlling for individual volunteering (Weitzman and Kawachi, 2000).
The reciprocal relationships that exist between peers, residence and lifestyle factors are hypothesized to have a synergistic influence on what young people know, believe, endorse and do with regard to alcohol and on harms resulting from its misuse. This process involves self-selection as well as social influence. For example, students who join fraternities are more likely to engage in heavy episodic drinking in high school (Treno et al., 2001; Wechsler et al., 1996; Weitzman et al., 2003b). Parental supervision and friends' drinking-related norms and behaviors also influence adolescent drinking (Bahr et al., 1995; Kandel, 1978).
Adolescent Development and Drinking Progression
The transition to college from high school is a point at which parental supervision diminishes and friendships, attachments to work and extracurricular activities shift (Bachman et al., 1984). Upon entering college, students re-establish attachments and social roles with new peers and institutions, and this transition may comprise a key developmental moment in which drinking behaviors shift.
While a large minority of college students binge drink during their high school years, a substantial number of them adopt binge drinking oncein college. In fact, binge drinking isnot invariant in young adulthood (Schulenberg et al., 1996). From high school to college it appears to reflect at least four distinct progression patterns described in Figure 2 as: acquisition or uptake of binge drinking in college, continuation of binge drinking from high school to college, discontinuation in college, and avoidance in high school and college (Weitzman, unpublished data). The uptake or acquisition pattern is explained by a range of predictors, including: student demographic characteristics, residence with parents (protective), residence in a high-binge school or fraternity/sorority house (risky), ease of access of alcohol (risky), close peer networks that involve alcohol (risky), attitudes that favor heavier and/or younger drinking (risky), very low or discounted price for alcohol (most risky) (Weitzman et al., 2003b). From a prevention and treatment perspective, it may be important to match interventions onto particular progression patterns and subgroups for maximum effect.
Environmental Influences on Binge Drinking
Features of college environments play a powerful role in promoting heavy alcohol use (National Institute on Alcohol Abuse and Alcoholism, 2002; Substance Abuse and Mental Health Services Administration, 1999; Treno et al., 2001). Rates of binge drinking vary dramatically by college, geographic region (lower in the West), and by the sets of policies and laws governing alcohol sales and use (Wechsler et al., 2002b, 2000).
Among the most important environmental determinants of binge drinking are pricing and promotion of alcoholic beverages (Chaloupka and Wechsler, 1996). Low prices and easy access promote underage alcohol use (Kuo et al., 2003). High density of alcohol outlets around campuses correlates with higher levels of frequent and heavy drinking and drinking-related problems including among women, underage students and those who report they were not binge-drinkers in high school but picked up the behavior in college (Weitzman et al., 2003a).
Select campus and community factors may help control binge drinking in college. Substance-free residences, where students are prohibited from using alcohol and tobacco products, are associated with less alcohol use and fewer secondhand effects of alcohol (Wechsler et al., 2001). The National Minimum Legal Drinking Age law appears effective (Toomey and Wagenaar, 2002; Wagenaar and Toomey, 2002). Extensive laws restricting underage and high-volume drinking at state and local levels are associated with lower odds of drinking and binge drinking among underage students (Wechlser et al., 2002b, 2002c) and college students (Wechsler et al., 2003).
The effects of environmental risk and protective factors are under-researched as they may affect particularly vulnerable groups, including children of alcoholics or young people with mental health problems, such as depression.
Harms and Health Consequences
As a result of binge drinking, college students experience substantial harm, from academic problems to physical and sexual assault, overdose, injury and death (Perkins, 2002; Wechsler et al., 2002a). Problems increase with consumption (Wechsler et al., 1995). Some 1,400 U.S. college students die annually from alcohol-related motor vehicle crashes and unintentional injuries, while over 2 million drive under the influence, 3 million ride with an intoxicated driver and half a million are unintentionally non-fatally injured under the influence (Hingson et al., 2002).
As with young people in other types of settings, alcohol use/abuse in college predicts other drug use, including tobacco (Rigotti et al., 2000), marijuana and other illicit drug use (Gledhill-Hoyt et al., 2000). Binge drinking may be a marker for multiple problems or high-risk profile that includes elevated odds for firearm possession on campus (Miller et al., 2002).
Approximately one-third of college students and three in five frequent binge-drinkers qualify for a diagnosis of alcohol abuse, while one in 17 (one in five frequent binge-drinkers) could be diagnosed as alcohol dependent (Knight et al., 2002) based on DSM-IV criteria. Despite their alcohol-related problems, few students who drink heavily perceive that they are heavy or problem drinkers and even fewer report that they have sought treatment or counseling (Knight et al., 2002), findings that hold even among presumably high-awareness groups such as self-identified children of problem drinkers (Weitzman and Wechsler, 2000). The effects of binge drinking in college on later, post-college outcomes are not known.
In addition to their adverse effects on drinkers, heavy drinking patterns in college negatively impact others--so called "secondhand" effects (Wechsler et al., 1995). Secondhand effects range in severity from typically nuisance disorders such as finding vomit in one's residence, to serious offenses including sexual and/or physical assault. Risks for secondhand effects mount substantially in high-binge college settings. Secondhand effects are also experienced by residents of communities nearby colleges, particularly those in which larger percentages of students binge drink (Wechsler et al., 2002a), a finding almost entirely explained by the density of alcohol outlets in neighborhoods adjacent to universities.
Binge drinking is a serious and heterogeneous problem affecting a substantial minority of young people in college today. It is exacerbated both by factors students bring with them to college--such as positive family histories of alcohol problems, or established histories of heavy or binge drinking in high school--and by features of the college environment. Effective prevention and treatment will require a nuanced approach to assess risk, recognize individual vul-nerabilities and reduce individual, as well as environmental, hazards that play on them.
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